[A clinical study of psychopathology in systemic lupus erythematosus]

Thirty patients (24 inpatients and 6 outpatients) with a clinical diagnosis of SLE were examined between September 1, 1998 and August 1, 1999 in the rheumatology clinic of Jichi Medical School Hospital. All of these patients fulfilled the 1982 revised criteria of the American Rheumatism Association for the classification of SLE and had some psychiatric manifestations (psychiatric SLE; P-SLE group). Mean patient age was 38.6 +/- 13.0, and there were 5 males and 25 females. When classified into 5 subgroups according to the most prominent symptoms, the distribution was as follows: consciousness disturbance group: 6 (20%), schizophrenia-like group: 5 (16.7%), mood disorder group: 7 (23.3%), neurosis-like group: 10 (33.3%), and convulsive disorder group: 2 (6.7%). Among all 37 psychiatric episodes, symptoms appeared in 37.8% of cases during the acute phase of SLE (during onset or recurrence) and in 62.9% during the chronic phase (during remission). The profile of the P-SLE group showed that the psychiatric symptoms of the SLE patients were milder and more chronic than those described in previous reports. To begin to comprehend the psychopathology of SLE, we put forward the concept of "Psychiatric basal state" and "psychiatric conjugated state". The former is considered a direct reflection of the acute-phase SLE process on mental condition. It is defined clinically as psychiatric symptoms that parallel the activity of SLE and respond well to steroid therapy. The latter include all other psychiatric problems in which one cannot rule out the effects of pharmacological, somatic, personality, and environmental effects on psychiatric symptoms. Only 3 patients in the P-SLE group fulfilled the criteria for the "psychiatric basal state". All three patients belonged to the consciousness disturbance group, whose clinical features were defined as slight clouding of consciousness, so-called "Amentia" in the sense of the German terminology. The clinical profile of this state is: 1. the patients are young (about 16 years old), 2. the onset of psychiatric symptoms is within 5 years after the onset of SLE, 3. confusion and disorientation are the most characteristic features, and 4. the clinical course of this state is almost 2 months. The experience structure of the "psychiatric basal state" consists of: 1. difficulty in selecting and holding a topic in cognition, 2. confusion and emotional instability as the basal mood, and 3. primitive and floating forms of delusions and hallucinations. Using this concept of the "psychiatric basal state" as a clue, we can hypothesize the continuity of diverse psychiatric symptoms in SLE. The "proper process of SLE (Harada)" has a disintegrating effect on the "ego" and it allows various psychopathological phenomena to emerge in the experience field. Against this background, additional factors, such as secondary organ damage, personality structure, and social environment, induce organization of the "psychiatric conjugated state".