Organic psychosis

Clinical Pathology Conference (CPC)
Date: 13/9/2018
Venue: DK4

1. Organic Psychosis
CPC 13
th
Sep 2018
DR ZAHIRUDDIN OTHMAN
PSYCHIATRY, PPSP USM

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

3. Organic vs. Functional Disorder
Organic
Structural
lesion or
physiological
dysfunction of
the brain
Identifiable
secondary
causes
Attention,
cognitive &
visual
symptoms

4. 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

5. 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

6. 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.

7. 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.

8. 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

9. Infection in Mental Disorders
Genetic or other
vulnerabilities

Exposure to agent

Mental and/or
physical stress
Chronic stress

Generalized stress
response

Decrease immune
functioning
Chronic persistent
infection

And/or

Agent persist in
inactive states
Inactive state
become active
Injury as a result of pathology
such as vasculitis, direct cell
injury, inflammation,
autoimmune & excitatory
Progression of disease
Initial infection
Vicious cycle

10. 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