Bechter Karl, Deisenhammer Florian
Clinic for Psychiatry and Psychotherapy II, Ulm University, Bezirkskrankenhaus Günzburg, Günzburg, Germany.
Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
Handb Clin Neurol. 2017;146:285-296. doi: 10.1016/B978-0-12-804279-3.00017-4.
There is wide variability in how psychiatry guidelines and textbooks address the question of cerebrospinal fluid (CSF) diagnostics in the screening of psychiatric disorders. A United States-based textbook confirms that there is no consensus about which laboratory investigation should be routinely performed in psychiatric patients, but with respect to CSF diagnostics, the differences are even more striking. A survey among European experts showed a wide variety of opinions regarding clinical use and criteria in various countries of Europe and worldwide: some psychiatrists, mostly university hospital-based, recommended performing CSF diagnostics in every patient first experiencing severe mental illness (SMI), but especially in patients from the schizophrenia spectrum, whereas others almost never perform CSF examinations themselves and usually refer patients to neurology departments if necessary. Minor neurologic signs are generally frequent in SMI, mainly in affective and schizophrenic disorders. Even with neurologic signs present, there are no clear guidelines regarding CSF evaluation, leaving doctors with experience-based decision making. However, the field is evolving. A recent review provides helpful yellow and red flags for differential diagnosis of SMI from autoimmune encephalitis; interestingly, minor CSF abnormalities are considered a red flag, suggesting that CSF should be routinely performed in acute psychiatric patients. There are reports of single cases identified as an established neurologic disorder: patients within affective and schizophrenic spectrum disorders systematically underwent CSF examination, and were rediagnosed based on CSF results. This was often to the surprise of the psychiatric doctors. Overall, an increasing number of psychiatrists believe that CSF is too rarely examined in psychiatric patients. This chapter provides an overview of differential diagnostic issues in SMI, particularly for new-onset cases. The general recommendations regarding CSF examination procedures can be found in other chapters of this book. Here we focus on specific aspects of differential diagnosis in SMI. Also, there will be an overview of admittedly limited CSF research efforts in psychiatric disorders, focusing on more recent CSF studies. CSF studies in SMI performed with state-of-the-art methods, for example proteomics or assessments of cytokines, were intriguing but difficult to interpret and required critical considerations regarding respective methodology, an undertaking which is outside the scope of this chapter.
在精神疾病筛查中，精神病学指南和教科书在如何处理脑脊液（CSF）诊断问题上存在很大差异。一本美国的教科书证实，对于精神科患者应常规进行哪些实验室检查尚无共识，但就脑脊液诊断而言，差异更为显著。一项针对欧洲专家的调查显示，在欧洲各国及全球范围内，关于临床应用和标准存在各种各样的观点：一些精神科医生，大多来自大学医院，建议对每一位首次出现严重精神疾病（SMI）的患者进行脑脊液诊断，尤其是精神分裂症谱系的患者，而另一些人几乎从不亲自进行脑脊液检查，必要时通常将患者转诊至神经科。轻微神经体征在严重精神疾病中通常很常见，主要见于情感性和精神分裂症性障碍。即使存在神经体征，关于脑脊液评估也没有明确的指南，医生只能基于经验进行决策。然而，该领域正在不断发展。最近的一篇综述为鉴别诊断严重精神疾病与自身免疫性脑炎提供了有用的警示信号；有趣的是，轻微脑脊液异常被视为一个警示信号，这表明在急性精神科患者中应常规进行脑脊液检查。有报告称个别病例被确诊为一种已明确的神经疾病：情感性和精神分裂症谱系障碍患者系统地接受了脑脊液检查，并根据脑脊液结果重新进行了诊断。这常常让精神科医生感到惊讶。总体而言，越来越多的精神科医生认为精神科患者很少进行脑脊液检查。本章概述了严重精神疾病的鉴别诊断问题，特别是新发病例。关于脑脊液检查程序的一般建议可在本书的其他章节中找到。在此我们重点关注严重精神疾病鉴别诊断的具体方面。此外，还将概述在精神疾病方面公认有限的脑脊液研究工作，重点是最近的脑脊液研究。使用蛋白质组学或细胞因子评估等先进方法在严重精神疾病中进行的脑脊液研究很有趣，但难以解释，并且需要对各自的方法进行批判性思考，这一工作超出了本章的范围。
