Diagnosing autoimmune encephalitis in psychiatry: clinical recommendations and unresolved challenges from the GENERATE network
Abstract
Psychiatric syndromes can be caused by underlying autoimmune encephalitis (AE). This represents a diagnostic challenge at the interface of psychiatry and neurology. While AE mostly manifests with a combined, complex neuropsychiatric syndrome, some patients with AE may (initially) present with predominant or isolated psychiatric symptoms. These cases can be difficult to classify, and diagnostic approaches vary considerably across clinical settings. This paper from the GErman NEtwork for Research on AuToimmune Encephalitis (GENERATE) provides interdisciplinary expert recommendations from psychiatry and neurology for the diagnostic evaluation of patients with suspected AE as the cause of psychiatric syndromes for psychiatric care settings. It integrates current scientific evidence with practical, empirical considerations from routine clinical care in different healthcare settings. The proposed diagnostic approach to detect psychiatric manifestations of AE emphasizes a rational, stepwise evaluation incorporating clinical assessment, magnetic resonance imaging, electroencephalography, blood testing, cerebrospinal fluid (CSF) analysis, and neuronal/glial antibody testing in serum and CSF. In diagnostically ambiguous individuals, [¹⁸F]fluorodeoxyglucose positron-emission-tomography and advanced antibody testing (e.g., live-cell-based assays) or neuroimaging techniques (e.g., volumetric analysis) may provide additional supportive information. Typical findings and limitations of diagnostic modalities are discussed to facilitate appropriate interpretation and to avoid under-recognition or overdiagnosis. Importantly, these recommendations do not aim to define new disease entities or diagnostic criteria, but rather to support a harmonized and pragmatic diagnostic approach to patients presenting with psychiatric syndromes suspected to be caused by underlying AE. Finally, key unresolved issues in this evolving field of immunopsychiatry are outlined, and promising research strategies are described.
// Source
Authors: Dominique Endres, Katharina von Zedtwitz, Ludger Tebartz van Elst, Katharina Domschke, Judith Weiser, Arnim Johannes Gaebler, Thomas Frodl, Elias M. Wagner, Iris Jäger, Alkomiet Hasan, Josef Priller, Cora Schefft, Paul Wirsching, Sibylle Haußleiter, Georg Juckel, Philipp Müller, David H. V. Vogel, Alexandra Philipsen, Timo Jendrik Faustmann, Daniel Kamp, Leonhard Schilbach, Dag Scherfeld, Milenko Kujovic, Eva Meisenzahl, Stefanie Fischer, Jonathan Repple, Udo Dannlowski, Niels Hansen, Karl Bechter, Oliver Tüscher, Heiko Paland, Daniel Luedecke, Hannah B. Maier, Margarete Mattern, Michael Kluge, Alexandra Neyazi, Johann Steiner, Sebastian Walther, Ilya Ayzenberg, Manuel Alexander Friese, Tania Kümpfel, Sven Guenther Meuth, Kevin Rostasy, Simone C. Tauber, Franziska S. Thaler, Klaus-Peter Wandinger, Brigitte Wildemann, Carsten Finke, Jan Lewerenz, Christian Geis, Nico Melzer, Harald Prüß, Frank Leypoldt
Institutions: Charité - Universitätsmedizin Berlin, Düsseldorf University Hospital, Heinrich Heine University Düsseldorf, Otto-von-Guericke-Universität Magdeburg, Leipzig University, Ludwig-Maximilians-Universität München, Heidelberg University, University Hospital Heidelberg, University of Edinburgh, Universitätsklinikum Würzburg, Universitätsklinikum Aachen, RWTH Aachen University, University of Münster, Carl von Ossietzky Universität Oldenburg, Universität Hamburg, University Medical Center Hamburg-Eppendorf, Humboldt-Universität zu Berlin, German Centre for Cardiovascular Research, University of Freiburg, Goethe University Frankfurt, University of Lübeck, Technical University of Munich, University Hospital Schleswig-Holstein, Ruhr University Bochum, Martin Luther University Halle-Wittenberg, Jena University Hospital, University Medical Center Freiburg, University of Augsburg, Medizinische Hochschule Hannover, Universität Ulm, Bethel University, LMU Klinikum, UK Dementia Research Institute, St. Josef-Hospital, German Center for Neurodegenerative Diseases, LWL-Universitätsklinikum Bochum, University Hospital Bonn, Christian-Albrechts-Universität zu Kiel, Witten/Herdecke University, KUKA (Germany), Agaplesion Bethesda Krankenhaus, Helios Amper-Klinikum Dachau, Institute of Neuroimmunology and Multiple Sclerosis, Institut für Klinische Neuroimmunologie