Metro South Addiction and Mental Health, Brisbane, Australia.
University of Queensland, Brisbane, Australia.
Psychol Med. 2021 Feb;51(3):435-440. doi: 10.1017/S0033291719003283. Epub 2019 Nov 19.
Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder which requires multi-disciplinary treatment including immunomodulation therapy. First presentation is most commonly to psychiatric services and continuing psychiatric care is required to treat disabling symptoms, such as behaviour disturbance, psychosis and catatonia. There is minimal available evidence to guide symptomatic treatment and concern for increased sensitivity to antipsychotics complicates traditional approaches.
All cases of cerebrospinal fluid positive anti-NMDAR encephalitis tested in Queensland, Australia were identified. Demographic, clinical and therapeutic data were collected and reviewed by two independent clinicians. Pre-specified variables reflecting possible treatment side effects were compared.
The majority of the 30 cases (83%) had early psychiatric symptoms and were treated with antipsychotics (67%), average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, there was little improvement in psychosis, affective symptoms or catatonia with antipsychotics alone. In the cases with psychiatric symptoms, there was no significant difference in the rate of occurrence of neurological and autonomic symptoms between cases prescribed and not prescribed antipsychotics.
Psychiatric input is imperative for both acute and longer-term management of anti-NMDAR encephalitis. Primary symptomatic treatment should remain immunotherapy and surgery. Antipsychotic medications have particular value in managing agitation and aggression. Potential side effects from antipsychotic treatment are difficult to differentiate from progression of anti-NMDAR encephalitis but there was no evidence in this cohort of increased antipsychotic sensitivity. Treatment with psychotropic medication should be individualised and adjusted during the course of the illness.
抗 N-甲基-D-天冬氨酸受体（NMDAR）脑炎是一种免疫介导的疾病，需要包括免疫调节治疗在内的多学科治疗。首次就诊最常到精神科，需要持续的精神科护理来治疗致残症状，如行为障碍、精神病和紧张症。目前几乎没有可用的证据来指导对症治疗，而对抗精神病药物敏感性增加的担忧使传统方法复杂化。
在澳大利亚昆士兰州鉴定了所有脑脊液阳性抗 NMDAR 脑炎的病例。收集并由两名独立临床医生审查了人口统计学、临床和治疗数据。比较了反映可能治疗副作用的预定义变量。
大多数 30 例（83%）有早期精神病症状，在免疫调节治疗前接受了抗精神病药物（67%）治疗，奥氮平的平均日等效剂量为 11.5mg。尽管攻击行为的病例减少了 88%，但单独使用抗精神病药物对精神病、情感症状或紧张症的改善甚微。在有精神病症状的病例中，处方和未处方抗精神病药物的病例发生神经和自主症状的发生率没有显著差异。
精神病学的投入对于抗 NMDAR 脑炎的急性和长期管理都是至关重要的。主要的对症治疗应仍然是免疫疗法和手术。抗精神病药物在治疗激越和攻击方面具有特殊价值。抗精神病药物治疗的潜在副作用难以与抗 NMDAR 脑炎的进展区分开来，但在本队列中没有证据表明抗精神病药物敏感性增加。治疗精神药物应个体化，并在疾病过程中进行调整。
