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Anti-N-methyl-d-aspartate receptor encephalitis: A targeted review of clinical presentation, diagnosis, and approaches to psychopharmacologic management

Jennifer L. Kruse, MD*

Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA

Jessica K. Jeffrey, MD, MPH, MBA*

Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA

Michael C. Davis, MD, PhD

VA Greater Los Angeles, Los Angeles, California, USA, Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA

Joanna Dearlove, MD, MPH

Department of Neurology, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA

Waguih William IsHak, MD, FAPA

Department of Psychiatry and Behavioral Neurosciences, Cedars-Sinai Medical Center, Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA

John O. Brooks III, PhD, MD

Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine at UCLA, Los Angeles, California, USA

*These authors contributed equally

BACKGROUND: Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis was formally described in 2007 and includes a range of psychiatric and neurologic symptoms. Most patients with anti-NMDAR encephalitis initially present to psychiatrists for diagnosis and treatment. However, there is limited literature summarizing treatment strategies for psychiatric symptoms. In an effort to improve identification and treatment, this review article provides an overview of anti-NMDAR encephalitis, with a focus on psychopharmacologic treatment strategies. Two case reports provide a clinical context for the literature review.

METHODS: The authors conducted a PubMed search.

RESULTS: Prominent psychiatric symptoms of anti-NMDAR encephalitis include psychosis, agitation, insomnia, and catatonia. Neuroleptics may be helpful for managing psychosis and agitation, but may exacerbate movement abnormalities. Diphenhydramine and benzodiazepines are helpful for agitation and insomnia. In addition, the anticholinergic affinity of diphenhydramine can improve dystonia or rigidity attributable to anti-NMDAR encephalitis, while benzodiazepines and electroconvulsive therapy have been used for catatonia associated with this condition.

CONCLUSIONS: Psychiatrists play an important role in the diagnosis and treatment of anti-NMDAR encephalitis. Recognizing the typical clinical progression and closely monitoring for accompanying neurologic symptoms will facilitate diagnosis and timely treatment. Careful selection of psychopharmacological interventions may reduce suffering.

KEYWORDS: N-methyl-d-aspartate receptor, limbic encephalitis, behavioral symptoms, benzodiazepines, antipsychotic agents

ANNALS OF CLINICAL PSYCHIATRY 2014;26(2):111-119

CORRESPONDENCE: John O. Brooks III, PhD, MD, UCLA Semel Institute, 760 Westwood Plaza, B3-267, Los Angeles, CA 90024-1759 USA E-MAIL: john.brooks@ucla.edu
Annals of Clinical Psychiatry ©2014 Quadrant HealthCom Inc.

 
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