Hello everyone! I found a realy informative video on what Drs. look for on a MRI when diagnosing MS. The web address is mscare.org/cmsc/index/php on the side of the page just click on the topic. I hope this might answer some questions !
Thank you for posting this, it was really informative for me.
As a limbolander with an abnormal, but atypical for MS, MRI, this helped me understand why my neurologist is so keen on taking more time to wait and see what happens clinically.
I was surprised to see this doctor's study results showing that 70% of patients with white spots at this university MS clinic were not diagnosed with MS.
I think I'll go look up that paper, because I want to know how many went undiagnosed as opposed to having another definitive diagnosis...because I know I don't have an alternative diagnosis. And I wonder how many eventually do end up with an MS diagnosis...
OK, I found the text of the entire article here:
I feel a little remiss in posting it because it appears that a good number of those not diagnosed with MS, or possible MS, receive a diagnosis of a psychiatric disorder. Which, in light of recent discussions here, is a bit disheartening.
This study, mentioned in the podcast, was a study of patients being referred to a University MS Center with abnormal MRI results. They all saw the same health care professional at the MS Center, so that seems like it could be a bias to me.
"Of 281 patients referred to evaluate the possibility of MS, after initial review 33% were diagnosed with MS or possible MS by the McDonald criteria. The rest had other neurological conditions (31.5%), probable psychiatric diagnoses (22.5%), or no clear diagnosis was made (12.5%)."
There is a table in the article that shows all of the alternative diagnoses that were made.
Hello back again, I just typed in mscare.org in the address bar this time & it brought up the main page then go to top 10 things(icon on list ar R side of page) then a video screen will come up but its only the sound (at least on my computer) underneath there should be different subjects then click on the one for the slide show & when that came up I had to click out of the previous one so that I didn't have 2 playing at once. I hope I didn't make this too complicated but I found it very informative.
Regarding that Arch Neuro paper, the period the paper covers is 30 months. As many folks here can tell you, what gets dismissed as psychiatric one year turns out to be something "real" a couple of years down the road. This is a retrospective study with no long-term follow-up...or any follow-up, actually. They looked at what the patient had going on in the referral, looked at what dx was made following a single office visit to their MS clinic, and that was it. All evaluations were done by a single practitioner. Once. They were done using the McDonald criteria from the "old" version of those criteria (this paper covers patients referred from 2001 to 2003).
In other words, one neuro examined every patient, one time, and made a dx, which they used in this retrospective analysis.
And if I'm interpreting correctly, that "diagnosis" of "unidentified psychiatric problems" happened at that single visit. In other words, that single neurologist who examined all of the patients decided that 63 of those who did not have MS had "somatoform disorder, mood disorder, anxiety disorder, or some combination of these" as the cause of their symptoms. Strangely enough, there is no mention of "psychiatric disorders" among the population of 93 patients who DID receive an MS dx. That's rather odd, don't you think, given (a) the rates of such disorders in the general population and (b) the rates of specific disorders related to MS in the MS population?
I note, finally, that the paper says "probable" psychiatric diagnoses. That means no one followed up on it, no one confirmed. It's simply the opinion of that single practitioner from that single appt. We all know exactly what that is worth.
One of the problems with retrospective studies with no follow-up. I wonder what a retrospective study of these same patients, especially that group of 63, would reveal about their diagnoses now that six years have passed?
I am answering this post before looking at the "studies" in question.
Bio - I also find this kind of "science" disheartening. We have seen several studies like this purporting to "find" that upwards of three quarters of the people presenting to "an MS Clinic" are actually suffering from a psychiatric disorder. They all point back to some study done several years ago that "validates" this, especially the diagnosis of somatoform disorder. I have repeatedly rasied the questions that Bio raises. What kind of followup determined this? Was it careful evaluation by a psychiatrist? Was it the continuing lack of a diagnosis? Did psychiatric care relieve the symptoms? If even part of the validation was that the person did not have a neurologic diagnosis, then the study is patently bogus. It is hubris on the part of the neurology community to believe that, if they can't find a diagnosis by 30 (or 60!) months, then the patient must indeed be a psych case.
All of us are aware of the situation in which people are dismissed (that's a whole 'nother discussion) as "head cases" and no further effort is made to look at them. In my case if someone had followed up 24 months, their assessment would have been validated.
Bio brings up the enormously important fact that people with MS may have psychiatric disease called by the MS itself, especially depression and anxiety. How ironic to have the diagnosis dismissed by a condition caused by the disease they are missing.
I have seen multiple publications by a group out of Wisconsin that pushes this theory with abandon. There was an article, fraudulently called "The Differential Diagnosis of Multiple Sclerosis" published online The Neurologist Journal by this group in 2007. They claimed that only a "rare" person with one of their "red flags" actually had MS. The article is only partially about all the things that can look like MS. It has a hidden agenda of telling general neurologists that 72% of the patients coming to see them really have no real neuro disease. The bulk of this article is really about somatoform disorder and how hard it is to treat. (Possibly because it is too often used and causes the doctor to ignore real neurologic signs and symptoms, perhaps?)
I will be interested in seeing if this group is involved in this article. I become so angry reading this article that I am immobilized. This group is close in geographical location to the Mayo in Rochester and I wonder if that is a factor.
Here are the "Red Flags" that should make a doctor discount MS. They say in words that these are things that should make a doc think extra hard in making the diagnosis, but then throughout the article they emphasize that "only a rare person with one of these flags actually has MS." It is this subtle bias that changes the red flags from alerts to be careful to actually dismissing the diagnosis. I have reprinted their red flags and my comments.
I. Red flags in the history and examination
1. Normal neurologic examination
(if the exam is very thorough, done serially and expertly done this should be a caution to look further)
2. Abnormality in a single location; no dissemination in space
(WTF!!! MS does not always present multifocally. My didn't. I had left leg weakness only. The patient MUST be followed serially!)
3. Progressive from onset; no dissemination in time
(??!!!! 15% of people with MS have PPMS. There is nothing in the article that specifies that they are talking only about RRMS!! So they are dismissing outright 1 in 7 people who actually have the disease!!)
4. Onset in childhood or over age 50
(This is tragic. These age groups comprise at least 5% of MS patients. We are going to dismiss 1 in 20??? That is sloppy diagnostic work!)
5. Psychiatric disease present, ie, another explanation for findings
(I could go on-and-on about this, but let's just be reminded that 50% of people with MS will suffer depression at some point in their disease course and that a major depressive episode within two years of diagnosis is considered to have been one of the initial attacks)
6. Systemic disease present, ie, another explanation for findings
(This is legitimate. In the presence of a systemic disease like lupus, diabetes, HIV, Lyme, the diagnosis of MS should be withheld until there is good evidence that the problems are not caused by that other disease.)
7. Prominent family history; consider genetic disease
(Uhhh......MS is considered to be partially a genetic disease. A strong family history should sway they doctor in favor of looking at MS! What are these dimwits thinking about???)
8. Gray matter symptoms: dementia, seizures, aphasia
(Uhhhhh......uhh......MS is a gray matter disease - with gray matter symptoms. I'll agree that overt dementia is reported to be rare, but seizures, aphasia, dysgraphia, cognitive problems, memory problems are seen in up to 90% of people with MS.)
9. Peripheral symptoms: peripheral neuropathy, fasciculations
(This should be a flag only. If peripheral symptoms are the only ones found, than this is not MS)
10. Acute hemiparesis
(Actually this is well-reported)
11. Lack of typical symptoms: no optic neuritis, bladder problems, Lhermitte sign, sensory level, etc
(Basically these guys are saying that if a patient is not classic, it is not MS.)
12. Prolonged benign course, ie, diagnosis made years ago with few
(Re-evaluation is appropriate)
II. Red flags in the laboratory tests
1. Normal or atypical MRI
(We have discussed this. The "Atypical" really frosts me)
2. Normal CSF
(When did these guys study?? There is no need to have a positive CSF!)
3. Abnormal blood tests, though many are false positives
(Isn't this a little vague?)
To everyone who wonders why it can be hard to get a diagnosis, these are among the reasons. This stuff is actively being taught in the Continuing Education stuff and probably in the medical schools, residencies and fellowships. There is another topic that I want to bring up some time and that is the growing theory that MS is highly underdiagnosed.
now I'm going to see if this article from "archneur.ama-assn" involves these yahoos from Wisconsin.
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