Volume 5 Issue 6 June 2015
Introduction: The etiopathogenesis of psychosis is complex and multifactorial. Neurodevelopmental cause, dopaminergic hypothesis are widely accepted etiology for psychosis. This article highlights the role of immune hypothesis in psychosis. Antibodies to N-methyl – D – aspartate receptor (NMDAR) and the voltage-gated potassium channel complex (VGKC) have been described in patients with schizophrenia. Although NMDAR encephalitis and schizophrenia are clinically distinct entities, the link between psychosis and antibody associated disease has been reinforced by the detection of anti- NMDAR antibodies in patients with psychosis only.
NMDAR antibody encephalopathy: It is rapidly progressive neurological illness in young women characterised by
prolonged psychosis or altered behaviour, followed by a life-threatening state of autonomic instability, coma and dystonic movement disorder and an underlying ovarian teratoma. The antibodies are highly specific, demonstrably absent in large numbers of healthy and disease controls.
VGKC antibody encephalopathy: Patients having antibodies against components of the voltage-gated potassium
channel complex presents, usually present to psychiatric services with symptoms of agitation, hallucinations or behaviour change associated with amnesia and seizures. In few cases antibodies are only discovered following the development of hyponatraemia or seizures.
Antibodies in Schizophrenia & Psychoses: Steiner & Colleagues compared 121 patients with acute presentations of
schizophrenia vs. 70 patients with major depression, 38 patients with borderline personality disorder, and 230 healthy
matched controls. 12 of 121 (9.9%) schizophrenic patients were found to be antibody positive in serum, but two were
retrospectively deemed to have been misdiagnosed cases of NMDAR encephalitis against fewer antibody-positive
samples in the borderline personality disorder (0/38), major depression (2/70), and healthy control (1/230) groups.
Clinical implications: If paraneoplastic causes are excluded, are aggressive treatment with intravenous
methylprednisolone and early reduction in the antibodies with plasma exchange, intravenous immunoglobulin or both,
and/or combined with longer-term high-dose steroids or another immunosuppressive drug is advisable.
Now is the high time for young generation to understand the disaster these drugs cause in total rather than using them to escape hard realities of life. The management aims at each level including family, society, health care providers to help these patients in their rehabilitation.
Conclusion: Psychiatrists need to be vigilant in patients presenting with first episode psychosis and rule out the NMDAR and VGKC mediated encephalitis as early diagnosis and treatment can save mortality in patient by investigating the NMDAR & VGKC antibody levels in serum and/or CSF. Further studies are needed to assess the prevalence and role of antibodies in disease pathogenesis and the extent of clinical improvement upon immunotherapy in schizophrenia and psychoses.
Lecturer, Dept Of Psychiatry. MGM Medical College & Hospital, Navi Mumbai
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