Enviar pesquisa
Carregar
Bipolar
•
2 gostaram
•
438 visualizações
M
malviani56
Seguir
Saúde e medicina
Denunciar
Compartilhar
Denunciar
Compartilhar
1 de 5
Recomendados
Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
College of Medicine, Sulaymaniyah
Schizophrenia & gangguan bipolar
Schizophrenia & gangguan bipolar
fta_triastuti
Depression, self injurious behavior and suicidality among adolescents
Depression, self injurious behavior and suicidality among adolescents
Milen Ramos
Behaviourial manifestation in neurologic disease
Behaviourial manifestation in neurologic disease
assam1
Presentation(lokesh)
Presentation(lokesh)
Lokesh Agrawal
Depression
Depression
delacruz_kennedy
Presentation(lokesh)
Presentation(lokesh)
Lokesh Agrawal
An Exploration of Depressive Symptoms in Hepatitis CPatients Taking Interfero...
An Exploration of Depressive Symptoms in Hepatitis CPatients Taking Interfero...
Jocelyn Red Red
Recomendados
Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
College of Medicine, Sulaymaniyah
Schizophrenia & gangguan bipolar
Schizophrenia & gangguan bipolar
fta_triastuti
Depression, self injurious behavior and suicidality among adolescents
Depression, self injurious behavior and suicidality among adolescents
Milen Ramos
Behaviourial manifestation in neurologic disease
Behaviourial manifestation in neurologic disease
assam1
Presentation(lokesh)
Presentation(lokesh)
Lokesh Agrawal
Depression
Depression
delacruz_kennedy
Presentation(lokesh)
Presentation(lokesh)
Lokesh Agrawal
An Exploration of Depressive Symptoms in Hepatitis CPatients Taking Interfero...
An Exploration of Depressive Symptoms in Hepatitis CPatients Taking Interfero...
Jocelyn Red Red
Bipolar a complex disorder
Bipolar a complex disorder
Timuçin Oral
Does “icu psychosis” really exist
Does “icu psychosis” really exist
Carmela Domocmat
Psychiatry In Medicine
Psychiatry In Medicine
Adil Mehmood
Birmaher et al 2009; coby study
Birmaher et al 2009; coby study
Maria Karagkouni
Impulsive control disorder
Impulsive control disorder
UrvashiMirpuri
Epidemiology anxiety disorders
Epidemiology anxiety disorders
NurEduc
Depression feb2012
Depression feb2012
MPH_training_committee
Somatic Symptom and Related Disorders [2020]
Somatic Symptom and Related Disorders [2020]
Zahiruddin Othman
somatoform disorder
somatoform disorder
Sandeep Shrestha
Negative emotions and health: Why do we keep stalking bears.ehps
Negative emotions and health: Why do we keep stalking bears.ehps
James Coyne
Prodromal psychosis talk 25-11-09
Prodromal psychosis talk 25-11-09
Jennifer Spencer
W1 The Psychiatry of AIDS Treisman
W1 The Psychiatry of AIDS Treisman
DSHS
psyhogenic Disorders 4rth Course 2nd semester psychiatry
psyhogenic Disorders 4rth Course 2nd semester psychiatry
Karan Deep
Negative emotion and health why do we keep stalking bears, when we only find ...
Negative emotion and health why do we keep stalking bears, when we only find ...
James Coyne
Mood disorders
Mood disorders
Anselm Eldergill
Debra Lampshire, Making Sense of Psychosis
Debra Lampshire, Making Sense of Psychosis
NZ Psychological Society
Bipolar disorder
Bipolar disorder
OscarMilano4
Bipolar disorders in DSM-5: strengths, problems and perspectives
Bipolar disorders in DSM-5: strengths, problems and perspectives
Lena Setianingsih
Role of dopamin in major depressive disorders final (2)
Role of dopamin in major depressive disorders final (2)
Nasar Khan
Avaya统一通信主打胶片
Avaya统一通信主打胶片
abcd098123
Blanca nelly diaz
Blanca nelly diaz
Katterin Castillo
Plusvoorzieningen Roermond
Plusvoorzieningen Roermond
JitskevE
Mais conteúdo relacionado
Mais procurados
Bipolar a complex disorder
Bipolar a complex disorder
Timuçin Oral
Does “icu psychosis” really exist
Does “icu psychosis” really exist
Carmela Domocmat
Psychiatry In Medicine
Psychiatry In Medicine
Adil Mehmood
Birmaher et al 2009; coby study
Birmaher et al 2009; coby study
Maria Karagkouni
Impulsive control disorder
Impulsive control disorder
UrvashiMirpuri
Epidemiology anxiety disorders
Epidemiology anxiety disorders
NurEduc
Depression feb2012
Depression feb2012
MPH_training_committee
Somatic Symptom and Related Disorders [2020]
Somatic Symptom and Related Disorders [2020]
Zahiruddin Othman
somatoform disorder
somatoform disorder
Sandeep Shrestha
Negative emotions and health: Why do we keep stalking bears.ehps
Negative emotions and health: Why do we keep stalking bears.ehps
James Coyne
Prodromal psychosis talk 25-11-09
Prodromal psychosis talk 25-11-09
Jennifer Spencer
W1 The Psychiatry of AIDS Treisman
W1 The Psychiatry of AIDS Treisman
DSHS
psyhogenic Disorders 4rth Course 2nd semester psychiatry
psyhogenic Disorders 4rth Course 2nd semester psychiatry
Karan Deep
Negative emotion and health why do we keep stalking bears, when we only find ...
Negative emotion and health why do we keep stalking bears, when we only find ...
James Coyne
Mood disorders
Mood disorders
Anselm Eldergill
Debra Lampshire, Making Sense of Psychosis
Debra Lampshire, Making Sense of Psychosis
NZ Psychological Society
Bipolar disorder
Bipolar disorder
OscarMilano4
Bipolar disorders in DSM-5: strengths, problems and perspectives
Bipolar disorders in DSM-5: strengths, problems and perspectives
Lena Setianingsih
Role of dopamin in major depressive disorders final (2)
Role of dopamin in major depressive disorders final (2)
Nasar Khan
Mais procurados
(19)
Bipolar a complex disorder
Bipolar a complex disorder
Does “icu psychosis” really exist
Does “icu psychosis” really exist
Psychiatry In Medicine
Psychiatry In Medicine
Birmaher et al 2009; coby study
Birmaher et al 2009; coby study
Impulsive control disorder
Impulsive control disorder
Epidemiology anxiety disorders
Epidemiology anxiety disorders
Depression feb2012
Depression feb2012
Somatic Symptom and Related Disorders [2020]
Somatic Symptom and Related Disorders [2020]
somatoform disorder
somatoform disorder
Negative emotions and health: Why do we keep stalking bears.ehps
Negative emotions and health: Why do we keep stalking bears.ehps
Prodromal psychosis talk 25-11-09
Prodromal psychosis talk 25-11-09
W1 The Psychiatry of AIDS Treisman
W1 The Psychiatry of AIDS Treisman
psyhogenic Disorders 4rth Course 2nd semester psychiatry
psyhogenic Disorders 4rth Course 2nd semester psychiatry
Negative emotion and health why do we keep stalking bears, when we only find ...
Negative emotion and health why do we keep stalking bears, when we only find ...
Mood disorders
Mood disorders
Debra Lampshire, Making Sense of Psychosis
Debra Lampshire, Making Sense of Psychosis
Bipolar disorder
Bipolar disorder
Bipolar disorders in DSM-5: strengths, problems and perspectives
Bipolar disorders in DSM-5: strengths, problems and perspectives
Role of dopamin in major depressive disorders final (2)
Role of dopamin in major depressive disorders final (2)
Destaque
Avaya统一通信主打胶片
Avaya统一通信主打胶片
abcd098123
Blanca nelly diaz
Blanca nelly diaz
Katterin Castillo
Plusvoorzieningen Roermond
Plusvoorzieningen Roermond
JitskevE
Cisco uc(统一通信)培训资料
Cisco uc(统一通信)培训资料
abcd098123
Psychotherapist who abstain from personal theraphy
Psychotherapist who abstain from personal theraphy
malviani56
Catalouge
Catalouge
Rahul Rao
Teoría del vínculo (1)
Teoría del vínculo (1)
malviani56
Minicurso: Python em 4 horas - FATEC SCS 2015
Minicurso: Python em 4 horas - FATEC SCS 2015
Alan Justino da Silva
Pdf fernando-colina
Pdf fernando-colina
malviani56
Destaque
(9)
Avaya统一通信主打胶片
Avaya统一通信主打胶片
Blanca nelly diaz
Blanca nelly diaz
Plusvoorzieningen Roermond
Plusvoorzieningen Roermond
Cisco uc(统一通信)培训资料
Cisco uc(统一通信)培训资料
Psychotherapist who abstain from personal theraphy
Psychotherapist who abstain from personal theraphy
Catalouge
Catalouge
Teoría del vínculo (1)
Teoría del vínculo (1)
Minicurso: Python em 4 horas - FATEC SCS 2015
Minicurso: Python em 4 horas - FATEC SCS 2015
Pdf fernando-colina
Pdf fernando-colina
Semelhante a Bipolar
Bipolar dis copy
Bipolar dis copy
MPH_training_committee
Hanipsych,, biology of borderline personality disorder
Hanipsych,, biology of borderline personality disorder
Hani Hamed
The Negative Symptoms of Schizophrenia
The Negative Symptoms of Schizophrenia
iCliniq
Literature Review- Major Depressive Disorder
Literature Review- Major Depressive Disorder
Cooper Feild
Behaviour As Predictor of Dementia
Behaviour As Predictor of Dementia
Neurokrish - the neuropsychiatry centre
Psychosis
Psychosis
Madhu Sameer
Bipolar disorder mrcpsych
Bipolar disorder mrcpsych
Walk KD
45304607-Schizophrenia.pptx
45304607-Schizophrenia.pptx
AkshayWankhede14
Etiopathogenesis of obsessive compulsive disorder [autosaved]
Etiopathogenesis of obsessive compulsive disorder [autosaved]
sadaf89
La genetica della Depressione: i nuovi approcci metodologici
La genetica della Depressione: i nuovi approcci metodologici
MerqurioEditore_redazione
SCHIZOPHRENIA.pptx
SCHIZOPHRENIA.pptx
Ameena Kadar
psychosis 8.ppt
psychosis 8.ppt
SamuelAbebe11
How much do we really understand about Schizophrenia and to what extent is so...
How much do we really understand about Schizophrenia and to what extent is so...
Pırıl Erel
New: Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
New: Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
College of Medicine, Sulaymaniyah
Schizophrenia
Schizophrenia
Richard Asare
Ocd a hidden_epidemic
Ocd a hidden_epidemic
IMH chennai
Delusional disorder
Delusional disorder
Dr.Jeet Nadpara
Judgement
Judgement
Dr Wasim
Prediction of mood disorders and imaging phenotypes from genomic data
Prediction of mood disorders and imaging phenotypes from genomic data
Yasir Hameed
schizophrenia-151005154837-lva1-app6891.pdf
schizophrenia-151005154837-lva1-app6891.pdf
FadilaLawal
Semelhante a Bipolar
(20)
Bipolar dis copy
Bipolar dis copy
Hanipsych,, biology of borderline personality disorder
Hanipsych,, biology of borderline personality disorder
The Negative Symptoms of Schizophrenia
The Negative Symptoms of Schizophrenia
Literature Review- Major Depressive Disorder
Literature Review- Major Depressive Disorder
Behaviour As Predictor of Dementia
Behaviour As Predictor of Dementia
Psychosis
Psychosis
Bipolar disorder mrcpsych
Bipolar disorder mrcpsych
45304607-Schizophrenia.pptx
45304607-Schizophrenia.pptx
Etiopathogenesis of obsessive compulsive disorder [autosaved]
Etiopathogenesis of obsessive compulsive disorder [autosaved]
La genetica della Depressione: i nuovi approcci metodologici
La genetica della Depressione: i nuovi approcci metodologici
SCHIZOPHRENIA.pptx
SCHIZOPHRENIA.pptx
psychosis 8.ppt
psychosis 8.ppt
How much do we really understand about Schizophrenia and to what extent is so...
How much do we really understand about Schizophrenia and to what extent is so...
New: Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
New: Psychiatry 5th year, 4th & 5th lectures (Dr. Nazar M. Mohammad Amin)
Schizophrenia
Schizophrenia
Ocd a hidden_epidemic
Ocd a hidden_epidemic
Delusional disorder
Delusional disorder
Judgement
Judgement
Prediction of mood disorders and imaging phenotypes from genomic data
Prediction of mood disorders and imaging phenotypes from genomic data
schizophrenia-151005154837-lva1-app6891.pdf
schizophrenia-151005154837-lva1-app6891.pdf
Mais de malviani56
Koro
Koro
malviani56
Curso tratamiento psicologico_trastorno_obsesivo_compulsivo_2012
Curso tratamiento psicologico_trastorno_obsesivo_compulsivo_2012
malviani56
Pre programa fearp
Pre programa fearp
malviani56
Enero junio 2012 udmsm
Enero junio 2012 udmsm
malviani56
Psicoanalisis multifamiliar
Psicoanalisis multifamiliar
malviani56
Enero junio 2012 udmsm
Enero junio 2012 udmsm
malviani56
Psicosis, trauma y disociación
Psicosis, trauma y disociación
malviani56
Rehabilitación psicosocial
Rehabilitación psicosocial
malviani56
Tratamiento ambulatorio
Tratamiento ambulatorio
malviani56
Psicoterapias humanistico existenciales
Psicoterapias humanistico existenciales
malviani56
Goreti Díaz Marrero
Goreti Díaz Marrero
malviani56
Embarazo parto y lactancia
Embarazo parto y lactancia
malviani56
Tratamiento
Tratamiento
malviani56
El paciente agitado o violento
El paciente agitado o violento
malviani56
El miedo a ser uno mismo
El miedo a ser uno mismo
malviani56
El miedo a ser uno mismo
El miedo a ser uno mismo
malviani56
Autoconocimiento y reacciones especulares
Autoconocimiento y reacciones especulares
malviani56
Programa jornadas violencia cop sctfe 2011
Programa jornadas violencia cop sctfe 2011
malviani56
Guia enfermeria 2011
Guia enfermeria 2011
malviani56
Revisión bibliográfica
Revisión bibliográfica
malviani56
Mais de malviani56
(20)
Koro
Koro
Curso tratamiento psicologico_trastorno_obsesivo_compulsivo_2012
Curso tratamiento psicologico_trastorno_obsesivo_compulsivo_2012
Pre programa fearp
Pre programa fearp
Enero junio 2012 udmsm
Enero junio 2012 udmsm
Psicoanalisis multifamiliar
Psicoanalisis multifamiliar
Enero junio 2012 udmsm
Enero junio 2012 udmsm
Psicosis, trauma y disociación
Psicosis, trauma y disociación
Rehabilitación psicosocial
Rehabilitación psicosocial
Tratamiento ambulatorio
Tratamiento ambulatorio
Psicoterapias humanistico existenciales
Psicoterapias humanistico existenciales
Goreti Díaz Marrero
Goreti Díaz Marrero
Embarazo parto y lactancia
Embarazo parto y lactancia
Tratamiento
Tratamiento
El paciente agitado o violento
El paciente agitado o violento
El miedo a ser uno mismo
El miedo a ser uno mismo
El miedo a ser uno mismo
El miedo a ser uno mismo
Autoconocimiento y reacciones especulares
Autoconocimiento y reacciones especulares
Programa jornadas violencia cop sctfe 2011
Programa jornadas violencia cop sctfe 2011
Guia enfermeria 2011
Guia enfermeria 2011
Revisión bibliográfica
Revisión bibliográfica
Último
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
parulsinha
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
narwatsonia7
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
GENUINE ESCORT AGENCY
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
tanya dube
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Dipal Arora
Call Girls Vasai Virar Just Call 9630942363 Top Class Call Girl Service Avail...
Call Girls Vasai Virar Just Call 9630942363 Top Class Call Girl Service Avail...
GENUINE ESCORT AGENCY
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
GENUINE ESCORT AGENCY
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
Call Girls In Delhi Whatsup 9873940964 Enjoy Unlimited Pleasure
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Dipal Arora
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
GENUINE ESCORT AGENCY
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
mahaiklolahd
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
khalifaescort01
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
jageshsingh5554
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
parulsinha
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Dipal Arora
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
aartirawatdelhi
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
chandars293
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Sheetaleventcompany
Call Girls Shimla Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Shimla Just Call 8617370543 Top Class Call Girl Service Available
Dipal Arora
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
narwatsonia7
Último
(20)
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
Top Rated Bangalore Call Girls Mg Road ⟟ 9332606886 ⟟ Call Me For Genuine S...
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Hosur Just Call 9630942363 Top Class Call Girl Service Available
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Vasai Virar Just Call 9630942363 Top Class Call Girl Service Avail...
Call Girls Vasai Virar Just Call 9630942363 Top Class Call Girl Service Avail...
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Raipur Just Call 9630942363 Top Class Call Girl Service Available
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Rishikesh Just Call 8250077686 Top Class Call Girl Service Available
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
Call Girl in Indore 8827247818 {LowPrice} ❤️ (ahana) Indore Call Girls * UPA...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
VIP Service Call Girls Sindhi Colony 📳 7877925207 For 18+ VIP Call Girl At Th...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Russian Call Girls Service Jaipur {8445551418} ❤️PALLAVI VIP Jaipur Call Gir...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 8250077686 Top Class Call Girl Service Ava...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
Night 7k to 12k Navi Mumbai Call Girl Photo 👉 BOOK NOW 9833363713 👈 ♀️ night ...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Shimla Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Shimla Just Call 8617370543 Top Class Call Girl Service Available
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Bipolar
1.
Bipolar disorder and
resembling special psychopathological manifestations in multiple sclerosis: a review Apostolos Iacovides and Elias Andreoulakis 3rd Department of Psychiatry, Aristotle University of Purpose of review Thessaloniki, AHEPA General Hospital, Thessaloniki, Greece The higher prevalence of psychiatric disorders in multiple sclerosis (MS) compared with the general population is well documented, with depression being the leading disorder. Correspondence to Apostolos Iacovides, PhD, MD, Professor Psychiatry, Director of 3rd Department of Apart from depression, other psychiatric disorders and symptoms such as bipolar Psychiatry, Aristotle University of Thessaloniki, AHEPA disorder, pseudobulbar affect, euphoria sclerotica, anxiety and personality changes are General Hospital, 1, St Kyriakidi Str, Thessaloniki 54636, Greece also reported to be overpresented in MS patients. Psychiatric disorders in MS lead to Tel: +30 231 0994 626; fax: +30 231 0994 623; significant disruption in patients’ family, work and social life, affecting patients’ quality of e-mail: apiacov@med.auth.gr life in general. Moreover, they are reported to be associated with poorer adherence to Current Opinion in Psychiatry 2011, 24:336–340 MS medication. The literature concerning bipolar disorder and affect disorders in MS is rather scarce. The purpose of this article is to provide a critical review on the latter subject. Recent findings This review focuses upon the recent findings with regard to the epidemiology and the comorbidity rates of bipolar and affect disorders in MS, questions raised about the potential underlying mechanisms that could explain such a high comorbidity, diagnostic issues and the recent developments in the treatment of those psychiatric disorders in MS. Summary Despite the fact that the higher prevalence of psychiatric disorders in MS is well established, such disorders still remain underdiagnosed and undertreated. A shift in the clinical suspicion towards the psychiatric morbidity in MS patients and the optimal treatment of those disorders is fundamental. Keywords affect, bipolar, euphoria, mood, multiple sclerosis, pathological laughing and crying, pseudobulbar affect Curr Opin Psychiatry 24:336–340 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 0951-7367 The neuropsychiatric manifestations in MS fall into two Introduction broad categories: disorders of mood, affect and behavior The occurrence of psychopathological symptoms and on the one hand, and cognitive impairment on the signs in multiple sclerosis (MS) was underlined and other, with considerable overlapping between these systematically described as early as in 1877 by Charcot. two categories. As far as mood and affect disorders The psychopathological symptoms mentioned included are concerned, they are mainly represented by major pathological laughing and weeping (also variably termed depression, bipolar disorder, euphoria and PBA. nowadays ‘pseudobulbar affect’ (PBA), ‘emotional incontinence’, or – most recently – ‘involuntary The main body of the literature focuses on the comorbid emotional expression disorder’), euphoria, mania, depres- depression found in MS, whereas the bibliography sion and hallucinations. concerning bipolar disorder, euphoria sclerotica and PBA remains rather scarce. This disproportion obviously Psychiatric symptoms are regarded as occurring more reflects the fact that depression is the most frequent commonly during the evolution of MS. Although among psychiatric disorders seen in MS, with a lifetime there are a few case studies reporting such symptoms prevalence reaching 50% and a 12-month prevalence of as the initial manifestations of MS, this phenomenon is 15.7%, the latter being twice as high as in the general thought to be rather uncommon. According to Fermo population (odds ratio: 2.3) [2]. et al. [1], the frequency of psychiatric symptoms among the presenting manifestations of MS ranges from 0.2 The purpose of this article is to provide a critical review of to 2%. the recent findings with regard to the relationship of MS 0951-7367 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/YCO.0b013e328347341d Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
2.
Bipolar disorder in
multiple sclerosis Iacovides and Andreoulakis 337 with mood and affect disorders beyond depression, Key points that is, bipolar disorder, euphoria sclerotica and PBA in the fields of epidemiology, comorbidity, diagnosis, Bipolar disorder and special emotional psycho- pathological symptoms in multiple sclerosis. pathophysiology and treatment. Diagnostic features, prevalence, etiopathological factors. Comorbidity. Bipolar disorder Treatment. The lifetime prevalence of bipolar disorder in the general population is often estimated to be around 1%. However, Perala et al. [3] in a recent population study reported found to be reversed when chronic corticosteroid a 0.24% life-prevalence, 0.31% for men and 0.18% therapy is concerned, with depression being the leading for women, with a difference in sexes which was not mood disorder. These drug-induced hypomanic or manic statistically significant. Moreover, the lifetime prevalence symptoms are dose dependent, often occur during the of bipolar disorder showed no significant difference first few weeks of the therapy and are reversible with among age groups, being 0.22, 0.36, 0.23, 0.14% in dose reduction or treatment discontinuation. A preven- age groups of 30–44, 45–54, 55–64 and over 65 years, tive benefit of lithium and phenytoin against the steroid- respectively. With regard to the prevalence and induced mood disturbances has been reported. However, comorbidity rates of bipolar disorder in MS in particular, Jefferies [10] points out the lack of sufficient clinical trials they have been reported to range from 0.3 to 32% [4–7]. investigating the effective treatment of manic episodes The great variability in the sample sizes, the prospective in MS patients in particular. or retrospective planning and the evaluation methods used in each study could account for such a diversity Concerning neuroimaging findings, corticosteroid use in the reported rates. However, the particularly high rates has been associated with changes in the temporal lobe reported in earlier studies are no longer supported in [11]. recent population studies and have declined to 0.3–2.4% [8,9]. Most recently, Marrie et al. [9] in a large population Interferon (INF) has been another medication implicated study (8983 patients with MS) reported a prevalence rate in side effects concerning mood. Depression is regarded of 2.4% for bipolar disorder in MS . Conclusively, bipolar as a potential side effect of the use of INF (particularly disorder seems to be two to three times more frequent in INF-a, but also INF-b), especially, though not necess- MS than in the general population. arily, in patients with a previous history of depression. The mechanism of the action of INF-b in inducing The relationship of bipolar disorder and MS, though depression has not been thoroughly investigated yet. well established, remains complex. The cause of such Fragoso et al. [12] reported 11 cases of severe depression a high comorbidity is regarded as being multifactorial. It with suicidal ideation in patients under INF-b therapy. is attributed to a variety of factors, such as the medication In some of the cases, depression was accompanied by used in MS, the demyelination brain lesions, genetics, psychotic or manic behavior, leading them to suggest or, finally, the psychological reactions and adjustment that there might be a psychiatric syndrome associated difficulties – associated with premorbid personality with INF-b therapy that goes beyond depression. vulnerabilities – to the chronic, severe and progressive character of the disease (the latter particularly concerning With regard to the investigation of a potential causal the appearance of depression in MS). association between demyelinating lesions due to MS and the appearance of bipolar disorder, there are Among medication used in MS implicated in inducing some studies that investigated the morphological findings hypomanic or manic episodes are the corticosteroids, in MRI patients who exhibited bipolar disorder or baclofen, dantrolene, tizanidine and illicit drugs [10]. similar symptoms. Plaques in bilateral temporal horn However, the medication side effects alone cannot fully areas [13] and ubiquitous white matter changes [14] account for the higher comorbidity between mania or were reported. According to Fazzito et al. [15], the hypomania and MS. psychiatric disorders shown in MS patients are thought to be secondary to temporal lobe demyelinating As far as the corticosteroids are concerned, mood disturb- lesions, though the physiopathology still remains not ances are reported to be the most common psychiatric fully known. side effects associated with them. Brown [11], in the most recent study on the subject, stated that hypomania and Concerning two newer medications applied in MS, mania have been reported as the most common mood mitoxantrone and natalizumab, there is not sufficient changes during acute corticosteroid therapy, whereas evidence regarding their potential psychiatric side effects depression comes in second place. This relation has been to date. Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
3.
338 Medical comorbidity
Another hypothesis stated is that of a genetic relationship between MS and bipolar disorder – reflecting a potential Pseudobulbar affect common genetic susceptibility – based on findings from This terminology points out the importance of bulbar familial bipolar disorder and MS studies, in which high nuclei in the brain stem thought to be implicated in similarity concerning the human leukocyte antigen controlling emotional expression, whereas the alternative (HLA) system genes, particularly of class II (DR, DQ), terms used – mentioned in the introduction section – was found [16–18]. mainly focus on the phenomenology of this entity. PBA is an affective disinhibition syndrome, a condition in which Finally, concerning the treatment of bipolar disorder in mood (emotional experience) and affect (emotional MS, bipolar disorder is usually treated with lithium or expression) are not in concordance. It is characterized anticonvulsants [19]. However, no sufficient data are by spontaneous, involuntary and uncontrollable outbursts available regarding the effect of mood stabilizers such of contextually inappropriate crying or laughing that as carvamazepine or valproic acid, because there are no are inconsistent with the patient’s underlying mood, controlled trials of their use in treating manic symptoms disproportionate or incongruent to the patient’s in MS in particular. underlying feelings or to external triggers. Uncontrollable crying seems to be more common than laughing. Never- Apart from bipolar depression, individual symptoms theless, the patient’s insight is spared. This emotional of euphoria and PBA have also been reported in MS incontinence is perceived as ego-dystonic by the patient, patients. causes significant social embarrassment and urges the patient to voluntarily control it, though inadequately. What makes it superficially similar to bipolar disorder Euphoria is that such an emotional lability (though the latter Euphoria can be defined as ‘a fixed state of well being, tends to be regarded as a distinct entity) could be despite the presence of considerable physical morbidity’. misinterpreted as being a manifestation of a mixed mood This definition points out the lack of insight regarding episode or even a rapid-cycling bipolar disorder. the severity of the illness, which results in an elevated However, what mainly distinguishes the two entities is affect and an overoptimistic attitude. Compared with the disassociation of the affect and the underlying mood, hypomania or mania, euphoria looks similar concerning resulting in emotional expression incongruent or dispro- the presence of elevated affect but is distinguished by the portionate to the underlying emotional experience or to lack of hyperactivity, pressured speech, racing thoughts, the external stimuli, the shorter duration of such episodes grandiosity ideas and so on. compared with a more sustained underlying emotional state in mood episodes and, finally, the fact that such an There are no studies investigating the prevalence rate of outburst is ego-dystonic and causes significant distress to this entity in the general population. The estimates of the patient, who feels unable to control it. Moreover, PBA euphoria’s prevalence in MS are declining throughout can also be distinguished from a bipolar disorder mood time. Initially, in the 1920s, euphoria had been episode by the lack of specific symptoms and signs such overestimated – reported to be found in over two-thirds as hyperactivity, poor sleep, pressured speech and so on. of MS patients and regarded as the specific psychopatho- However, although distinct entities, PBA and a mood logical trait of MS. In 1990, Rabins [20] summarized the disorder – particularly depression – could also coexist, at mean prevalence rate of euphoria in MS to 25% among a rate as high as 50% [24]. the studies they investigated. Later on, Diaz-Olavarieta et al. [7] reported that euphoria was present in 13% of There are no studies concerning the prevalence rate of 44 MS patients studied compared with 0% of 25 control PBA in the general population. PBA is not exclusively individuals [7]. found in MS but can also be found in other neurological disorders such as amyotrophic lateral sclerosis, the Regarding the stage of the illness, euphoria seems to cerebellar type of multiple system atrophy, cerebro- occur in the later stages of MS [21]. It is reported to be vascular disease, Parkinson’s disease, traumatic brain associated with significant cognitive impairment, heavy injury, dementia, migraine, progressive supranuclear total load of brain demyelinating lesions, especially in the palsy and mass lesions, particularly in the cerebellopon- frontal lobe, significant cerebral atrophy and ventricular tine junction [25]. Haussleiter et al. [26] summarized enlargement [20,22] and reduced global gray matter PBA prevalence rate in MS to a mean of 10%. However, volume [23]. most recently, Strowd et al. [27] reported a prevalence rate ranging from 7 to 52% and a mean occurrence of one Euphoria mainly remains untreated, as it does not such episode every 2 days (3.6 days per week) [27]. PBA cause any distress to patients that would make them in MS is generally regarded to occur in the chronic– seek help. progressive type of MS and seems to be associated with Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
4.
Bipolar disorder in
multiple sclerosis Iacovides and Andreoulakis 339 severe disability, cognitive impairment and longer depression, suggests that PBA and depression are distinct disease duration, whereas no correlation has been found entities, although they often co-occur in MS patients [46]. with MS relapses [28]. Treatment with anticonvulsants such as lamotrigine has also been reported [47]. A novel treatment [dextro- Concerning the pathophysiology of PBA, a three- methorphan–quinidine (DMQ)] with a combination structured model was originally proposed: the cortex of dextromethorphan (DM), a s-1 receptor agonist inhi- being the controller, the bulbar nuclei as the physiologi- biting glutaminergic signaling and quinidine (Q), used cal effector and the hypothalamus in an integrating role as a CYP2D6 inhibitor in order to increase plasma levels [29]. The role of the prefrontal cortex in PBA pathophy- of dextromethorphan, which is vulnerable to extensive siology has been pointed out, based on the poorer metabolism by CYP2D6, has also been pointed out as performance of the MS patients group in specific tasks beneficial recently [34]. According to Wortzel et al. [36], which are regarded as being mediated by this region and the SSRIs are the recommended first-line pharma- the fact that this region is regarded as taking part in cotherapy for PBA. When SSRIs turn out to be not well keeping emotional expression compatible with social tolerated or ineffective, alternative treatments such as contexts [30]. Findings concerning not only the interrup- those mentioned above should be considered. However, tion of cortical inhibition of postulated laughing and Strowd et al. [27], based on the lack of large well con- crying centers in the upper brainstem but also the trolled clinical trials concerning the treatment of PBA, dysfunction resulting from lesions in the cerebro- posed the issue that antidepressants might be helpful ponto-cerebellar pathways, which are thought to be in treating coexisting depression, but not sufficient in involved in appropriate adjustment to social and treating PBA, raising implications for a better tailored cognitive context, provided a further link of PBA to pharmacological treatment of PBA. the cerebellum [31]. Moreover, the case of a 46-year- old woman, suffering from idiopathic Parkinson’s disease, who exhibited pseudobulbar crying induced by stimu- Conclusion lation in the region of the subthalamic nucleus was Despite the fact that the coexistence of psychopatho- reported [32]. Recent studies implicate widely dispersed logical symptoms in MS is well established, most of lesions including bilateral medial inferior frontal, bilateral the affected patients are still underdiagnosed and under- inferior parietal and brainstem regions and also basal treated. A shift concerning the clinical suspicion and ganglia [33,34]. Summarizing, Parvizi et al. [35] in the the treatment of psychiatric disorders in MS seems most recent and thorough review on the subject con- fundamental, as they can have a considerable impact cluded that basis pontis is the only identified anatomical on the patients’ quality of life and also on the MS site in which a discrete lesion can cause PBA. Other treatment adherence. anatomical sites also implicated in the pathophysiology of PBA are the prefrontal cortex and anterior cingulate, the In the reverse direction, because psychopathological internal capsula, the thalamus and subthalamic nucleus, symptoms and signs might represent, though not very the cerebral peduncles and the cerebellum [35]. often, the first clinical manifestations of MS – even in the absence of neurological clinical findings, or in the pre- Regarding the neurochemistry of PBA, neurotransmitters sence of ‘mild’ ones – MS should be also be considered such as serotonin, dopamine, noradrenaline and gluta- in the differential diagnosis in some people presenting mate appear to be implicated in the pathophysiology of with such symptoms as euphoria, pseudobulbar affect or PBA. However, although the role of serotonergic systems even a manic episode with atypical features, cognitive seems better established, the role of nonserotonergic impairment, peripheral physical findings or a lack of systems still remains speculative [36]. response to the standard bipolar disorder treatment. Regarding the treatment of PBA, several types of Acknowledgements psychotropic drugs have been applied. Amantadine and The authors have no conflicts of interest to declare. levodopa [37], tricyclic antidepressants (TCAs) such as amitriptyline [38] and nortriptyline [24], selective sero- tonin reuptake inhibitors (SSRIs) such as fluoxetine [39], References and recommended reading citalopram [40] and sertraline [41], serotonin–norepi- Papers of particular interest, published within the annual period of review, have been highlighted as: nephrine reuptake inhibitors (SNRIs) such as duloxetine of special interest [42], venlafaxine [43] and revoxetine [44] and other of outstanding interest Additional references related to this topic can also be found in the Current antidepressants such as mirtazapine [45]. The response World Literature section in this issue (p. 363). to the treatment with antidepressants has been reported 1 Fermo SL, Barone R, Patti F, et al. Outcome of psychiatric symptoms to be quite rapid, within a few (often 1–3) days. Such presenting at onset of multiple sclerosis: a retrospective study. Mult Scler a difference in the response rate, compared with 2010; 16:742–748. Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.
5.
340 Medical comorbidity
2 Patten SB, Beck CA, Williams JVA, et al. Major depression in multiple sclerosis. 25 Parvizi J, Archiniegas DB, Bernardini GL, et al. Diagnosis and management A population-based perspective. Neurology 2003; 61:1524–1527. of pathological laughter and crying. Mayo Clin Proc 2006; 81:1482– 1486. 3 Perala J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007; 26 Haussleiter IS, Brune M, Juckel G. Psychopathology in multiple sclerosis: 64:19–28. diagnosis, prevalence and treatment. Therapeutic Advances in Neurological Disorders 2009; 2:13–29. 4 Schiffer RB, Wineman NM, Weikamp LR. Association between affective bipolar disorder and multiple sclerosis. Am J Psychiatry 1986; 143:94–95. 27 Strowd RE, Cartwright MS, Okun MS, et al. Pseudobulbar affect: prevalence and quality of life impact in movement disorders. J Neurol 2010; 257:1382– 5 Joffe RT, Lippert GP, Gray TA, et al. Mood disorder and multiple sclerosis. 1387. Arch Neurol 1987; 44:376–378. 28 Feinstein A, O’Connor P, Gray T, Feinstein KJ. The prevalence and neuro- 6 Minden SL, Schiffer RB. Affective disorders in multiple sclerosis. Review and behavioral correlates of pathological laughing and crying in multiple sclerosis. recommendations for clinical research. Arch Neurol 1990; 47:98–104. Arch Neurol 1997; 54:1116–1121. 7 Diaz-Olavarrieta C, Cummings JL, Velazquez J, Garcia de la Cadena C. 29 Black DW. Pathological laughter: a review of the literature. J Nerv Ment Dis Neuropsychiatric manifestations of multiple sclerosis. J Neuropsychiatry Clin 1982; 170:67–71. Neurosci 1999; 11:51–57. 30 Feinstein A, O’Connor P, Gray T, Feinstein KJ. Pathological laughing and 8 Edwards LJ, Constantinescu CS. A prospective study of conditions asso- crying in multiple sclerosis: a preliminary report suggesting a role for the ciated with multiple sclerosis in a cohort of 658 consecutive outpatients prefrontal cortex. Mult Scler 1999; 5:69–73. attending a multiple sclerosis clinic. Mult Scler 2004; 10:575–581. 31 Parvizi J, Anderson SW, Martin CO, et al. Pathological laughter and crying: a 9 Marrie RS, Horwitz R, Cutter G, et al. The burden of medical comorbidity in link to the cerebellum. Brain 2001; 124:1708–1719. multiple sclerosis: frequent, underdiagnosed and undertreated. Mult Scler 2009; 15:385–392. 32 Okun MS, Raju DJ, Walter BL, et al. Pseudobulbar crying induced by stimulation in the region of the subthalamic nucleus. J Neurol Neurosurg 10 Jefferies K. The neuropsychiatry of multiple sclerosis. Adv Psychiatric Treat Psychiatry 2004; 75:921–923. 2006; 12:214–220. 33 Ghaffar O, Chamelian L, Feinstein A. Neuroanatomy of pseudobulbar 11 Brown ES. Effects of glucocorticoids on mood, memory and the hippocampus. affect: a quantitative MRI study in multiple sclerosis. J Neurol 2008; 255: Treatment and preventive therapy. Ann NY Acad Sci 2009; 1179:41–55. 406–412. 12 Fragoso YD, Comini Frota ER, Lopes JS, et al. Severe depression, suicide 34 Panitch HS, Thisted RA, Smith RA, et al. Randomized, controlled trial of attempts and ideation during the use of interferon beta by patients with dextromethorphan/quinidine for pseudobulbar affect in multiple sclerosis. Ann multiple sclerosis. Clin Neuropharmacol 2010; 33:312–316. Neurol 2006; 59:780–787. This article reports 11 cases of severe mood effect and suicidal ideation in patients treated with INF-b. 35 Parvizi J, Coburn KL, Shillcutt SD, et al. Neuroanatomy of pathological laughing and crying: A report of the American Neuropsychiatric Association 13 Feinstein A, du Boulay G, Ron MA. Psychotic illness in multiple sclerosis. A Committee on Research. J Neuropsychiatry Clin Neurosci 2009; 21:75–87. clinical and magnetic resonance study. Br J Psychiatry 1992; 161:680–685. 36 Wortzel HS, Oster TJ, Anderson CA, Archiniegas DB. Pathological laughing 14 Young CR, Weiss EL, Bowers MB Jr, Mazure CM. The differential diagnosis and crying: epidemiology, pathophysiology and treatment. CNS Drugs 2008; of multiple sclerosis and bipolar disorder. J Clin Psychiatry 1997; 58:123. 22:531–545. 15 Fazzito MM, Jordy SS, Tilbery CP. Psychiatric disorders in multiple sclerosis 37 Udaka F, Yamao S, Nagata H, et al. Pathologic laughing and crying treated patients. Arq Neuropsiquiatr 2009; 67:664–667. with levodopa. Arch Neurol 1984; 41:1095–1096. 16 Schiffer RB, Weitkamp LR, Wineman M, Guttormsen S. Multiple sclerosis and 38 Schiffer RB, Herndon RM, Rudick RA. Treatment of pathologic laughing and affective disorder. Family history, sex and HLA-DR antigens. Arch Neurol weeping with amitriptyline. New Engl J Med 1985; 312:1480–1482. 1988; 45:1345–1348. 39 Seliger GM, Hornstein A, Flax J, et al. Fluoxetine improves emotional incon- 17 Modrego PJ, Ferrandez J. Familial multiple sclerosis with repetitive relapses of tinence. Brain Inj 1992; 6:267–270. manic psychosis in two patients (mother and daughter). Behav Neurol 2000; 12:175–179. 40 Andersen G, Vestergaard K, Riis JO. Citalopram for poststroke pathological crying. Lancet 1993; 342:837–839. 18 Bozikas VP, Anagnostouli MC, Petrikis P, et al. Familial bipolar disorder and multiple sclerosis: a three-generation HLA family study. Prog Neuropharmacol 41 Burns A, Russel E, Stratton-Powell H, et al. Sertraline in stroke-associated Biol Psychiatry 2003; 27:835–839. lability of mood. Int J Geriatr Psychiatry 1999; 14:681–685. 19 Ameis SH, Feinstein A. Treatment of neuropsychiatric conditions associated 42 Ferentinos P, Paparrigopoulos T, Rentzos M, Evdokimidis I. Duloxetine for with multiple sclerosis. Expert Rev Neurotherapeutics 2006; 6:1555–1567. pathological laughing and crying. Int J Neuropsychopharmacol 2009; 12:1429–1430. 20 Rabins PV. Euphoria in multiple sclerosis. In: Rao SM, editor. Neurobehavioral aspects of multiple sclerosis. New York: Oxford University Press; 1990. pp. 43 Smith AG, Montealegre-Orjuella M, Douglas JE, Jenkins EA. Venlafaxine for 180–185. pathological crying after stroke. J Clin Psychiatry 2003; 64:731–732. 21 Benedict RH, Bobholtz JH. Multiple sclerosis. Semin Neurol 2007; 27:78– 44 Moller M, Andersen G. Inhibition of selective noradrenergic reuptake as 85. treatment of pathological laughter. J Clin Psychopharmacol 2007; 27: 108–110. 22 Ron MA, Callanan MM, Warrington EK. Cognitive abnormalities in multiple sclerosis: a psychometric and MRI study. Psychol Med 1991; 21:59–68. 45 Kim SW, Shin IS, Kim JM, et al. Mirtazapine treatment for pathological laughing and crying after stroke. Clin Neuropharmacol 2005; 28:249–251. 23 Sanfilipo MP, Benedict RH, Weinstock-Guttman B, Bakshi R. Gray and white matter brain atrophy and neuropsychological impairment in multiple sclerosis. 46 Nahas Z, Arlinghaus KA, Kotrla KJ, et al. Rapid response of emotional Neurology 2006; 66:685–692. incontinence to selective serotonin reuptake inhibitors. J Neuropsychiatry Clin Neurosci 1998; 10:453–455. 24 Robinson RG, Parikh RM, Lipsey JR, et al. Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind 47 Ramasubbu R. Lamotrigine treatment for poststroke pathological laughing treatment study. Am J Psychiatry 1993; 150:286–293. and crying. Clin Neuropharmacol 2003; 26:233–235. Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.