This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Copyright © 2017 Cruz Fourcade, J. F. josefernando.cruz@salud.madrid.org
Cruz Fourcade, J.F.1; García Poggio, M.1; Martín Aragón, R.1; Molina
Cambra, R.1; Muñoz Domenjó, A.1
1Hospital General Universitario de Móstoles. Madrid. Spain.
Introduction
This paper is a review of literature about the relation in some
cases between psychotic symptoms and NMDA antibodies.
Initially, typically Neurologist or Internal Medicine doctors are
called to valuate this patients, and they usually ask for several
complementary petitions, as: complete blood exam (with
autoinmunity and tumoral markers), Computed axial
tomography, magnetic resonance imaging,
electroencephalogram ; to mention some of the most
requested petitions.
Usually they found NOTHING wrong with this tests, but they
cannot explain the symptoms; so they decide to “call the
psychiatrists” bewaring that the patient could be “crazy”, until
the cerebro-spinal fluid analysis has the verdict: Positive NMDA
antibodies.
Most of these cases are early observed and treated by
psychiatry, observing torpid evolution and symptoms that are
rarely observed in Psychiatry patients, like visual hallucinations
or rapid fluctuations of symptoms .
Objectives
Make a review of psychotic symptoms and NMDA antibodies,
to think about other options when we are in front of some
unusual cases in psychiatry, and it seems that “nothing is
working”
Methods
Systematic review of Pub Med literature, applying the
keywords: “psychotic” and “NMDA antibodies” of last 5 years.
Psychotic symptoms in patients with NMDA antibodies
Results
We found that in most of cases the patients presents
rhythmic and non-rhythmic involuntary movements of the
mouth and jaw, catatonia, extrapiramidal symptoms and
Opisthotonus, and most of them had a psychiatric
evaluation for those symptoms. Psychotic symptoms are
observed in 65% of encephalitis cases with antibodies
against NMDA-R. The syndrome predominantly presents in
young women with 60% of them having a neoplasm
(usually, ovarian teratoma).
There was no response to antipsychotics treatment. The
treatment is with immunotherapy: Intravenous (IV) Ig,
Corticosteroids or Plasmapheresis. If there is less than
adequate or no response, treatment is with second line
therapy of Cyclophosphamide or Rituximab. After recovery,
some recommend continued immunosuppression for at
least 1 year in view of relapses. Up to 75 % of patients
recover.
Conclusions
In Psychiatry we have to think in some cases that maybe
“the patient could have something else than a psychiatric
disease”, most when we found that the symptoms has a
rare presentation and the treatment is not effective.
Anti-NMDA receptor encephalitis gives us the opportunity to
reconsider the rigid boundaries between neurology and
psychiatry. Future research should aim for a non-
reductionistic integration of these two disciplines.
We encourage our colleagues to “think outside the box”
when something like this occurs, and hesitate about our
own valuations of the patients, when the case is atypical
strange.
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