Increased serum anti-N-methyl-D-aspartate receptor antibody immunofluorescence in psychiatric patients with past catatonia

Gaps and Controversies in Catatonia as a Movement Disorder

The term "catatonia" was introduced by German psychiatrist Karl Kahlbaum in 1874. Although historically tied to schizophrenia, catatonia exhibits a diverse range of phenotypes and has been observed in various medical and neuropsychiatric conditions. Its intrinsic movement characteristics and association with hypokinetic and hyperkinetic phenomenologies place catatonia within the purview of movement disorders. Despite the presence of catatonia in psychiatry literature for over 150 years, many gaps and controversies persist regarding its etiopathogenesis, phenomenology, diagnostic criteria, and treatment. The current versions of the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) require clinicians to identify any three signs of 15 (ICD-11) or 12 (DSM-5) for the diagnosis of catatonia. Catalepsy and waxy flexibility are the only motor features with high specificity for the diagnosis. We highlight the gaps and controversies in catatonia as a movement disorder, emphasize the lack of a clear definition, and discuss the inconsistencies in the description of various catatonic signs. We propose the exploration of a bi-axial classification framework similar to that used for dystonia and tremor to encourage the evaluation of underlying etiologies and to guide therapeutic decisions to improve the outcome of these patients. © 2024 International Parkinson and Movement Disorder Society.

Catatonia: demographic, clinical and laboratory associations

BACKGROUND

Catatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia.

METHODS

Electronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case-control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality.

RESULTS

We identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 μmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45-0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29-1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment.

CONCLUSIONS

In the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.

Catatonia associated with epileptic seizures: A systematic review of case reports

The association of catatonia with epileptic seizures is a rare phenomenon that is poorly understood and needs more clinical research. This systematic review included all published case reports of patients with catatonia meeting ICD-11 criteria associated with epileptic seizures, published until December 2021 in PubMed. Case reports were synthesized and results were expressed as percentages. In total, 42 articles with 52 case reports were included. Most patients were adults with a dispersed age (mean age 44.9 ± 19.3), slightly more males (59.6 %), with psychiatric history (76.9 %) of affective disorders (26.9 %) or psychotic episodes (13.5 %) and/or neurological history (61.5 %) of epileptic seizures (38.5 %) or head trauma (13.5 %). Their clinical presentation consisted mostly of decreased psychomotor activity (mutism: 94.2 %; stupor: 78.8 %; staring: 57.7 %; negativism: 36.5 %) with some abnormal psychomotor activity (catalepsy: 40.4 %; rigidity: 40.4 %; waxy flexibility: 23.1 %; posturing: 21.2 %) and half had clinical epileptic seizures (51.9 %), mostly generalized tonic-clonic (23.1 %). Almost all electroencephalograms (97.9 %) and half of brain imaging exams (47.4 %) performed had abnormal findings. The epileptic activity was mainly generalized (50 %) and associated with primary epilepsy (30.8 %), iatrogenesis (23.1 %), other secondary aetiologies (25 %) or unknown causes (21.2 %). Most improved with antiepileptic therapy (87.5 %) and had a complete remission (86.5 %). Catatonia secondary to epileptic seizures often has a nonspecific clinical presentation and appears in patients with previous psychiatric diagnoses, so any patient with catatonia should be properly investigated to avoid misdiagnosis and ineffective treatments.

Antibodies against N-Methyl D-Aspartate Receptor in Psychotic Disorders: A Systematic Review

OBJECTIVE

The objective of this study was to provide comprehensive evidence synthesis including all available up-to-date data about the prevalence of N-methyl D-aspartate receptor (NMDAR) antibodies (ABs) in psychotic patients in order to evaluate the clinical relevance of ABs as well as to specify potential explanations of the heterogeneity of the findings and determine areas for further research.

METHODS

A literature search was conducted using the PubMed/Medline, Web of Knowledge, and Scopus databases.

RESULTS

Forty-seven studies and 4 systematic reviews (including 2 meta-analyses) were included in the present review. Studies that used cell-based assays (CBAs) provided heterogeneous results on AB prevalence, obviously depending on the type of detection assay and sample characteristics. Improvement of AB detection methods is necessary to determine the real prevalence of ABs across different groups of patients and healthy people. Live CBAs seem to have better sensitivity but probably poorer specificity than fixed CBAs. Moreover, some links between AB-positive status and acute symptoms are possible. A small amount of data on immunotherapy in AB-positive patients raises the possibility of its effectiveness but obviously require further research.

CONCLUSIONS

NMDAR ABs are definitely present in a subset of psychotic patients. NMDAR ABs might shape psychosis and underlie some symptoms, and immunotherapy might be regarded as a treatment option for patients failing to respond to other therapies.

N-methyl-D-aspartate Receptor Antibody and White Matter Deficits in Schizophrenia Treatment-Resistance

Insufficient or lack of response to antipsychotic medications in some patients with schizophrenia is a major challenge in psychiatry, but the underlying mechanisms remain unclear. Two seemingly unrelated observations, cerebral white matter and N-methyl-D-aspartate receptor (NMDAR) hypofunction, have been linked to treatment-resistant schizophrenia (TRS). As NMDARs are critical to axonal myelination and signal transduction, we hypothesized that NMDAR antibody (Ab), when present in schizophrenia, may impair NMDAR functions and white matter microstructures, contributing to TRS. In this study, 50 patients with TRS, 45 patients with nontreatment-resistant schizophrenia (NTRS), 53 patients with schizophrenia at treatment initiation schizophrenia (TIS), and 90 healthy controls were enrolled. Serum NMDAR Ab levels and white matter diffusion tensor imaging fractional anisotropy (FA) were assessed. The white matter specificity effects by NMDAR Ab were assessed by comparing with effects on cortical and subcortical gray matter. Serum NMDAR Ab levels of the TRS were significantly higher than those of the NTRS (P = .035). In patients with TRS, higher NMDAR Ab levels were significantly associated with reduced whole-brain average FA (r = -.37; P = .026), with the strongest effect at the genu of corpus callosum (r = -.50; P = .0021, significant after correction for multiple comparisons). Conversely, there was no significant correlation between whole-brain or regional cortical thickness or any subcortical gray matter structural volume and NMDAR Ab levels in TRS. Our finding highlights a potential NMDAR mechanism on white matter microstructure impairment in schizophrenia that may contribute to their treatment resistance to antipsychotic medications.

Home-based nursing for improvement of quality of life and depression in patients with postpartum depression

BACKGROUND

Postpartum depression is a common mental illness in puerpera, with an incidence of approximately 3.5%-33.0% abroad, and the incidence of postpartum depression in China is higher than the international level, reaching 10.0%-38.0%. Providing effective nursing care in clinical nursing activities is one of the key points of obstetrical care. However, little research has been designed to investigate the positive role of home-based nursing in the prevention of postpartum depression .

AIM

To study the effect of home-based nursing for postpartum depression patients on their quality of life and depression.

METHODS

The clinical data of 92 patients with postpartum depression treated at our hospital were retrospectively analyzed. The patients were grouped according to the nursing methods used; 40 patients receiving basic nursing were included in a basic nursing group, and 52 receiving home-based nursing were included in a home-based nursing group. Depression and anxiety were evaluated and compared between the two groups. The estradiol (E2), serotonin (5-hydroxytryptamine, 5-HT), and progesterone (PRGE) levels were measured.

RESULTS

The SAS and SDS scores of the home-based nursing group were significantly lower than those of the basic nursing group (P < 0.05). The E2 and 5-HT levels of the home-based nursing group were significantly higher than those of the basic nursing group, but the PRGE level was significantly lower than that of the basic nursing group. The GQOLI-74 scores (material, social, somatic, and psychological) and nursing satisfaction were significantly higher in the home-based nursing group (P < 0.05).

CONCLUSION

Postpartum depression through home-based nursing can effectively alleviate depression and improve the quality of life of patients, help modulate their serum E2, 5-HT, and PRGE levels, and improve their satisfaction with nursing care.

Storms and silence: a case report of catatonia and paroxysmal sympathetic hyperactivity following cerebral hypoxia

BACKGROUND

Delayed Post Hypoxic Leukoencephalopathy (DPHL) is a syndrome that occurs after hypoxia, and can present with a variety of neuropsychiatric symptoms, including catatonia and paroxysmal sympathetic hyperactivity (PSH). The gold standard for the treatment of catatonia is electroconvulsive therapy (ECT). However, ECT can exacerbate the paroxysms of sympathetic hyperactivity and complicate recovery from DPHL. The treatment of PSH is not well established.

CASE PRESENTATION

We present a case of a patient with multiple opiate overdoses who presented with altered mental status. He was diagnosed with catatonia and subsequently treated with ECT. His clinical condition worsened, and a revised diagnosis of PSH was established. The patient's condition improved with medical management.

CONCLUSION

This case highlights the need to distinguish between these two related symptom clusters, as the incidence of DPHL and opioid overdose related neuropsychiatric problems increase. This distinction can greatly influence the course of treatment, and the need to consider alternative treatments.

Elevated serum anti-NMDA receptor antibody levels in first-episode patients with schizophrenia

Accumulating evidence has shown that N-methyl-D-aspartate (NMDA) glutamate receptors (NMDAR) are implicated in the pathophysiology of neurological and psychiatric disorders, and that patients with NMDAR antibody encephalitis develop psychopathological symptoms. Therefore, we hypothesized that NMDAR antibodies play a key role in the etiology of schizophrenia. In this study, we enrolled 110 first-episode patients with schizophrenia (FEP) and 50 healthy controls (HC). Cognitive function and psychopathology were assessed using the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB) and Positive and Negative Syndrome Scale (PANSS), respectively. NMDAR antibody levels were measured using enzyme-linked immunosorbent assay. Our results showed that FEP with schizophrenia exhibited cognitive deficits in all domains of the MCCB and had elevated levels of serum anti-NMDAR antibody compared with the healthy controls (9.2 ± 3.5 vs. 7.3 ± 2.9 ng/ml, t = 3.10, p = 0.002). Furthermore, serum antibody levels were positively correlated with PANSS positive, negative and total score, and inversely correlated with performances of verbal learning and memory, working memory, speed of processing and MCCB total score in the patient group. These results indicate that elevated levels of NMDAR antibody may play a role in the pathogenesis of schizophrenia, leading to NMDAR dysfunction, thereby inducing symptoms of psychosis and cognitive impairment. Therefore, NMDAR antibodies may serve as a biomarker and provide a new avenue for treatment of schizophrenia.

Adjunctive memantine for major mental disorders: A systematic review and meta-analysis of randomized double-blind controlled trials

OBJECTIVE

As a non-competitive N-methyl-d-aspartate receptor antagonist, memantine has been used to treat major mental disorders including schizophrenia, bipolar disorder, and major depressive disorder (MDD). This meta-analysis systematically investigated the effectiveness and tolerability of adjunctive memantine for patients with schizophrenia, bipolar disorder, and MDD.

METHODS

Only randomized controlled trials (RCTs) were identified and included in the study. Data of the three disorders were separately synthesized using the RevMan 5.3 software.

RESULTS

Fifteen RCTs (n = 988) examining memantine (5-20 mg/day) as an adjunct treatment for schizophrenia (9 trials with 512 patients), bipolar disorder (3 trials with 319 patients), and MDD (3 trials with 157 patients) were analyzed. Memantine outperformed the comparator regarding total psychopathology with a standardized mean difference (SMD) of -0.56 [95% confidence interval (CI): -1.01, -0.11; I² = 76%, P = 0.01] and negative symptoms with an SMD of -0.71 (95% CI: -1.09, -0.33; I² = 74%, P = 0.0003) in schizophrenia, but no significant effects were found with regard to positive symptoms and general psychopathology in schizophrenia, or depressive and manic symptoms in bipolar disorder or depressive symptoms in MDD. Memantine outperformed the comparator in improving cognitive performance in schizophrenia with an SMD of 1.07 (95% CI: 0.53, 1.61; P < 0.0001, I² = 29%). No group differences were found in the rates of adverse drug reactions and discontinuation due to any reason in the three major mental disorders.

CONCLUSIONS

Memantine as an adjunct treatment appears to have significant efficacy in improving negative symptoms in schizophrenia. The efficacy and safety of adjunctive memantine for bipolar disorder or MDD needs to be further examined.

REVIEW REGISTRATION

PROSPERO: 42018099045.

Catatonia and the immune system: a review

Catatonia is a psychomotor disorder featuring stupor, posturing, and echophenomena. This Series paper examines the evidence for immune dysregulation in catatonia. Activation of the innate immune system is associated with mutism, withdrawal, and psychomotor retardation, which constitute the neurovegetative features of catatonia. Evidence is sparse and conflicting for acute-phase activation in catatonia, and whether this feature is secondary to immobility is unclear. Various viral, bacterial, and parasitic infections have been associated with catatonia, but it is primarily linked to CNS infections. The most common cause of autoimmune catatonia is N-methyl-D-aspartate receptor (NMDAR) encephalitis, which can account for the full spectrum of catatonic features. Autoimmunity appears to cause catatonia less by systemic inflammation than by the downstream effects of specific actions on extracellular antigens. The specific association with NMDAR encephalitis supports a hypothesis of glutamatergic hypofunction in catatonia.

A clinical approach to new-onset psychosis associated with immune dysregulation: the concept of autoimmune psychosis

Growing data point to the overlap between psychosis and pathological processes associated with immunological dysregulation as well as inflammation. Notably, the recent discovery of antibodies against synaptic and neuronal cell membrane proteins such as anti-N-methyl-d-aspartate receptor provides more direct evidence of the etiological connection between autoimmunity and subsequent hazard of psychosis. Here, we advocate the use of term “autoimmune psychosis,” as this term suggests that autoimmune disorders can masquerade as drug-resistant primary psychosis, and this subtype of psychosis has anatomical and immunological footprints in the brain, despite the frequent absence of structural abnormalities on conventional brain MRI. Furthermore, this term might serve as a reminder not to overlook appropriate neurological workup such as neuroimaging and EEG testing, as well as CSF analysis, for cases with acute or subacute atypical onset of neuropsychiatric presentations including those dominated by acute psychotic symptoms. We propose etiologically and serologically oriented subclassification as well as multi-modal diagnostic approach to address some of the challenges inherent to early diagnosis of patients presenting with atypical and refractory new-onset psychotic symptoms of autoimmune origin. This is particularly relevant to the diagnosis of seronegative but probable autoimmune psychosis (SPAP) that might masquerade as antipsychotic drug-resistant primary psychotic disorder. This distinction is therapeutically important as autoimmune-related psychotic symptomatology can frequently respond well to timely treatment with proper immune modulatory therapies.