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Steiner J, Vasilevska V. Inflammation und psychische Erkrankung. INFO NEUROLOGIE + PSYCHIATRIE 2021. [PMCID: PMC8601778 DOI: 10.1007/s15005-021-2121-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Johann Steiner
- Universitätsklinikum Magdeburg, Klinik für Psychiatrie und Psychotherapie & Labor für Translationale Psychiatrie, Leipziger Str. 44, 39120 Magdeburg, Germany
| | - Veronika Vasilevska
- Universitätsklinikum Magdeburg, Klinik für Psychiatrie und Psychotherapie & Labor für Translationale Psychiatrie, Leipziger Str. 44, 39120 Magdeburg, Germany
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Weiss D, Kertzscher L, Degering M, Wozniak D, Kluge M. Anti-NMDA receptor encephalitis and overlapping demyelinating disorder in a 20-year old female with borderline personality disorder: proposal of a diagnostic and therapeutic algorithm for autoimmune encephalitis in psychiatric patients "case report". BMC Psychiatry 2021; 21:355. [PMID: 34266413 PMCID: PMC8280600 DOI: 10.1186/s12888-021-03269-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/09/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anti-NMDA receptor encephalitis (NMDAR-E) is an autoimmune encephalitis (AE) mainly affecting young females. It typically presents with isolated psychiatric symptoms (e.g. depressed mood) at first and neurological abnormalities (e.g. seizures, movement disorders) only develop later. Thus, there is a high risk of overlooking NMDAR-E in patients with preexisting psychiatric illness due to symptom overlap in the prodromal period of the disease when treatment is most effective. Although rare, concomitant or sequential development of a demyelinating disorder is increasingly recognized as an associated disease entity (overlap syndrome), with immediate diagnostic and therapeutic implications. CASE PRESENTATION We report a patient with a borderline personality disorder (BPD), which developed NMDAR-E and an overlapping demyelinating disorder with anti-Myelin oligodendrocyte glycoprotein (MOG) -IgG positivity. The initial clinical presentation with predominantly affective symptoms (e.g. mood lability, anxiety, depressed mood) lead us to suspect an exacerbation of the BPD at first. However, acute changes in premorbid behavior, newly developed psychotic symptoms and memory deficits lead us to the correct diagnosis of an AE, which was further complicated by the development of a demyelinating disorder. As a result of impaired illness awareness and psychosis, diagnostic and treatment was difficult to carry out. The symptoms completely remitted after treatment with methylprednisolone 1 g daily for 5 days and 5 cycles of plasma exchange. CONCLUSIONS Continuous awareness for neuropsychiatric clinical warning signs in patients with a pre-diagnosed psychiatric disorder is important for a timely diagnosis. Therefore, we believe that the diagnostic and therapeutic algorithm provided here, for the first time specifically addressing patients with preexisting psychiatric illness and integrating overlap syndromes, can be a useful tool. Moreover, in order to timely perform diagnostics and treatment, judicial approval should be obtained rapidly.
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Affiliation(s)
- David Weiss
- Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany. .,Department of Neurology, Rostock University Medical Center, Germany; Gehlsheimer Straße 20, 18147, Rostock, Germany.
| | - Lisa Kertzscher
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Magdalena Degering
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - David Wozniak
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Michael Kluge
- grid.9647.c0000 0004 7669 9786Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
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Vasilevska V, Guest PC, Schlaaff K, Incesoy EI, Prüss H, Steiner J. Potential Cross-Links of Inflammation With Schizophreniform and Affective Symptoms: A Review and Outlook on Autoimmune Encephalitis and COVID-19. Front Psychiatry 2021; 12:729868. [PMID: 34650454 PMCID: PMC8507462 DOI: 10.3389/fpsyt.2021.729868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/23/2021] [Indexed: 01/08/2023] Open
Abstract
Based on current implications of the SARS-CoV-2 pandemic with regards to mental health, we show that biological links exist between inflammation and mental illness in addition to psychoreactive effects. We describe key principles of the biological interaction of the immune system and the mind, as well as the possible routes of viral entry into the brain. In addition, we provide a stepwise scheme for the diagnosis and therapy of autoimmune-encephalitis with schizophrenia-like symptomatology as a general guide for clinical practice and in the specialized scenario of infections, such as those caused by the SARS-CoV-2 virus.
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Affiliation(s)
- Veronika Vasilevska
- Department of Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Paul C Guest
- Laboratory of Neuroproteomics, Department of Biochemistry and Tissue Biology, University of Campinas, Campinas, Brazil
| | - Konstantin Schlaaff
- Department of Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Enise I Incesoy
- Department of Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,German Center for Neurodegenerative Diseases, Magdeburg, Germany.,Institute of Cognitive Neurology and Dementia Research, Otto-von-Guericke-University, Magdeburg, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases, Berlin, Germany.,Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Steiner
- Department of Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Laboratory of Translational Psychiatry, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany.,German Center for Mental Health, Center for Intervention and Research on Adaptive and Maladaptive Brain Circuits Underlying Mental Health, Magdeburg, Germany
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Steiner J, Prüss H, Köhler S, Frodl T, Hasan A, Falkai P. Autoimmune encephalitis with psychosis: Warning signs, step-by-step diagnostics and treatment. World J Biol Psychiatry 2020; 21:241-254. [PMID: 30513253 DOI: 10.1080/15622975.2018.1555376] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objectives: Despite intensive research, schizophrenia and schizoaffective disorders continue to be theoretical constructs that describe clinical syndromes and no pathophysiologically defined diseases. Moreover, there are no clear biomarkers at hand. Therefore, these diagnoses are still set up based on clinical ICD-10/DSM-5 criteria and the exclusion of alcohol-/drug-associated, systemic or other brain organic causes.Methods: Recently, autoimmune encephalitis with psychotic symptoms caused by specific antineuronal antibodies has been identified as a rare, but potentially treatable differential diagnosis. However, these inflammatory brain diseases are not reliably detected by our current routine diagnostic workup in psychiatry. This qualitative review provides structured diagnostic and therapeutic support for clinical practice.Results: Disturbances of consciousness and orientation, catatonia, speech dysfunction, focal neurological signs, epileptic seizures/EEG abnormalities or autonomic dysfunction are warning signs in psychiatric patients which should always induce cerebrospinal fluid analysis with determination of antineuronal autoantibodies. Currently established immunotherapy strategies are summarised, taking into account international expert advice.Conclusions: Guided by clinical warning signs, our qualitative review enables rapid and reliable diagnosis of definite autoimmune encephalitis. This is of high relevance for the affected individuals, since early and sufficiently intense immunotherapy often leads to a good prognosis despite severe illness.
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Affiliation(s)
- Johann Steiner
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Harald Prüss
- German Center for Neurodegenerative Diseases (DZNE) Berlin and Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Köhler
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy, Otto-von-Guericke University of Magdeburg, Magdeburg, Germany.,Center for Behavioral Brain Sciences, Magdeburg, Germany
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
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5
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[Autoimmune encephalitis-Diagnostic and therapeutic decision tree from a psychiatric, neurological and ethico-legal point of view : Approach in cases of lack of ability to give consent and permissibility of compulsory treatment]. DER NERVENARZT 2020; 91:122-130. [PMID: 31538211 DOI: 10.1007/s00115-019-00802-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with severe mental illnesses who are unable to give consent often need a rapid diagnosis and treatment but due to the psychiatric symptoms they often reject such measures. In the routine practice, the question arises to what extent the patient's expressed will should dictate the treatment steps and whether a decision against the patient's will is medically reasonable, ethically justifiable or even demanded and legally permissible. Autoimmune encephalitides, such as N‑methyl-D-aspartate receptor (NMDAR) encephalitis, have recently become important differential diagnoses due to their relative frequency, manifold symptoms and good treatability, as the underlying autoantibodies frequently cause organic psychoses. Using a complex case of a patient with NMDAR encephalitis, which was confirmed in the course of treatment, this article discusses the ethical and legal issues that are relevant in practice, from initial invasive diagnostics to involuntary confinement and compulsory treatment. The article discusses how physicians can respect the autonomy of such patients in the best way and how they can identify and resolve potential contradictions between the free will and the expressed will. Various convictions of physicians about autonomy and coercive treatment are discussed on the basis of the legal situation. Finally, it is discussed how the indications for a short compulsory treatment can be justified before the court of protection on the grounds of an analogy of autoimmune encephalitis to other severe brain diseases.
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Autoimmune encephalitis as a differential diagnosis of schizophreniform psychosis: clinical symptomatology, pathophysiology, diagnostic approach, and therapeutic considerations. Eur Arch Psychiatry Clin Neurosci 2020; 270:803-818. [PMID: 32166503 PMCID: PMC7474714 DOI: 10.1007/s00406-020-01113-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/08/2020] [Indexed: 12/12/2022]
Abstract
Primary schizophreniform psychoses are thought to be caused by complex gene-environment interactions. Secondary forms are based on a clearly identifiable organic cause, in terms of either an etiological or a relevant pathogenetic factor. The secondary or "symptomatic" forms of psychosis have reentered the focus stimulated by the discovery of autoantibody (Ab)-associated autoimmune encephalitides (AEs), such as anti-NMDA-R encephalitis, which can at least initially mimic variants of primary psychosis. These newly described secondary, immune-mediated schizophreniform psychoses typically present with the acute onset of polymorphic psychotic symptoms. Over the course of the disease, other neurological phenomena, such as epileptic seizures, movement disorders, or reduced levels of consciousness, usually arise. Typical clinical signs for AEs are the acute onset of paranoid hallucinatory symptoms, atypical polymorphic presentation, psychotic episodes in the context of previous AE, and additional neurological and medical symptoms such as catatonia, seizure, dyskinesia, and autonomic instability. Predominant psychotic courses of AEs have also been described casuistically. The term autoimmune psychosis (AP) was recently suggested for these patients. Paraclinical alterations that can be observed in patients with AE/AP are inflammatory cerebrospinal fluid (CSF) pathologies, focal or generalized electroencephalographic slowing or epileptic activity, and/or suspicious "encephalitic" imaging findings. The antibody analyses in these patients include the testing of the most frequently found Abs against cell surface antigens (NMDA-R, CASPR2, LGI1, AMPA-R, GABAB-R), intracellular antigens (Hu, Ri, Yo, CV2/CRMP5, Ma2 [Ta], amphiphysin, GAD65), thyroid antigens (TG, TPO), and antinuclear Abs (ANA). Less frequent antineuronal Abs (e.g., against DPPX, GABAA-R, glycine-R, IgLON5) can be investigated in the second step when first step screening is negative and/or some specific clinical factors prevail. Beyond, tissue-based assays on brain slices of rodents may detect previously unknown antineuronal Abs in some cases. The detection of clinical and/or paraclinical pathologies (e.g., pleocytosis in CSF) in combination with antineuronal Abs and the exclusion of alternative causes may lead to the diagnosis of AE/AP and enable more causal therapeutic immunomodulatory opportunities.
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Pollak TA, Lennox BR, Müller S, Benros ME, Prüss H, Tebartz van Elst L, Klein H, Steiner J, Frodl T, Bogerts B, Tian L, Groc L, Hasan A, Baune BT, Endres D, Haroon E, Yolken R, Benedetti F, Halaris A, Meyer JH, Stassen H, Leboyer M, Fuchs D, Otto M, Brown DA, Vincent A, Najjar S, Bechter K. Autoimmune psychosis: an international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry 2020; 7:93-108. [PMID: 31669058 DOI: 10.1016/s2215-0366(19)30290-1] [Citation(s) in RCA: 203] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/15/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022]
Abstract
There is increasing recognition in the neurological and psychiatric literature of patients with so-called isolated psychotic presentations (ie, with no, or minimal, neurological features) who have tested positive for neuronal autoantibodies (principally N-methyl-D-aspartate receptor antibodies) and who have responded to immunotherapies. Although these individuals are sometimes described as having atypical, mild, or attenuated forms of autoimmune encephalitis, some authors feel that that these cases are sufficiently different from typical autoimmune encephalitis to establish a new category of so-called autoimmune psychosis. We briefly review the background, discuss the existing evidence for a form of autoimmune psychosis, and propose a novel, conservative approach to the recognition of possible, probable, and definite autoimmune psychoses for use in psychiatric practice. We also outline the investigations required and the appropriate therapeutic approaches, both psychiatric and immunological, for probable and definite cases of autoimmune psychoses, and discuss the ethical issues posed by this challenging diagnostic category.
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Affiliation(s)
- Thomas A Pollak
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Belinda R Lennox
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Sabine Müller
- Department of Psychiatry and Psychotherapy Charité Campus Mitte (CCM), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael E Benros
- Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Harald Prüss
- Department of Neurology, Charité - Universitätsmedizin Berlin, Germany; German Center for Neurodegenerative Diseases, CharitéCrossOver, Berlin, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hans Klein
- Department of Assertive Community Treatment, Lentis Mental Health Institute, Leek, Netherlands; Department of Assertive Community Treatment, VNN Addiction Care Institute, Groningen, Netherlands; Medical Imaging Centre, University of Groningen, Groningen, Netherlands
| | - Johann Steiner
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Thomas Frodl
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Bernhard Bogerts
- Department of Psychiatry and Psychotherapy and Center for Behavioral Brain Sciences, Otto von Guericke University of Magdeburg, Magdeburg, Germany
| | - Li Tian
- Psychiatry Research Centre, Beijing Huilongguan Hospital, Peking University, Beijing, China; Department of Physiology, Institute of Biomedicine and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Laurent Groc
- Interdisciplinary Institute for NeuroSciences, Université de Bordeaux, Bordeaux, France
| | - Alkomiet Hasan
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Germany
| | - Bernhard T Baune
- Department of Psychiatry, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia; The Florey Institute of Mental Health and Neurosciences, The University of Melbourne, Parkville, VIC, Australia; Department of Psychiatry, University of Münster, Münster, Germany
| | - Dominique Endres
- Department of Psychiatry and Psychotherapy, Medical Center, and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ebrahim Haroon
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Robert Yolken
- Department of Pediatrics, Stanley Neurovirology Division, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Francesco Benedetti
- Psychiatry and Clinical Psychobiology, Division of Neuroscience, Scientific Institute Ospedale San Raffaele, Milano, Italy; University Vita-Salute San Raffaele, Milano, Italy
| | - Angelos Halaris
- Department of Psychiatry, Loyola University Medical Center, Maywood, IL, USA
| | - Jeffrey H Meyer
- Research Imaging Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Institute of Medical Science, Toronto, ON, Canada; Departments of Psychiatry and Department of Pharmacology and Toxicology, Institute of Medical Science, Toronto, ON, Canada
| | - Hans Stassen
- Institute for Response-Genetics, Psychiatric University Hospital, Zurich, Switzerland
| | - Marion Leboyer
- Inserm U955, Fondation FondaMental, Department of Psychiatry and Addiction, Mondor University Hospital, University Paris-Est-Créteil, Créteil, France
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Markus Otto
- Department of Neurology, University Clinic, Ulm University, Ulm, Germany
| | - David A Brown
- Department of Immunopathology and Department Clinical Immunology, New South Wales Health Pathology, Institute for Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Angela Vincent
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, UK
| | - Souhel Najjar
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Karl Bechter
- Department of Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany
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8
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Endres D, Bechter K, Prüss H, Hasan A, Steiner J, Leypoldt F, Tebartz van Elst L. [Autoantibody-associated schizophreniform psychoses: clinical symptomatology]. DER NERVENARZT 2019; 90:547-563. [PMID: 30968197 DOI: 10.1007/s00115-019-0700-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
According to present concepts, primary psychotic disorders in the schizophrenia spectrum are probably caused by a complex interaction between multigenetic vulnerability and causally relevant environmental factors. In contrast, secondary psychotic disorders are the result of likely identifiable organic factors either in terms of a first causation (etiology) or a secondary cause (pathogenesis). In this context, autoantibody(ab)-associated autoimmune encephalitis (AE) plays an increasingly important role. Within the group of ab-associated AE with neuropsychiatric symptoms, anti-N-methyl-D-aspartate receptor encephalitis is the most prevalent one. Psychopathologically, polymorphic psychotic symptoms are often observed at onset of AE; however, over the course of this condition or even initially other neuropsychiatric phenomena are also common. The ill-defined entity of a steroid-responsive encephalopathy with thyroid antibodies (Hashimoto's encephalitis) is a heterogeneous syndrome that may also comprise isolated psychotic disorders presenting as classical schizophrenia.
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Affiliation(s)
- Dominique Endres
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland
| | - Karl Bechter
- Klinik für Psychiatrie und Psychotherapie II, Bezirkskrankenhaus Günzburg, Universität Ulm, Günzburg, Deutschland
| | - Harald Prüss
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Berlin, Berlin, Deutschland.,Experimentelle Neurologie und Klinik und Poliklinik für Neurologie, Charité Universitätsmedizin, Berlin, Deutschland
| | - Alkomiet Hasan
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Klinikum der Universität München, LMU, München, Deutschland
| | - Johann Steiner
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
| | - Frank Leypoldt
- Institut für Klinische Chemie und Klinik, Universitätsklinik Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - Ludger Tebartz van Elst
- Sektion für experimentelle Neuropsychiatrie, Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland.
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Tebartz van Elst L, Bechter K, Prüss H, Hasan A, Steiner J, Leypoldt F, Endres D. Autoantikörper-assoziierte schizophreniforme Psychosen: Pathophysiologie, Diagnostik und Therapie. DER NERVENARZT 2019; 90:745-761. [DOI: 10.1007/s00115-019-0735-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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[Poison in the filter: implementing detoxification procedures in schizophrenia]. DER NERVENARZT 2019; 90:1135-1143. [PMID: 30617571 DOI: 10.1007/s00115-018-0665-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In the history of psychiatry a variety of "blood detoxification" procedures have repeatedly been used to treat schizophrenic disorders under the assumption of autointoxication. In the 1970s this led to the use of dialysis. In addition to the historical classification of this therapeutic approach, particularly the protagonists active in the German Democratic Republic (GDR) as well as the dimension of research and science policy are highlighted. Despite the relatively low success rate of the treatment overall, the question of which patients actually had a positive response to the treatment arises. This seemed to primarily be the case for young patients in whom acute catatonic symptoms occurred. From today's perspective there are striking indications that the patients who were successfully treated at that time could belong to the group of autoimmune encephalitis, as they are known today. Autoimmune encephalitis and specifically anti-N-methyl-D-aspartate receptor encephalitis (NMDA-R) demonstrate a characteristic clinical progression with the frequent occurrence of psychiatric symptoms, which also include catatonic symptoms. These can occur in a variety of mental and neurological disorders but are often associated with schizophrenia. To primarily reduce the risk of diagnostic errors, they should initially be considered as non-specific from a diagnostic perspective. In the future, correlating immunological and psychopathological changes may help to delineate groups for whom specific therapies are particularly suitable.
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11
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Macher S, Zimprich F, De Simoni D, Höftberger R, Rommer PS. Management of Autoimmune Encephalitis: An Observational Monocentric Study of 38 Patients. Front Immunol 2018; 9:2708. [PMID: 30524441 PMCID: PMC6262885 DOI: 10.3389/fimmu.2018.02708] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 11/01/2018] [Indexed: 12/30/2022] Open
Abstract
Over the last years the clinical picture of autoimmune encephalitis has gained importance in neurology. The broad field of symptoms and syndromes poses a great challenge in diagnosis for clinicians. Early diagnosis and the initiation of the appropriate treatment is the most relevant step in the management of the patients. Over the last years advances in neuroimmunology have elucidated pathophysiological basis and improved treatment concepts. In this monocentric study we compare demographics, diagnostics, treatment options and outcomes with knowledge from literature. We present 38 patients suffering from autoimmune encephalitis. Antibodies were detected against NMDAR and LGI1 in seven patients, against GAD in 6 patients) one patient had coexisting antibodies against GABAA and GABAB), against CASPR2, IGLON5, YO, Glycine in 3 patients, against Ma-2 in 2 patients, against CV2 and AMPAR in 1 patient; two patients were diagnosed with hashimoto encephalitis with antibodies against TPO/TG. First, we compare baseline data of patients who were consecutively diagnosed with autoimmune encephalitis from a retrospective view. Further, we discuss when to stop immunosuppressive therapy since how long treatment should be performed after clinical stabilization or an acute relapse is still a matter of debate. Our experiences are comparable with data from literature. However, in contrary to other experts in the field we stop treatment and monitor patients very closely after tumor removal and after rehabilitation from first attack.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Desiree De Simoni
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Romana Höftberger
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus S Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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12
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Hermetter C, Fazekas F, Hochmeister S. Systematic Review: Syndromes, Early Diagnosis, and Treatment in Autoimmune Encephalitis. Front Neurol 2018; 9:706. [PMID: 30233481 PMCID: PMC6135049 DOI: 10.3389/fneur.2018.00706] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 08/03/2018] [Indexed: 12/15/2022] Open
Abstract
In recent years, new antibodies have been discovered which mediate autoimmune encephalitis. This immunological response can be triggered by an infection or a tumor. Classical onconeuronal antibodies are directed against intracellular neuronal agents but recently, a novel group of antibodies to neuronal cell-surface and synaptic antigens associated with different CNS-syndromes, has been discovered. Interestingly, the syndromes in this group can be successfully treated with immunotherapy and frequently do not have underlying tumors. The aim of this review is to describe the current state of knowledge about autoimmune encephalitis, in order to provide clinicians with a concise, up-to-date overview. Thus, a comprehensive literature search was performed in medical databases. The literature was carefully studied and new findings focusing on the symptoms, diagnosis and treatment were summarized and interpreted. Even though it might be challenging in some cases, the awareness of certain symptom constellations and demographic information, in combination with laboratory- and MRI-results, allows clinicians to make the diagnosis of probable autoimmune encephalitis at an early stage. Treatment can therefore be initiated faster, which significantly improves the outcome. Further investigations could define the underlying pathogenic mechanisms. Randomized controlled trials, paired with increasing clinical experience, will be necessary to improve the identification of affected patients, treatment strategies, and outcomes in the years to come.
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Affiliation(s)
| | - Franz Fazekas
- Department of Neurology, Medical University of Graz, Graz, Austria
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