Anti-NMDA Receptor Encephalitis: Differential Diagnosis in Psychosis

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This paper gives a critique of a study conducted by Barry et al. Barry et al. conducted a study on Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis to gauge whether it can be used as differential diagnosis in psychosis. NMDA receptor encephalitis is a type of encephalitis with an autoimmune etiology. It develops when antibodies attack and destroy NRI and NR2 subunits of the Anti-N-methyl-D-aspartate receptor¹. The condition is found mainly in women. Individuals suffering from NMDA receptor encephalitis present psychotic symptoms. They also they encounter motor and behavior changes¹. In addition, they present autonomic dysfunction and compromised consciousness.

The study was conducted by a team of eight experienced researchers¹. Helen Barry is a physician and a Member of the Royal College of Psychiatrists (MRCPsych). Orla, Hardiman holds a Doctor of Medicine (MD) Degree. He is also a Fellow of the Royal College of Psychiatrists of Ireland (FRCPI). Daniel G. Healy is PHD holder and has been certified by Membership of the Royal College of Ireland (MRCPI). Mary Keogan has also been certified by Membership of the Royal College of Ireland (MRCPI). She is also a pathologist certified by FRCPath (Fellowship Examination of the Royal College of Ireland of Pathologist). Joan Maroney also holds a Doctor of Medicine (MD) Degree, and she has been certified by Membership of Royal College of Ireland (MRCPI). Peter Molnar has a PHD and MD Degree. In addition, he holds a Doctor of Science (D.Sc.) Degree.

David Cotter is a PHD holder and a Member of the Royal College of Psychiatrists (MRCPsych). On the other hand, Kieran Murphy is a PhD holder, a Fellow of the Royal College of Psychiatrists of Ireland (FRCPI) and he has been certified by FRCPath. The researchers are experienced in their fields of study, and they have been certified by distinguished bodies. The study occurred in Dublin Ireland. The peer reviewers of the study indicated that all the authors had an equal contribution. The study was conducted in collaboration with local hospitals, a local university and local examining bodies¹. The correspondence included David Cotter, Department of Psychiatry, Royal College of Surgeons in Ireland, RCSI Education and Research Center and Beaumont hospital in Dublin Ireland.

This article falls in the category of open access, peer reviewed journals. An open access is a communication channel that allows for universal access to peer reviewed scholarly journals. On the other hand, a peer review is a self-regulatory protocol that checks the qualifications of professionals in a given field. The protocol aims at enhancing credibility and maintaining standards. Peer reviews also increase performance. Scholarly peer review is carried out by a team/community of qualified experts in a particular field. The experts are required to give an impartial critique of an author’s/authors’ work, research or ideas before they are sent for publication.

After conducting a review, the experts might decide to accept the work as it is, or, with revisions. On the other hand, the experts might decide to reject the piece of work should it fail to meet the set standards. The process of peer review starts when the editor sends copies of an author’s work to a team of reviewers. This can be done via mail or online manuscript processing system. The reviewers are required to scrutinize the piece of work and then offer their suggestions. The reviewers usually send their comments to the editor who then forwards them to the author. The reviewers act as advisors. However, the editor can either accept or reject their opinion.

The comments from the reviewers come with several options. First, the reviewers might permit the publication of the work in its current form. Second, the reviewers might accept the piece of work on condition that the author agrees to implement the suggested corrections. Third, the reviewers might reject the work but encourage the authors to correct a few issues and then resubmit the work for a second consideration. Fourth, the reviewers might reject the piece of work in case it fails to meet the set standards. Scientific peer reviewers might have conflicting comments. Thus, the editor and the author need to come up with strategic plans to convince the reviewers to approve the piece of work at hand.

This journal article was selected because it gives some new insights in psychiatry. Its manuscript was sent to the British Journal of Psychiatry only. There is no other information suggesting that the manuscript was sent to other journals. The study offered a new proposition in the differential diagnosis of psychosis. The most recent impact factor of the study involves the demonstration of a new and treatable cause of psychosis. This might prompt further studies to shade more light on Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis.

The study is guided by a clear hypothesis; Anti-NMDA receptor encephalitis: an important differential diagnosis in psychosis¹. In addition, the central hypothesis states that psychosis is caused by NMDA receptor hyper-function. The hypothesis is also research driven. The findings of the article rely on three case studies involving four females with confirmed Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis. Psychiatry is an area with high research activity. However, studies involving Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis are limited.

The study’s main aim was to indicate the importance of Anti-NMDA receptor encephalitis in the differential diagnosis of psychosis. The study based its findings on four case studies involving patients with a primary psychiatric disorder at an early stage of their illness. “The first case involved a 19 year old female with no history of psychiatric disorder”¹. The patient had slurred speech and difficulties with concentration and word finding. Routine tests conducted on her appeared normal thus; a provisional diagnosis of a conversion disorder was speculated¹. The patient was found to have antibodies that destroy NMDA receptor.

The second case involved 29 year old female who had generalized tonic-clonic seizure¹. The patient was also found to have autoimmune antibodies that attack the NMDA receptor. The third case also involved a 29 year old female with a history of seizure like activity¹. In the fourth case, a 20 year old female presented slurred speech and fatigue like symptoms¹. The patient’s health deteriorated a month later, and became emotionally unstable.

None of them had a history of psychosis¹. Treatment for the condition included immunomodulatory agents, high dose steroids and IVIg. The findings indicated the key features of Anti-NMDA receptor encephalitis. It required clinicians to be in a position to conduct psychiatric diagnoses. The four patients were found to be anti-NMDA receptor antibody positive¹. However, the patients showed a significant recovery progress when given psychotropic medication.

The psychiatric presentations of the four patients provide a boost to the hypothesis. The findings confirmed that an autoimmune reaction against the anti-NMDA receptor causes psychosis. The researchers indicated that their understanding is a preliminary finding. They argued that the disorder might be under recognized at the moment¹. Therefore, more studies need to be carried out to provide conclusive results. Controversy still rages in cases with pure psychiatric presentation but with low antibody titres¹.

The researchers suggested “a new onset of psychosis that presents catatonia, seizures and dyskinesias calls for a referral to neurology for consideration of this disorder”¹. The literature does not indicate whether Barry et al.’s work has been cited elsewhere. Moreover, there is no data that indicates how the results of this study have been viewed by other researchers in this field.

The paper offers a straight forward explanation of the study conducted by Barry et al. However, the study shows findings from only four cases. A wider research needs to be undertaken that includes patients with varied clinical symptoms. There are no data showing a theoretical framework. In addition, the study should not be done in a single location. The most significant findings of this study involve the diagnosis of psychosis. The study found out that NMDA receptor hyper function leads to the development of psychosis.

The hyper function originates from autoimmune reactions. Auto immune antibodies seem to be the initiators of the autoimmune reaction. The findings also indicated that the disorder is not known to many. The study also “demonstrated a new treatable cause of psychosis”¹. The study conducted by Barry et al. will prompt other research studies on psychosis. Besides, the results of the study revealed significant clinical finding that will be essential in the management of psychotic patients. The study provides a basis for future studies that main investigate novel psychotic treatments. In addition, psychotic diagnostic procedures can be deduced from the study.

Reference

Barry et al. Anti-NMDA Receptor Encephalitis: an important differential diagnosis in psychosis. BJ Psych. [2012]; 1(1): [about 2 pgs.]. Web.

Footnotes

Barry et al.

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Anti-NMDA Receptor Encephalitis: Differential Diagnosis in Psychosis

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