Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review of Psychiatric Phenotypes and Management Considerations: A Report of the American Neuropsychiatric Association Committee on Research

Abstract

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by prominent neuropsychiatric symptoms. Given the nature of its pathophysiology, psychiatrists tend to be one of the first clinicians encountering patients with the disease. In the current review of all patients described in the literature with psychiatric symptoms, we aimed to characterize the psychiatric symptomatology of the disease and its management in adults and children. A total of 544 patients fulfilled the inclusion criteria. We found that 77% of patients with NMDAR encephalitis presented initially with psychiatric symptoms. These were mostly commonly psychotic symptoms (in 62 %: especially disorganized behavior and visual/auditory hallucinations) and agitation (56%), with agitation even more commonly being the presenting symptom in children (66%). Where psychotic symptoms were detailed, visual (64%) and auditory (59%) hallucinations were the most common, as well as persecutory delusions. However delusions were not clearly characterized in most cases. Catatonia was described in 42% of adult patients and 35% of children. Of the patients with documented exposure to antipsychotics, 33% were suspected to have an adverse drug reaction notably neuroleptic malignant syndrome in 22% of the cases. Based on these findings, it is possible to important to raise the suspicion of anti-NMDAR encephalitis in patients with an acute onset psychosis, especially in association with agitation, catatonia, or adverse response to antipsychotics. Furthermore it is important to use antipsychotics with caution in patients with suspected or confirmed anti-NMDAR encephalitis.

Bilateral thalamic changes in anti-NMDAR encephalitis presenting with hemichorea and dystonia and acute transient psychotic disorder

“…Our patient presented with subacute onset behavioral abnormality, cognitive difficulties, and psychiatric symptoms, followed by hemichorea and dystonia, a constellation of clinical features germane to diagnosis of anti-NMDAR encephalitis. In about 70% of patients with anti-NMDAR encephalitis, there is a prodromal phase characterized by headache, fever, gastrointestinal symptoms and upper respiratory tract illness, (Dalmau et al, 2011;Dalmau et al, 2019;Sarkis et al, 2019) which was not reported in our patient. Credible explanations are prodromal symptoms were there, but her relatives probably ignored them, as she was not with her at that time and the patient herself could not give proper account of the initial illness.…”

“…(Dalmau et al, 2019) In a large study including 544 diagnosed cases of anti-NMDAR encephalitis, 77% of patients presented with neuropsychiatric complaints, most of them were agitation and psychotic symptoms, especially disorganized behavior and visual-auditory hallucinations as well as persecutory delusions. (Sarkis et al, 2019).…”

Catatonia secondary to anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis: a review

“…44,58 It is in this phase that many patients present to psychiatrists or are admitted to psychiatric units with a diagnosis of acute psychosis or schizophrenia. 58 A 2018 review of the psychiatric phenotypes seen in anti-NMDAr encephalitis by Sarkis et al, 77 found that 77% of patients with this type of encephalitis presented initially with psychiatric symptoms and of those, catatonia was present in 42% of adult patients and 35% of children. Interestingly, they also found that in many cases, although the signs and symptoms of catatonia were clearly described, the authors did not explicitly identify catatonia.…”

Olanzapine and Lorazepam Used in the Symptomatic Management of Excited Catatonia Secondary to Anti-N-Methyl-D-Aspartate Receptor Encephalitis

“…It was initially thought to be a paraneoplastic syndrome primarily associated with women with coexisting ovarian teratomas [1]. However, as the literature has expanded, studies have suggested it actually to be the second most common cause of autoimmune encephalitis [3].…”

“…The initial illness portion of the condition often includes psychiatric symptoms such as anxiety, insomnia, agitation, paranoia, hallucinations (visual and auditory), delusions, and disorganized thinking [1][2]. Catatonia has also been described in numerous case reports, with studies suggesting that it is present in approximately 42% of patients with anti-NDMA receptor encephalitis [3]. Further progression can affect 1 1 2 1 cognition, speech, and memory.…”