Organic Psychosis

CPC 13th Sep 2018

DR ZAHIRUDDIN OTHMAN
PSYCHIATRY, PPSP USM
Psychosis vs. Neurosis

Neurosis
Psychosis
Emotional instability
Hallucinations & delusions
Severe impairment
Loss of reality testing/ ego
boundary
Organic vs. Functional Disorder

Identifiable
secondary
causes
Structural
Attention,
lesion or
cognitive &
physiological
visual
dysfunction of
symptoms
the brain

Organic
Delirium vs. Psychotic Disorder

Delirium
•Acute generalized cognitive disturbance
•Transient, usually reversible cerebral
dysfunction
•Major attention deficit, reduced awareness of
surrounding, fluctuating course

Psychotic disorder due to GMC

•Occurs in clear consciousness
Viral infection & Mental Disorders

 In utero Infection
 increased risk of schizophrenia in the offspring
 Flu, rubella, herpes, toxoplasmosis
 Mechanism?
 Immune-mediated damage to developing brain
 Dormant infection

 Chronic infection & neuropsychiatric symptoms

 HIV, Herpes
Herpes Simplex Encephalitis &
Psychosis

 Herpes encephalitis as a cause of psychosis is rare, affecting about 1 per

200,000 cases per year
 HSV psychosis is probably caused by inhibition of NMDA receptor (Klein, 2015)
 HSV glycoprotein on microglia
 direct inhibition by HSV antibody
 It typically presents as psychomotor agitation, fever, headache, visual
hallucination, paranoia, seizures, and altered level of consciousness (Steadman,
1992)
 Prodromal symptoms days to weeks

H. C. Klein, J. Doorduin, L. de Witte, and E. F. de Vries, “Microglia activation, herpes infection, and NMDA receptor inhibition: common pathways to psychosis?” in Immunology and
Psychiatry, vol. 8 of Current Topics in Neurotoxicity, pp. 243–254, 2015
P. Steadman, “Herpes simplex mimicking functional psychosis,” Biological Psychiatry, vol. 32, no. 2, pp. 211–212, 1992.
A case report

 55-year-old woman diagnosed with HSE  treated with acyclovir

 6 month later, abrupt onset of psychosis  confused & agitated
 MRI showed gliosis at temporal/frontal lobes  consistent with previous HSE
 EEG was normal
 The patient remain unresponsive to antipsychotics for 7 months
 Dramatically improved with carbamazepine 400mg twice daily

Gaber TAK, Eshiett M. Resolution of psychiatric symptoms secondary to herpes simplex encephalitis. Journal of Neurology, Neurosurgery & Psychiatry 2003;74:1164.
 HSE can trigger anti-NMDA receptor encephalitis

 A 24-year-old man presented with a 24-hour history of confusion,

delusional thoughts, and disorientation  diagnosed as HSVE
 6-week post HSVE, presented with manic symptoms
 CSF negative for HSV, no new necrotic lesions, and no response to acyclovir
 IgG NMDAR antibodies were detected in CSF (titer 1:160) and serum (1:800)
 Started on IV methylprednisolone 1,000 mg (day 48 post HSVE) for 5 days
followed by oral tapering
 At 160-day post HSVE, symptoms had further improved

Leypoldt F, Titulaer MJ, Aguilar E, et al. Herpes simplex virus–1 encephalitis can trigger anti-NMDA receptor encephalitis: Case report. Neurology.
2013;81(18):1637-1639
Infection in Mental Disorders

Genetic or other Chronic persistent

vulnerabilities infection

Exposure to agent And/or

Initial infection
Mental and/or Agent persist in
physical stress inactive states

Chronic stress

Generalized stress
Inactive state
response
Vicious cycle become active
Decrease immune
functioning

Injury as a result of pathology

such as vasculitis, direct cell
Progression of disease
injury, inflammation,
autoimmune & excitatory
Conclusions

 Organic psychotic disorder should be

suspected
 Atypical of functional disorders
 Medical condition affecting the
nervous system
 Viral infection has a role in the
development of a psychiatric disorder
 Neurodevelopmental
 Neuropsychiatric symptoms or
sequelae