Stiff-person syndrome in a patient with comorbid bipolar and panic disorders: A case report and literature review

Complexities in Managing Psychosis in a Patient With Stiff-Person Syndrome: A Case Report

Stiff-person syndrome (SPS) is an uncommon autoimmune neurological disorder marked by painful muscle stiffness, muscle spasms, and limb weakness. Neurological symptoms in SPS can mimic a psychogenic movement disorder in which symptoms are triggered by sudden movement and emotional distress, which might delay proper treatment. However, psychiatric symptoms are far less common, and there is limited understanding regarding the co-occurrence of psychiatric conditions. Psychiatric symptoms include nonspecific anxiety, agoraphobia, and depression, which can be triggered by sudden movement, noise, or emotional stress. This case report dives into the psychiatric manifestations seen in a patient with SPS. The case report focuses on a 42-year-old female with SPS, migraines, systemic lupus erythematosus, Sjogren's syndrome, and a psychiatric history of anorexia, depression, and anxiety. Her unique presentation underscored the necessity for a multidisciplinary approach to psychiatric care. The patient was evaluated and managed during her admission to the psychiatric unit for unspecified psychosis. Her course included a complicated medical evaluation for cardiovascular and neurologic symptoms and comprehensive psychiatric management. She manifested resistance to specific psychiatric medications and care strategies. She had atypical presentations, like sensory symptoms and left-sided chest pain. She exhibited paranoia and psychosis, which were managed with a combination of pharmacologic treatments, including aripiprazole. Psychotic symptoms were resolved upon discharge, with an emphasis on strict outpatient follow-up. This case report enhances our understanding of the clinical nuances associated with SPS and its intersection with psychiatric symptoms. The objective of this case report is to detail the diagnostic and therapeutic complexities of managing psychosis in a patient with SPS, along with a pre-existing complex medical and psychiatric profile, and to contribute to a deeper understanding of SPS and associated psychiatric conditions and more effective management strategies.

Psychiatric Symptoms in Stiff-Person Syndrome: A Systematic Review and a Report of Two Cases

BACKGROUND

The clinical spectrum of stiff-person syndrome (SPS) encompasses a wide range of signs including psychiatric symptoms (PS).

OBJECTIVE

Our objective was to provide an overview of the spectrum of PS in SPS through a systematic literature search and 2 illustrative case reports.

METHODS

We reported 2 anti-glutamic acid decarboxylase-positive SPS cases that presented with phobic disorder, and we performed a systematic review by following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles published in PubMed, MEDLINE on Ovid, Embase, and via a manual search before October 20, 2020, were selected by 2 independent reviewers. Original studies, case reports, editorials, commentaries, and letters to the editor reporting cases of SPS with PS were all included. Conference abstracts, reviews and book chapters, unavailable articles, and those not reporting SPS cases or PS were excluded. Quantitative summary data were calculated.

RESULTS

In addition to our 2 cases, we identified 237 cases of SPS with PS from 74 additional included publications totaling 239 patients. Anxiety (56%) and depression (45%) were the most common PS in SPS. Mean diagnostic delay was 4.7 years. Among the 3 SPS phenotypes, the classic form was predominant (77%), followed by stiff-limb syndrome (13%) and progressive encephalomyelitis with rigidity and myoclonus (10%). The most frequent etiology of SPS with PS was autoimmune (90%), followed by cryptogenic (7%) and paraneoplastic forms (7%). These patients were mainly treated with immune-mediated therapies and GABAergic drugs.

CONCLUSIONS

Our review revealed that the most common PS of SPS are anxiety and depression occurring mostly in autoimmune and classic forms, allowing a clearer understanding of this entity, which may lead to earlier diagnosis and better outcome.

Paraneoplastic stiff-person syndrome with lung cancer: a case report and literature review

Stiff person syndrome is a rare autoimmune disease of the central nervous system that manifests as stiffness and painful spasms of the trunk axis and lower limb muscles. Benzodiazepines are the first choice for the clinical treatment of the disease. We reported a case of SPS. The patient presented with stiffness and convulsions of lower limbs, weakness after convulsions, falling off easily, abdominal muscle stiffness, and painful spasms lasting for several minutes and alleviating spontaneously. This was caused or aggravated by fatigue or mental stimulation. Left stiffness and weakness of the muscle after relief was present. A chest-enhanced computed tomography scan (CT) suggested two large ground glass nodules in the upper lobe of the left lung. Biopsy pathology indicated the nodules as adenocarcinoma in situ. The patient's symptoms were significantly relieved after treatment with clonazepam and diazepam combined with pregabalin. The clinical manifestations of SPS vary among patients. The symptoms of the disease are mild or severe. Early identification and treatment can improve the prognoses of these patients.

A Rarity Among the Rare: Psychiatric Manifestations in a Young Woman With Stiff-Person Syndrome

Stiff-person syndrome (SPS) is a rare progressive neurologic disease associated with autoantibodies against glutamic acid decarboxylase, an intracellular enzyme involved in the production of gamma-aminobutyric acid. 

We present a case involving a 35-year-old Haitian female who was placed under the Baker Act in the emergency department for suicidal behavior and acute psychosis. She has a history of SPS with a positive glutamic acid decarboxylase (GAD) antibody, a condition most commonly found in females between 20 and 50 years of age. The condition was managed by an outpatient neurologist using diazepam, baclofen, and monthly intravenous immunoglobulin treatments. She also has an extensive history of organic neurological conditions, including traumatic brain injury at 18 years old and COVID-19-related anoxic encephalitis that occurred in December 2020. Both psychiatric and neurological physical exams were completed. They revealed a cerebellar tremor, bilateral ptosis, poor eye contact, decreased concentration, poor insight, depressed mood, flat affect, poor judgement, delusional thoughts and a disorganized thought process with tangential speech. CT and MRI imaging of the brain showed no acute intracranial abnormalities. A quantitative titer of the GAD antibody was completed and shown to be elevated >250IU/mL. Depakote 500mg twice daily and risperidone 3mg twice daily were prescribed. The patient had progressive improvement of psychosis including delusional thoughts over the following five days and was able to be discharged with instructions to follow-up with outpatient neurology. 

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.