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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 186-188

Blurring the boundaries of organic and functional psychosis


Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India

Date of Submission06-Apr-2022
Date of Decision17-May-2022
Date of Acceptance07-Jun-2022
Date of Web Publication19-Aug-2022

Correspondence Address:
Dr. Debolina Chowdhury
Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_58_22

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  Abstract 


Organic and non-organic illnesses may present with uncommon symptoms. In some cases, the presenting atypical symptoms make a prompt and accurate diagnosis difficult. Accordingly, unequivocal psychotic and affective symptoms also require adequate evaluation before determining the diagnosis and management. Here we present a case whose presenting symptoms strongly suggested an organic etiology, namely autoimmune psychosis, but failed to be diagnosed as such through laboratory tests and didn't respond to appropriate treatment. Re-evaluation of the case revealed significant past psychiatric history, suggesting functional psychosis but the patient did not respond to anti-psychotic medications either. This case therefore highlights the importance of complete unbiased work-up for all psychoses.

Keywords: Autoimmune encephalitis, anti-NMDA receptor encephalitis, atypical, schizophrenia, differential diagnosis, psychotic symptoms


How to cite this article:
Chowdhury D, Spoorthy MS, LungePatil SV, Gupta P. Blurring the boundaries of organic and functional psychosis. Ann Indian Psychiatry 2022;6:186-8

How to cite this URL:
Chowdhury D, Spoorthy MS, LungePatil SV, Gupta P. Blurring the boundaries of organic and functional psychosis. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Sep 30];6:186-8. Available from: https://www.anip.co.in/text.asp?2022/6/2/186/354120




  Introduction Top


Classificatory systems have delineated organic and nonorganic/functional psychosis based on the presence of obvious physical defect or damage to the brain. However, this differentiation does not seem to be valid or accurate as often there is overlap in symptoms. Furthermore, the term “psychosis” is used to describe the cluster of signs and symptoms occurring as a result of multiple causes such as medical/surgical disorders, neurological disorders, drug use, and physiological defect in the brain. However, to label something as “functional psychosis,” all the above-mentioned causes must be excluded.[1]

In some cases, the atypical presenting symptoms make a prompt and accurate diagnosis difficult and delay the initiation of correct treatment. A bird's eye view approach to avoid biased diagnostic impressions based simply on their presentation is important.

Accordingly, unequivocal psychotic and affective symptoms also require adequate evaluation before determining the diagnosis and management. This overlap between the symptoms of organic neurological conditions and psychiatric illnesses often leads to psychiatric patients presenting to neurologists for treatment, and vice versa, creating a symbiotic relationship between the two specialties.

We hereby report a case who presented to us with a confusing picture of functional psychosis but in due course of treatment, the “organic” domain unfolded. Informed consent was obtained from the patient and relatives before reporting.


  Case Report Top


A 50-year-old female presented with abnormal involuntary movements and confused behavior. She had a 3-month history of abnormal jerky limb movements, clenching of her jaw, frothing, and postepisode disorientation (four episodes). She was immobile and had poor oral intake.

On examination, all the four limbs were rigid, with tremors in both hands. Bilateral plantars were flexor. No neck rigidity was seen, and Kernig's sign was negative. The patient was admitted to the neurology ward as possible autoimmune encephalitis.

Routine blood investigations, thyroid tests with serum anti-thyroid peroxidase (anti-TPO) and serum anti-thyroglobulin antibodies (anti-TGAb), serum B12, and ammonia levels were normal. Magnetic resonance imaging (MRI) brain with contrast, cerebrospinal fluid studies (CSF) (total leukocyte count/differential leucocyte count, protein/sugar, Herpes simplex virus-polymerase chain reaction, and oligoclonal bands), and ultrasound abdomen/pelvis were unremarkable. Electroencephalogram (EEG) reported occasional evidence of beta over the delta, suggestive of the delta brush. While waiting for the reports of a complete autoimmune encephalitis panel, later known to be negative, antibiotics, antiepileptics, and injection methylprednisolone 1 mg once daily for 5 days was started. Injection lorazepam 2 mg twice a day was given to rule out catatonia, but it did not improve her condition. During hospitalization, she developed deep-venous thrombosis for which adequate referral and management were done.

After 20 days of hospitalization and extensive tests and medications, the patient's condition did not improve and a psychiatrist's opinion was requested.

The psychiatric evaluation revealed a behavioral change for 5 months, after spotting suspicious objects placed near her shop. She believed that her neighbor had cast a spell on her to bring her family misfortune and would not get convinced otherwise, despite contrary evidence. Subsequently, she developed a nonproductive cough (without pyrexia, breathlessness, or rhinorrhea) which intensified her belief in witchcraft. She became suspicious of people around her and appeared to be in constant fear of ill luck. During the day, she would be withdrawn and aloof, and at night, unable to sleep, she would complete her household chores. The patient claimed that she was losing control of her mind.

After 2 months, infrequent episodes of abnormal involuntary movements started. The patient was taken to faith healers and took ayurvedic medications. The patient's suspiciousness and irritability continued, and the patient started believing that her tongue had been cutoff and that she had swallowed it. Purposeless, uncharacteristic jerky movement of her limbs gradually got worse and she became withdrawn from her surroundings, appeared apathetic, and her biological and interpersonal relations further deteriorated. Her condition continued to worsen and her behavior became increasingly bizarre and disorganized. In one instance, she was found in the middle of the night, on her bed, with feces smeared over her body.

She acted peculiarly-repeating, seemingly meaningless movements of her hands and arms, mimicking things said or asked, or not responding to people or her environment. Tablet quetiapine 50 mg HS was started, and the patient was transferred to the psychiatry ward.

The patient was uncooperative for most parts of the mental status examination and her affect appeared to be predominantly anxious with almost inaudible speech and delayed reaction time. The delusions of persecution and reference were apparent from her interaction, but she denied any form of hallucinations. Higher function evaluation was grossly impaired, but she was oriented and denied having any illness at all.

Over 2 weeks, tablet quetiapine was gradually increased to 200 mg, and she became verbally responsive to conversation and commands, food intake improved, abnormal jerky movements of limbs, and the rigidity decreased allowing the patient to walk with support. She tolerated the antipsychotic treatment well and showed no signs of adverse effects and hence was discharged.

During follow-ups, after initially maintaining well, her daughter reported that the patient would say irrelevant things, would frequently cry for no apparent reason, and appeared to be fearful, constantly scanning her environment.

Her body had abnormal jerky movements with perioral movements, abnormal blinking, even at night. The patient's appetite increased leading to her eating at odd times of the day, and sometimes even uncooked food. During the OPD visits, she remained quiet and seemed to be anxious. Despite tablet quetiapine 400 mg HS, her condition further deteriorated wherein she had stopped eating food, drinking water, and started soiling her clothes. The patient was admitted again.

Tablet sodium valproate was added and gradually increased to 750 mg in divided doses. She was given intravenous fluids as oral intake was poor. A physician's opinion was taken to rule out organic causes, hyperammonemia was revealed and treatment started accordingly. Following the physician's suggestion for a less sedating antipsychotic and a lower dose of sodium valproate, quetiapine was cross tapered with amisulpride, and the dose of the latter was gradually increased to 100 mg at night. During periodic routine blood investigations, hyponatremia was revealed, and its correction was initiated. Unexpectedly, the patient had two episodes of seizures in the psychiatry ward, hence was shifted to the intensive care unit where low sodium correction continued, and Tablet brivaracetam 50 mg BD and Tablet sodium valproate 500 mg OD was added. EEG was normal. When her general medical condition stabilized, she was shifted back to the psychiatry ward. The dose of amisulpride was gradually increased to 300 mg HS.

In the following few days, her general condition and personal care progressively improved. Regular physiotherapy sessions helped her to gradually walk with support. Despite advice to continue in-patient care, she was discharged on her family's request.

The last 2 months since her discharge, she has been visiting the OPD regularly and her family members claim she maintains a 40%–50% improvement.


  Discussion Top


This report discusses about an interesting case of organic brain syndrome which posed several challenges in the diagnosis and management to the treating team.

As described by the family, there was an acute onset of paranoid delusions, which progressed into a mixture of neurological and psychiatric manifestations. The probability of a clear-cut psychiatric diagnosis gets questioned considering the history of seizure episodes, involuntary and abnormal limb movements, and rigidity at the major limb joints. Moreover, the course and progression of the illness are suggestive of autoimmune encephalitis[2] or autoimmune psychosis, which is when a patient presents predominately with psychotic symptoms, without or with minimum neurological manifestations, and who later test positive for antibodies and respond well to immunosuppression therapy.[3],[4]

In the index case, extensive workup showed negative autoimmune encephalitis panel report, including the anti-GluN1 antibody, normal CSF and EEG, MRI reports, and no improvement on first-line immunosuppression trial (methylprednisolone). Hence, despite the clinical picture, as the investigations suggested otherwise possibility of “functional psychosis” was considered. However, trials of lorazepam and antipsychotic medications showed unsatisfactory improvement.

Due to limited improvement, it is necessary to re-evaluate and consider alternative possibilities such as seronegative autoimmune encephalitis, for which a second-line immunotherapy trial of cyclophosphamide or rituximab is required.[5] Pragmatically, it appears to be an “organic brain syndrome,” an old but appropriate term in this case.

Although these are rare entities considering them in the differential diagnosis of such patients is important. This way we can ensure we will not miss potentially treatable conditions. Despite being a severe illness, early identification and treatment with immunotherapy make the prognosis better in such patients.[6]


  Conclusion Top


This reports highlight two important issues. First, the emergency team and physicians should be aware of the probable organic etiology of psychiatric presentations like in this case seronegative autoimmune encephalitis. Second, normal investigations at screening should not be a case of exclusion for organic etiology. A high index of suspicion, repeated physical and psychiatric examination with thorough investigations will lead the clinicians to the cause and serve as a guide for treatment.

Declaration of patient consent

The authors corroborate that informed consent was obtained from the patient and her husband in which they verify that they have consented to the publication of the patient's clinical case and supportive information and all efforts to maintain the patient's anonymity will be made but cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dilsaver SC. Differentiating organic from functional psychosis. Am Fam Physician 1992;45:1173-80.  Back to cited text no. 1
    
2.
Lancaster E. The diagnosis and treatment of autoimmune encephalitis. J Clin Neurol 2016;12:1-13.  Back to cited text no. 2
    
3.
Pollak TA, Lennox BR, Müller S, Benros ME, Prüss H, Tebartz van Elst L, et al. Autoimmune psychosis: An international consensus on an approach to the diagnosis and management of psychosis of suspected autoimmune origin. Lancet Psychiatry 2020;7:93-108.  Back to cited text no. 3
    
4.
Amugoda C, Chini Foroush N, Akhlaghi H. Anti-NMDAR encephalitis: Higher suspicious needed for earlier diagnosis (Case Report, Literature Review and Diagnostic Criteria). Case Rep Neurol Med 2019;2019:7476254.  Back to cited text no. 4
    
5.
Vadagandla K, Jahagirdar V, Rama K. The diagnostic challenge of seronegative autoimmune encephalitis with super-refractory status epilepticus. Cureus 2020;12:e11587.  Back to cited text no. 5
    
6.
Steiner J, Prüss H, Köhler S, Frodl T, Hasan A, Falkai P. Autoimmune encephalitis with psychosis: Warning signs, step-by-step diagnostics and treatment. World J Biol Psychiatry 2020;21:241-54.  Back to cited text no. 6
    




 

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