Catatonia in adult anti-NMDAR encephalitis: an observational cohort study

Abstract

Background Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is one of the most prevalent autoimmune encephalitis and is closely related to catatonia. This study aimed to investigate the clinical features and disease outcomes of adult catatonic anti-NMDAR encephalitis patients. Methods Adult patients diagnosed with anti-NMDAR encephalitis between January 2013 and October 2021 were retrospectively enrolled in this study. According to the Bush Francis Catatonia screening instrument (BFCSI), patients were divided into two groups: those with catatonia and those without catatonia. The modified Rankin scale (mRS), Clinical Assessment Scale for Autoimmune Encephalitis (CASE), Neuropsychiatric Inventory (NPI), Patient Health Questionnaire-9 (PHQ-9) and 7-item Generalized Anxiety Disorder Questionnaire (GAD-7) scores were assessed at follow-up. The Mann–Whitney U test (nonparametric), Student’s t test (parametric), and chi-squared test were used to analyse the differences between the two groups. Results Eighty-four patients were recruited, including twenty-five catatonic patients and fifty-nine noncatatonic patients. Among them, 28 had positive antibody only in cerebrospinal fluid (CSF), 4 had positive antibody only in serum and 52 had positive antibody both in CSF and serum. Catatonic patients experienced more disturbance of consciousness (p = 0.01), aggression (p = 0.046) and affective disorders (p = 0.043) than noncatatonic patients. The mRS scores of the catatonia group assessed at admission (p = 0.045) were worse than those of the non-catatonia group. Catatonic patients were more inclined to develop deep vein thrombosis (p = 0.003), decubitus (p = 0.046), pneumonia (p = 0.025), and to be admitted to the intensive care unit (ICU) (p = 0.011) than noncatatonic patients. All patients in the catatonia group received first-line immunotherapy. At the 24-month follow-up, 2 patients in the catatonia group did not achieve good outcomes. At the last follow-up, the catatonia group had more relapses (p = 0.014) and more neuropsychiatric problems (p = 0.035). Conclusions Adult anti-NMDAR encephalitis patients with catatonia present distinct clinical features in disease course and are prone to experience more relapses and long-term neuropsychiatric problems than those without catatonia.

Outcome and Sequelae of Autoimmune Encephalitis

“…We found six studies that assessed psychiatric outcomes. Many of the included patients had psychiatric sequelae at their last follow-up, with studies finding at least some type of psychiatric or behavioral disturbance in 33%–79%, 17 22 23 at least mild depression (10%–32%), 16 17 23 and at least mild anxiety (11.5%–60%) 16 17 23 when applying various assessment tools at various intervals. A prospective study of 40 patients by Heine et al 16 found that at a median of 2.3 years after symptom onset, moderate, mild, and minimal depressive symptoms persisted in 12%, 20%, and 12%, respectively, with no symptoms in 56%.…”

“…At the last follow-up, 8%, 12%, and 40% had at least mild psychosis, depression, and anxiety, respectively. 17 Wu et al 23 evaluated 52 patients after a median of 46 months and found that 33% had at least 1 neuropsychiatric symptom (Neuropsychiatric Inventory [NPI] score ≥1), 12% had anxiety (General Anxiety Scale [GAD-7] score ≥5), and 10% had depression (Patient Health Questionnaire-9 score ≥5). Wang et al 22 evaluated 39 patients and found that 79% had depression and/or anxiety according to the Zung Depression Scale and the Zung Anxiety Scale.…”

“…Scores on the Clinical Assessment Scale in Autoimmune Encephalitis (CASE) were evaluated in two other studies. 23 27 Wu et al 23 found that 82% of patients had a good outcome according to that scale (score=0–3) compared with 85% according to mRS (score=0–2), and Lee et al 27 found that 61% had what they reported as an excellent outcome (CASE score=0–4).…”

How to manage catatonia, Parkinson and dementia in ICU

“…While historically defined as a subtype of schizophrenia, it is currently well known that several psychiatric, neurologic and general medical conditions can lead or be revealed by inaugural catatonia [8]. Although the most frequent etiologies are psychiatric disorders (among which mood disorders, schizophrenia and neurodevelopmental disorders), NMDA-R encephalitis and others types of auto-immune encephalitis are a major cause of malignant catatonia in ICU patients [9]. The number and variety of other reported etiologies are extensive, including neurodegenerative, neurovascular, metabolic and respiratory disorders, and substance or medication intoxication or withdrawal.…”

Catatonia-like behavior and immune activation: a crosstalk between psychopathology and pathology in schizophrenia

“…Limbic encephalitis, associated with antibodies against the N-methyl-D-aspartate receptor (NMDAR), often presents with typical symptoms of catatonia, such as mutism, stereotyped movements, negativism, and psychomotor slowing [17]. The immune alterations and activation of microglia observed in catatonia and schizophrenia could underlie the same pathogenetic process represented by neuroin ammation [16,17,18,19].…”