Stiff-Person Syndrome and Psychiatric Comorbidities: A Systematic Review

BACKGROUND

Stiff-person syndrome (SPS) is a rare autoimmune neurologic disease characterized by painful rigidity and muscle spasms. Patients with SPS may present with psychiatric symptoms, and little is known about the presence of psychiatric comorbidities.

OBJECTIVE

The objective of this study was to provide an overview of the association between SPS and psychiatric illnesses.

METHODS

The protocol is registered in PROSPERO (Registration ID CRD42020159354). Peer-reviewed articles on adults with SPS and psychiatric comorbidities published before May 26, 2020, were selected by 2 independent reviewers. Qualitative summary data and relative risk of psychiatric disorders in patients with SPS compared with the general population and multiple sclerosis were calculated.

RESULTS

After screening 909 articles, 52 full texts were assessed for eligibility and 27 were ultimately included, 5 of which were selected for quantitative analysis. Although limited by small sample sizes leading to large confidence intervals, the relative risk of any psychiatric comorbidity in SPS was higher than that of the general population, ranging from estimates of 6.09 (95% confidence interval: 4.09, 9.08) to 11.25 (95% confidence interval: 3.27, 38.66). There was no statistically significant difference in the risk of any psychiatric comorbidity between SPS and multiple sclerosis. The review also highlighted delays in SPS diagnosis, often related to misattribution of symptoms as being solely secondary to a psychiatric cause.

CONCLUSIONS

The higher risk of psychiatric comorbidities emphasizes the important role of psychiatrists in recognizing the symptoms of SPS to reach timely diagnosis and treatment. The presence of psychiatric symptoms should support rather than delay the diagnosis of SPS.

Jaw Dystonia and Reversible Basal Ganglia Changes as an Initial Presentation of Systemic Lupus Erythematosus

Dystonia as a manifestation of neuropsychiatric lupus erythematosus (NPSLE) is uncommon. We report a 25-year-old woman who experienced progressive confusion, reduced speech, and difficulty opening her mouth approximately 2 weeks after development of a facial rash. Brain imaging showed bilateral, symmetric signal abnormalities within the basal ganglia and subcortical white matter. Despite treatment with high-dose steroids, she continued to have difficulty speaking with evidence of jaw dystonia on examination. Jaw dystonia rapidly improved with the initiation of levodopa. Repeat evaluation 3 months later exhibited the absence of jaw dystonia and near resolution of the imaging abnormalities. Our patient demonstrated a unique presentation with jaw dystonia refractory to traditional treatment for NPSLE. Such a presentation likely represents a severe variant of NPSLE requiring both immunosuppressive and symptomatic therapies.

Movement disorders in systemic lupus erythematosus and the antiphospholipid syndrome

Movement disorders (MDs), particularly chorea, may be the presenting neurological complication of systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS), but the association is not often initially recognized. Current evidence suggests an autoimmune mechanism related to antiphospholipid antibodies in these two conditions, although the antigenic target within the central nervous system has not yet been identified. Based on a comprehensive review of the literature, this article summarizes the current knowledge on MDs in SLE and APS. A high index of suspicion is required to make an early diagnosis and initiate appropriate treatment to provide symptomatic relief and to prevent other systemic complications related to the autoimmune process.

Movement disorders in autoimmune diseases

Movement disorders have been known to be associated with a variety of autoimmune diseases, including Sydenham's chorea, pediatric autoimmune neuropsychiatric disorders associated with streptococcus, systemic lupus erythematosus, antiphospholipid syndrome, gluten sensitivity, paraneoplastic and autoimmune encephalopathies. Tremors, dystonia, chorea, ballism, myoclonus, parkinsonism, and ataxia may be the initial and even the only presentation of these autoimmune diseases. Although antibodies directed against various cellular components of the central nervous system have been implicated, the pathogenic mechanisms of these autoimmune movement disorders have not yet been fully elucidated. Clinical recognition of these autoimmune movement disorders is critically important as many improve with immunotherapy or dietary modifications, particularly when diagnosed early. We discuss here the clinical features, pathogenic mechanisms, and treatments of movement disorders associated with autoimmune diseases, based on our own experience and on a systematic review of the literature.