Examining the Features of Neuroleptic Malignant Syndrome in Anti-NMDA Receptor Encephalitis: A Case-Control Study.

BACKGROUND: Anti-N-methyl-D-aspartate receptor encephalitis (ANMDARE) is a neuroimmunological disorder that frequently improves with immunotherapy. Symptomatic treatment with antipsychotics is common in the early stages when psychiatric symptoms predominate, and their use has been associated with serious side effects including neuroleptic malignant syndrome (NMS). The observation of an adverse response to antipsychotics, raising the suspicion of NMS, has been included as a criterion for possible autoimmune psychosis. METHODS: This case-control study included patients who received antipsychotics before referral to the National Institute of Neurology and Neurosurgery of Mexico, where they were diagnosed as having definite ANMDARE, and patients with ANMDARE who did not receive antipsychotics before referral. The neurologic and systemic features that are used to measure an adverse response to antipsychotics, raising the suspicion of NMS, were measured in both groups, including akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, and hyperthermia. A logistic regression analysis was used to determine the relationship between the previous use of antipsychotics and the occurrence of NMS-like reactions. RESULTS: A total sample of 112 patients with definite ANMDARE were included in the study. Fifty patients received antipsychotics before being referred to our institution. In this group, thirty-six patients (72%) were initially classified as having an adverse response, raising the suspicion of NMS, with the following features: akinesia (64%), autonomic instability (58%), generalized rigidity (52%), elevated concentrations of creatine phosphokinase (50%), and hyperthermia (14%). Six patients fulfilled the criteria for NMS (12%). The comparison with patients who did not receive antipsychotics before the clinical assessment did not show a significant difference between groups regarding the frequency of akinesia, autonomic instability, generalized rigidity, elevated concentrations of creatine phosphokinase, or hyperthermia. Among different antipsychotics, only haloperidol was significantly associated with generalized rigidity as compared to patients who did not receive antipsychotics. CONCLUSIONS: Our study supports previous observations about the high frequency of autonomic dysfunction, hyperthermia, tachycardia, rigidity, and elevated creatine phosphokinase levels in patients with anti-NMDAR encephalitis following the administration of antipsychotic medications. Nevertheless, our study does not suggest a causal link between atypical antipsychotics and the onset of these neurological symptoms, as they were equally frequent among the group of patients who did not receive antipsychotic treatment.

Prevalencia y características clínicas de los síntomas depresivos y ansiosos de los trabajadores de una institución de salud en Medellín durante la pandemia por COVID-19

Introducción: Afrontar las circunstancias de la vida y el trabajo que la pandemia por COVID-19 ha impuesto al personal sanitario implica un reto extraordinario: cuidar y atender a otros, exponiéndose a sí mismos al contagio. A médicos, enfermeras, terapeutas y demás personal asistencial y no asistencial en clínicas y hospitales, se les pide estar preparados para trabajar en situaciones extraordinariamente complejas y estresantes, lo que los hace vulnerables a problemas mentales. Objetivo: Determinar la prevalencia y las características clínicas de los síntomas ansiosos y depresivos del personal que trabaja en una institución de salud en Medellín, Colombia. Métodos: Estudio observacional, descriptivo y transversal, a partir de una encuesta disenada al efecto, la cual incluyó 2 escalas para tamizar síntomas depresivos y ansiosos, además de variables sociodemográficas. Resultados: Se incluyó a 1.247 trabajadores de la institución de salud. El 14,6% reportó síntomas depresivos y el 18,5%, ansiosos clínicamente significativos. Se encontró una mayor proporción de síntomas depresivos y ansiosos moderados-graves en la modalidad de trabajo presencial. Conclusiones: Los síntomas ansiosos y depresivos son muy prevalentes entre los trabajadores de una institución de salud de Medellín durante la pandemia de COVID-19. Dado el papel vital del sector salud en tiempos de pandemia, el desarrollo de programas de salud mental que aborden los problemas de esta población debería considerarse una prioridad.

Introduction: The COVID-19 pandemic has represented an extraordinary challenge for health workers as they care for others while exposing themselves to contagion. Doctors, nurses, therapists and other non-care staff in clinics and hospitals are asked to be prepared to work in particularly complex and stressful situations, which makes them vulnerable to mental health problems. Objective: To determine the prevalence and clinical characteristics of anxiety and depression symptoms in staff working at a health institution in Medellin, Colombia. Methods: Observational, descriptive and cross-sectional study, based on a survey designed for the investigation, which included two scales to screen depression and anxiety symptoms, as well as sociodemographic variables. Results: A total of 1,247 workers from the health institution were included. Of these, 14.6% reported symptoms of depression and 18.5% of clinically significant anxiety. A higher proportion of moderate to severe depression and anxiety symptoms was found in those working face to face. Conclusions: Anxiety and depression symptoms are highly prevalent among staff at a health institution in Medellin, Colombia, during the COVID-19 pandemic. Given the vital role of the health sector in times of pandemic, the development of mental health programmes that address the problems of this population should be considered a priority.

Involuntary Emotional Expression Disorder in a Patient With Toluene Leukoencephalopathy / Trastorno de expresión emocional involuntaria en un paciente con leucoencefalopatía por tolueno

ABSTRACT Objective: Inhalant users may develop toluene leukoencephalopathy, a devastating neuropsychiatric disorder. We present a case of toluene-induced damage to the corticospinal and the corticonuclear tracts, which presented with involuntary emotional expression dis-order. Methods: Case study of a 20-year-old man with a 3-year history of frequent solvent abuse was admitted to the Neuropsychiatry Unit of the National Institute of Neurology and Neurosurgery because "he could not speak or walk" but would keep "laughing and crying without reason". Results: Neuropsychiatric examination revealed pathological laughter and crying, facial and speech apraxia, a bilateral pyramidal syndrome, and lack of control of urinary sphincter. Magnetic resonance imaging revealed a highly selective bilateral damage to the pyramidal system and the somatosensory pathway. SPECT imaging showed left fronto-parietal hypoperfusion. Conclusions: This document provides support for the understanding of involuntary emotional expression disorders as a differential diagnosis in the clinical practice of psychiatrists, as well as the functional anatomy of these conditions.

RESUMEN Objetivo: Los usuarios de inhalantes pueden contraer leucoencefalopatía por tolueno, un trastorno neuropsiquiátrico devastador. Se presenta un caso de daño inducido por tolueno en el tracto corticoespinal y corticonuclear, que se manifestó con un trastorno involuntario de la expresión emocional. Métodos: Un varón de 20 años con antecedente de 3 años de abuso de solventes ingresó en la Unidad de Neuropsiquiatría del Instituto Nacional de Neurología y Neurocirugía porque «no podía hablar ni caminar¼ y presentaba episodios súbitos de risa y llanto sin razón aparente. Resultados: La valoración neuropsiquiátrica reveló risa y llanto patológicos, apraxia facial y fonatoria, síndrome piramidal bilateral y ausencia de control del esfínter urinario. La resonancia magnética cerebral mostró un daño bilateral muy selectivo del sistema piramidal y la vía somatosensorial. La imagen de tomografía computarizada por emisión monofotónica mostró hipoperfusión frontoparietal izquierda. Conclusiones: Este documento proporciona apoyo para la comprensión de los trastornos de la expresión emocional involuntaria como diagnóstico diferencial en la práctica clínica de los psiquiatras, así como de la anatomía funcional de estas condiciones.

Clinical Significance of Delirium With Catatonic Signs in Patients With Neurological Disorders.

OBJECTIVE: According to DSM-5, catatonia and delirium are mutually exclusive clinical syndromes. The investigators explored the co-occurrence of delirium and catatonia (i.e., catatonic delirium) and the clinical significance of this syndrome with a sample of neurological patients. METHODS: This prospective study with consecutive sampling included patients diagnosed with delirium at the National Institute of Neurology and Neurosurgery of Mexico. DSM-5 criteria for delirium, the Confusion Assessment Method, and the Delirium Rating Scale-Revised-98 were used to select and characterize patients. Catatonia was assessed using the Bush-Francis Catatonia Rating Scale and DSM-5 diagnostic criteria. Logistic regression analysis was performed to identify etiological factors associated with catatonic delirium. RESULTS: A total of 264 patients with delirium were included, 61 (23%) of whom fulfilled the criteria for catatonia and delirium simultaneously. Brain tumors, subarachnoid hemorrhage, acute hydrocephalus, and ischemic stroke were associated with delirium without catatonic signs. Catatonic delirium was observed among patients with encephalitis, epilepsy, brain neoplasms, and brain tuberculosis. After multivariate analysis, the association between catatonic delirium and encephalitis (both viral and anti-N-methyl-d-aspartate receptor [NMDAR]) was confirmed. CONCLUSIONS: Delirium is a common complication of neurological diseases, and it can coexist with catatonia. The recognition of catatonic delirium has clinical significance in terms of etiology, as it was significantly associated with viral and anti-NMDAR encephalitis.

[Neuropsychiatric aspects of anti-NMDA receptor encephalitis]. / Aspectos neuropsiquiátricos de la encefalitis por anticuerpos contra el receptor NMDA.

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a potentially lethal clinical entity that belongs to the group of antibody-mediated encephalitis against synaptic proteins. It shows IgG antibodies against the NR1 subunit of the NMDA receptor (NMDA-R), which have been associated with psychiatric and neurological symptoms that develop in stages in the course of the disease. The predominance of neuropsychiatric symptoms in the early stages of the disease results in an increased number of patients that search for psychiatric evaluation as their first contact with the health system. For this reason, it is vital for physicians to recognize this entity as an important differential diagnosis in their clinical practice because, despite the severity of this condition, more than 75 % of patients achieve a substantial recovery with appropriate and timely treatment. We present a review of the literature on this disease, with special emphasis on the neuropsychiatric aspects.

La encefalitis por anticuerpos contra el receptor anti-N-metil-D-aspartato (NMDA) es una entidad clínica potencialmente letal perteneciente al grupo de las encefalitis mediadas por anticuerpos contra proteínas sinápticas. En esta se demuestran anticuerpos IgG contra el receptor de NMDA (NMDAr), asociados con síntomas psiquiátricos y neurológicos que se desarrollan por estadios en el curso de la enfermedad. El predominio de síntomas neuropsiquiátricos en las etapas tempranas provoca que un elevado porcentaje de pacientes busquen evaluación psiquiátrica como un primer contacto con el sistema de salud. Por esta razón, es vital que los médicos reconozcan esta entidad como un diagnóstico diferencial importante en la práctica clínica, puesto que, a pesar de la gravedad de esta condición, más de 75 % de los pacientes logra una recuperación sustancial con un tratamiento adecuado y oportuno. Presentamos una revisión de la literatura sobre esta enfermedad, con especial énfasis en los aspectos neuropsiquiátricos.

Delirious mania as a frequent and recognizable neuropsychiatric syndrome in patients with anti-NMDAR encephalitis.

BACKGROUND: Previous case reports showed that delirious mania could be one of the many neuropsychiatric presentations of Anti-N-methyl-d-aspartate receptor encephalitis (ANMDARE). OBJECTIVE: To evaluate the frequency of delirious mania and its associated factors in ANMDARE. METHOD: A prospective study, including all patients with ANMDARE admitted to the National Institute of Neurology and Neurosurgery of Mexico, from January 2014 to April 2019. The diagnosis of delirious mania was established when diagnostic criteria for mania and delirium were fulfilled simultaneously. RESULTS: 79 patients with definitive ANMDARE were included. Delirious mania was identified in 20 (25.3%) of these patients. Catatonia, psychomotor agitation, disinhibition, impulsivity, and grandiose delusions were significantly associated with delirious mania. Also, a lower frequency of EEG abnormalities, absence of extreme delta brush, and a shorter hospital stay was observed in these patients. CONCLUSION: Delirious mania proved to be a frequent neuropsychiatric presentation of ANMDARE, and its presence should warn the physician about the possibility of this diagnosis. It was mainly associated with higher rates of catatonia, psychomotor agitation, disinhibition, and psychotic symptoms. The lack of recognition of delirious mania as a neuropsychiatric presentation in ANMDARE may be a source of diagnostic and therapeutic errors, as most physicians associate this with bipolar disorder.

Depresión en personas con epilepsia. ¿Cuál es la conexión? / Depression in People with Epilepsy. What is the Connection?

RESUMEN Introducción: La depresión es la comorbilidad psiquiátrica más común en las personas con epilepsia, lo cual les empeora el pronóstico y la calidad. A pesar de esto, frecuentemente no se reconoce este problema y cuando se diagnostica, el tratamiento es subóptimo. Objetivo: Realizar una revisión narrativa a partir de la literatura médica, buscando reco pilar información útil sobre la relación entre epilepsia y depresión y la mejor forma de diagnosticarla y tratarla. Resultados: Se identificaron revisiones de tema, revisiones sistemáticas, metanálisis, ensa yos clínicos y estudios de seguimiento en inglés y español, sin límite de tiempo, que incluyen aspectos epidemiológicos, clínicos, factores asociados, explicaciones etiológicas y aproxi maciones diagnósticas y terapéuticas de la depresión comórbida con la epilepsia. Conclusiones: La relación entre epilepsia y depresión es compleja. Alguna evidencia científica disponible indica la posibilidad de una relación bidireccional, que podría explicarse a partir de mecanismos etiopatogénicos comunes. A pesar de la alta prevalencia de la depresión entre los pacientes epilépticos, los clínicos siguen identificando escasamente este trastorno mental. Para mejorar esto, se cuenta con instrumentos de fácil aplicación que permiten tamizar sistemáticamente a esta población de pacientes y contribuir de manera sustancial a hacer más visible el problema y procurar la mejora de la calidad de vida de estas personas.

ABSTRACT Introduction: Depression is the most common psychiatric comorbidity in people with epilepsy. It worsens the prognosis and quality of life of these patients. Despite this, depression is poorly diagnosed and when the treatment is given, it is frequently suboptimal. Objective: To perform a narrative review of the medical literature, seeking to collect useful information regarding the relationship between epilepsy and depression. Results: Narrative reviews, systematic reviews, meta-analyses, clinical trials, and follow-up studies were identified in English and Spanish with no time limit, including epidemiological, clinical, associated factors, etiological explanations, diagnostic and therapeutic approaches to comorbid depression in epilepsy. Conclusion: The relationship between epilepsy and depression is complex. The availa ble scientific evidence suggests the possibility of a bidirectional relationship that could be explained from common aetiopathogenic mechanisms. Despite the high prevalence of depression in epileptic patients, this mental disorder continues to be poorly identified by clinicians. To improve this, we have easy-to-apply instruments that routinely screen this patient population and contribute substantially to making the problem more visible and seek to improve the quality of life for this population.

Characterisation and outcome of neuropsychiatric symptoms in patients with anti-NMDAR encephalitis.

BACKGROUND: Encephalitis due to anti-N-methyl-D-aspartate receptor antibodies (ANMDARE) is the most frequent immune-mediated encephalitis. It is distinguished by the subacute onset of neuropsychiatric symptoms. OBJECTIVE: To evaluate the characteristic neuropsychiatric symptoms and their outcome in patients diagnosed with ANMDARE. METHODS: This was a prospective, longitudinal study in patients with a diagnostic suspicion of ANMDARE that presented to the National Institute of Neurology from March 2018 to February 2019. A comparative analysis of two groups (positive N-methyl-D-aspartate receptor [NMDAR] vs. negative NMDAR antibodies in cerebrospinal fluid [CSF]) was done on admission and at discharge. Neuropsychiatric systematic assessments included the Neuropsychiatric Inventory Questionnaire, the Bush Francis Catatonia Rating Scale, the Confusion Assessment Method Severity, the Montreal Cognitive Assessment, and the Overt Agitation Severity Scale. RESULTS: 24 individuals were analysed: 14 had positive NMDAR antibodies, and 10 had negative NMDAR antibodies in CSF. On admission, agitation/aggression, euphoria/exaltation, and disinhibition were more common in patients with positive antibodies. Excited catatonia and delirium were diagnosed more frequently in patients with positive antibodies. At discharge, there was an important decrease in neuropsychiatric symptoms, but substantial cognitive impairment remained. The mean hospitalisation length was 41.71 (SD 39.33) days for patients with definitive ANMDARE (p 0.259). CONCLUSIONS: Neuropsychiatric symptoms profile in ANMDARE was associated with the early onset of euphoria/exaltation and disinhibition, accompanied by marked psychomotor agitation. When ANMDARE was suspected, the presence of excited-type catatonia and delirium showed a tendency to predict definitive ANMDARE. At discharged, most patients recovered from catatonia, delirium, and psychosis, but marked cognitive symptoms, anxiety, and depression persisted at discharge.

Are We Missing Subtle Forms of Anti-N-Methyl-D-Aspartate Encephalitis With the Current Diagnostic Approach? A Case Report.

Encephalitis related to antibodies against the N-methyl-D-aspartate receptor (NMDAr) is a recently described clinical entity in which IgG autoantibodies against the NR1 subunit of the NMDAr lead to the appearance of complex neuropsychiatric symptoms. As psychiatric symptoms predominate in early stages, anti-NMDAr encephalitis is frequently mistaken as a primary psychiatric disorder which delays treatment and has serious consequences for patients. This report presents the case of a 24-year-old woman with a subacute onset of psychotic and catatonic symptoms in whom current diagnostic criteria for probable anti-NMDAr encephalitis were not fulfilled. On the basis of the red flags that have been proposed to raise suspicion of anti-NMDAr encephalitis, a study of fluorodeoxyglucose positron emission tomography was requested and demonstrated bilateral occipital hypometabolism consistent with clinical suspicion of anti-NMDAr encephalitis. Once the appropriate treatment was established, the patient recovered completely. This case supports the need to maintain clinical suspicion of anti-NMDAr encephalitis, even when conventional diagnostic tests have been normal. Psychiatrists should be familiar with this entity to promote timely diagnosis and prompt treatment.

Catatonia in patients with anti-NMDA receptor encephalitis.

AIM: There is a lack of studies related to the frequency, phenomenology, and associated features of catatonic syndrome in patients with anti-NMDA receptor encephalitis (ANMDARE). This study aimed to measure the frequency of catatonia in this condition and to delineate its particular symptoms. METHODS: A prospective study was done with all inpatients who fulfilled the criteria of definite ANMDARE admitted to the National Institute of Neurology and Neurosurgery of Mexico from January 2014 to September 2018. The Bush-Francis Catatonia Rating Scale and Braünig Catatonia Rating Scale were administered at admission. RESULTS: Fifty-eight patients were included and catatonia was diagnosed in 41 of these patients (70.6%). Immobility, staring, mutism, and posturing were the most frequent catatonic signs. Catatonia was associated with delirium, hallucinations, psychomotor agitation, generalized electroencephalography dysfunction, and previous use of antipsychotics. Mortality was present in 10% of the total sample; it was associated with status epilepticus, and was less frequent in the catatonia group. After immunotherapy, all cases showed a complete recovery from catatonic signs. CONCLUSION: This systematic assessment of catatonic syndrome shows that it is a frequent feature in patients with ANMDARE as part of a clinical pattern that includes delirium, psychomotor agitation, and hallucinations. The lack of recognition of this pattern may be a source of diagnostic and therapeutic errors, as most physicians associate catatonia with schizophrenia and affective disorders.

Red flags for suspecting anti-NMDAr encephalitis in a first psychotic episode: report of two cases. / Banderas rojas para sospechar encefalitis anti-NMDAr en un primer episodio psicótico: reporte de dos casos.

Anti-N-methyl-D-Aspartate receptor (NMDAr) encephalitis is a recently described clinical entity with an increasing number of reported cases. Psychiatric symptoms in the early stages of the disease constitute a diagnostic challenge for the treating physician. We present two clinical cases: clinical case 1, a 26-year-old man, and clinical case 2, an 18-year-old man; both presented with a first episode of psychosis and were hospitalized as psychiatric disorders. Subsequently, both cases were diagnosed as anti-NMDAr encephalitis. The high prevalence of psychiatric symptoms in anti-NMDAr encephalitis forces psychiatrists and neurologists to have a high degree of suspicion in the presence of atypical symptoms in patients evaluated for the first episode of psychosis.

Sexual abuse and neglect situations as risk factors for adolescent pregnancy / Abuso sexual y situaciones de negligencia como factores de riesgo de embarazo adolescente

Abstract Background: In Colombia, one out of five women between the ages of 15 and 19 years have been pregnant. Almost two-thirds (64%) of these pregnancies were unplanned. Objectives: To examine the socio-demographic, psychosocial and clinical risk factors associated with adolescent pregnancy. Methods: An analytical prevalence study was performed using secondary data from the First Demographic Study of Mental Health in Medellin, Colombia. Female adolescents between 13 and 19 years of age were included in the study. The population was evaluated using the Composite International Diagnosis Interview, a structured interview developed by the World Health Organization, which establishes diagnoses according to the DSM-IV and ICD-10 criteria. Results: A sample of 499 female adolescents was obtained, in which 135 adolescent pregnancies were identified, representing a prevalence of 21.5%. The large majority (84.4%) were between 16 and 19 years old. The median age was 17 years, with an interquartile range of 2 years. Almost two-thirds (61.2%) of female adolescents had initiated sexual activity at the age of 15 or later. Almost one-third (31.9%) reported being physically abused during childhood, and 6.7% sexually abused. Of those who were pregnant, 66.7% reported previous sexual abuse. A bivariate analysis showed that sexual abuse (OR = 7.68), childhood negligence (OR = 4.33), and having a partner (OR = 6.31) were factors associated with an adolescent pregnancy. Conclusions: Negligence and sexual abuse in childhood and adolescence can be prevented, and adolescent pregnancies can be decreased. This finding has important implications for clinical management and prognosis, and requires public preventive policies.

Resumen Introducción: En Colombia, 1 de cada 5 mujeres de 15-19 años ha estado embarazada. El 64% de estos embarazos no fueron planeados. Objetivo : Explorar los factores sociodemográficos, psicosociales y clínicos asociados con el embarazo adolescente. Métodos: Estudio de prevalencia analítica, de fuente secundaria (Primer Estudio Poblacional de Salud Mental Medellín). La muestra fue evaluada usando el Compositum International Diagnosis Interview, instrumento desarrollado por la Organización Mundial de la Salud para realizar diagnósticos con base en criterios diagnósticos del DSM-IV y el CIE-10. Resultados Se obtuvo una muestra de 499 adolescentes. Se identificaron 135 embarazos adolescentes, lo que lleva a una prevalencia de embarazo adolescente del 21,5%. El 84,4% de las adolescentes embarazadas tenían entre 16 y 19 años, y la edad mediana era 17 [intervalo intercuartílico, 2] anos. El 61,2% de ellas iniciaron la vida sexual a los 15 años. Del total de adolescentes, el 31,9% afirmaba haber sufrido maltrato físico y el 6,7%, haber sido violadas en la niñez. Del subgrupo de embarazadas, el 66,7% reportó haber sufrido violación. En el modelo bivariable, las variables que mostraron asociación con el embarazo adolescente fueron ser víctima de violación (odds ratio [OR] = 7,68), negligencia en la niñez (OR = 4,33) y tener pareja (OR = 6,31). Conclusiones: La negligencia y el abuso sexual en la infancia pueden evitarse buscando impactar positivamente el embarazo adolescente.