Psychiatric event in multiple sclerosis: could it be the tip of the iceberg?

Multiple sclerosis (MS) is a chronic progressive inflammatory disease of the central nervous system. Psychiatric comorbidities are highly prevalent in patients with MS, and can have drastic impact on quality of life and interpersonal relationships. Despite this high prevalence, whether psychiatric manifestations may represent the first signs of MS is still debatable. This constitutes an important issue, since early diagnosis of "psychiatric-onset MS" would result in prompt management, which usually ameliorates long-term prognosis. Here, we discuss clinical and radiological hints that suggest a diagnosis of psychiatric-onset MS. Briefly, this entity should be considered in healthy patients presenting with late-onset psychiatric symptoms, with or without cognitive decline, and with negative family history of psychiatric diseases. A thorough neurological exam is crucial to detect any subtle neurological signs. Brain magnetic resonance imaging is recommended to rule out frontotemporal lesions that might explain the clinical picture. Poor response to standard psychiatric treatments provides additional evidence for the diagnosis of an organic disease (e.g., MS). Combining psychopharmaceuticals with intravenous corticosteroids would result in good outcomes, but patients should be monitored carefully for possible psychiatric exacerbation, a common side effect of steroids.