Managing severe behavioral symptoms of a patient with anti-NMDAR encephalitis: case report and findings in current literature

Abstract

Objective: Psychiatric symptoms emerge in the early stages of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis, and patients often seek treatment in psychiatric departments before visiting any other general medical services. Numerous articles about anti-NMDAR encephalitis have been published in the scientific community worldwide, but few emphasize the role of psychiatry in symptom management. Case description: We describe the case of a patient with anti--NMDAR encephalitis seen in our service and discuss the management of behavioral symptoms based on current scientific literature. High doses of atypical antipsychotics and benzodiazepines were used to control agitation, and trazodone was administered to treat insomnia. Comments: Consultation-liaison psychiatry may help the healthcare team adjust the management of neuropsychiatric complications that might affect inpatients with anti-NMDAR encephalitis. Keywords: Anti-NMDAR encephalitis, consultation-liaison psychiatry, behavioral symptoms. ResumoObjetivo: Sintomas psiquiátricos surgem em estágios precoces da encefalite antirreceptor N-metil-D-aspartato (NMDAR), o que faz muitos pacientes procurarem tratamento em serviços de psiquiatria antes de se dirigirem a unidades de clínica geral. Embora muitos artigos sobre encefalite anti-NMDAR venham sendo publicados na comunidade científica internacional, poucos enfatizam o papel do psiquiatra no seu manejo sintomatológico. Descrição do caso: O presente artigo relata o caso de um paciente que desenvolveu encefalite anti-NMDAR em nosso serviço e discute manejo de alterações comportamentais com base na literatura científica atual. Altas doses de antipsicóticos atípicos e benzodiazepínicos foram usados para controle de agitação, e trazodona foi utilizada para tratar insônia. Comentários: A interconsulta psiquiátrica pode ajudar no ajuste de condutas de toda a equipe assistente para as complicações neuropsiquiátricas que possam surgir na evolução de pacientes internados por encefalite anti-NMDAR. Descritores: Encefalite anti-NMDAR, interconsulta psiquiátrica, sintomas comportamentais.

Cessation of dangerousness status: an analysis of 224 reports from the Instituto de Perícias Heitor Carrilho, Rio de Janeiro, Brazil

“…Another interesting finding of that work was the correlation between violence and organic brain disorders. Other studies report difficulty in managing these patients, 38,39 and the topic deserves further investigation . In our work, the diagnoses of personality disorder were factored into the analysis whenever they were present in the reports.…”

New Onset Insomnia in a Pediatric Patient: A Case of Anti-NMDA Receptor Encephalitis

“…Multiple studies have reported sleep-wake cycle disturbances and insomnia as characteristic symptoms in anti-NMDAR encephalitis [7] and while they have been described previously as the presenting feature in adults [16, 17], insomnia in children with anti-NMDAR encephalitis is typically described later in the clinical course [1, 26–29] or has not been mentioned as a feature of the illness [30–32]. Other studies suggest that children are more likely to present with predominantly neurologic symptoms (seizures, abnormal movements, and focal neurologic deficits) than with psychiatric symptoms [26].…”

Anti-NMDAR encephalitis for psychiatrists: the essentials

“…Caution must be employed with regards to the use of psychotropic medication, as this can complicate the fluctuating clinical picture; for example, benzodiazepines may exacerbate respiratory depression and impaired consciousness. [47][48][49] In addition, there may be an association between use of antipsychotics and neuroleptic malignant syndrome in anti-NMDAR encephalitis. 16 Overall, these risks need to be balanced against the potential benefit of alleviating distressing symptoms and hazardous behaviour.…”