I’ve been a New England Journal of Medication (NEJM)
subscriber since I left medical faculty.
It was a beneficial apply in my first yr Biochemistry class by the
distinguished professors in that class. We had very shut contact with them in
my medical faculty for 2 causes – each day seminars the place we mentioned analysis
papers within the relevant matters and their graduate college students speaking the identical
course. It was one of many extra
intellectually stimulating programs in medical faculty.
Over the next 43 years of subscribing, I’ve seen
a few tendencies. Essentially the most important
one is that psychiatry has been more and more represented on the pages
particularly prior to now 10-15 years. It’s extra probably that authors and
discussants within the weekly case displays will likely be psychiatrists. You may as well get updates on related
psychiatric papers despatched by e-mail. When you scan the desk of contents every week
it’s probably that 2 or 3 papers will likely be related to psychiatric apply – extra
in case you are a neuropsychiatrist or medical psychiatrist.
That brings me to Case 22-2025 from the July 25, 2025
challenge. I’ll describe the case as
briefly as doable as a consequence of copyright issues and the very fact you’ll be able to learn
all the main points in your medical library copy or entry. I wish to concentrate on the diagnostic course of and
what it implies for each psychiatric prognosis and therapy. I additionally wish to concentrate on the truth that there
are acute care psychiatrists in intensely medical settings and they’re very
educated and maintain very robust issues that no one else does. That may get misplaced on an nearly each day foundation as
you see provocative headlines and social media posts searching for consideration by
distorting what psychiatrists do and what they’re able to.
The affected person is a 19-year-old lady admitted with episodic
proper arm and leg shaking and weird conduct.
The signs developed over the ten days previous to admission with episodic
shaking and numbness of the proper arm, and slowed speech. Per week earlier than
admission she collapsed in public and full physique shaking was noticed. Within the emergency division she was famous to
be drooling, confused, and had bitten her tongue. She step by step grew to become extra alert. Within the MGH ED her examination was regular and the
solely exceptional lab discovering was an elevated lactate. CT and MRI of the mind have been regular. An EEG was regular. On day 1 she had sudden onset of intense worry
and dread adopted by complete physique shaking lasting 1-1 ½ minutes. With the final episode she had a decreased
oxygen saturation to 50%. She was
began on lorazepam and levetiracetam.
On day 2 she was began on lamotrigine. She was additionally seen by a
psychiatrist and was famous to have extension and stiffening of the proper arm,
flexion and stiffening of the left arm, turning the top to the proper and
whole-body stiffening. The episode lasted a minute and he or she described feeling
like “mind and thoughts have been disconnected”. She denied hallucinations, suicidal
ideation, and aggressive ideation however didn’t assume that she might return to
faculty. She grew to become extra agitated, tried
to expire of her room, and thought the employees have been attempting to kill her. She grew to become agitated and required bodily
restraint and IM olanzapine.
Further historical past was exceptional for a grandfather with
schizophrenia and previous therapy for anxiousness and melancholy – most not too long ago
with psychotherapy and no medicine.
Following a current discharge from one other hospital and a 5-day admission
she was taking levetiracetam, lamotrigine, melatonin, and folic acid. She was rehospitalized
after she developed signs on the best way house from that hospitalization.
This can be a extreme and acute drawback that each acute care
psychiatrist ought to be capable to analyze and deal with. The affected person reveals seizure like exercise,
catatonia, and psychosis within the type of disorganized conduct quite than any
descriptions of hallucinations or delusions.
The priority about hospital employees attempting to kill her could possibly be paranoia –
however except there may be corroboration that it was current for a while – it will probably
even be because of the important cognitive issues of poor reminiscence and
inattentiveness.
Within the subsequent dialogue and unfolding occasions – Judith A. Restrepo, MD – a C-L psychiatrist at MGH presents a refined strategy
to the issue as outlined within the graphic on the high of this submit. After describing the noticed traits
of the three syndromes on the left she seems at teams of problems that will
account for the syndromes and the way widespread they’re. Because the emergency screening has already
been completed, she will rule out any related to apparent abnormalities of mind
imaging research or lab exams. She goes
via every main class and states why a prognosis is probably going of not. For instance, within the Uncommon Problems The place
Psychotic Sx Are Typical she mentions acute intermittent porphyria and
Creutzfeldt-Jakob illness and the way they’re unlikely because of the sickness sample,
lack of GI sx, and a standard EEG.
In that very same class, Dr. Restrepo discusses autoimmune
encephalitis as a risk and ultimately lands on that prognosis. Within the subsequent analysis (anti-NMDA
receptor antibodies, CSF research, belly ultrasound and CT) the prognosis of
anti-NMDA receptor encephalitis secondary to a malignant blended germ cell tumor
of the left ovary was famous.
The case report is beneficial to learn in full due to the
difficult submit diagnostic course and outline of what’s recognized concerning the
therapy of this situation. I’m going
to concentrate on a few further diagnostic points and the implications for
psychiatrists.
Sample matching stays a essential facet of all medical
diagnoses and that features psychiatry. It
remains to be a preferred trope that psychiatric prognosis is DSM centric and nothing
could possibly be farther from the reality. The true worth of psychiatry is the coaching and
direct commentary and evaluation of actual issues. Studying a guidelines of
signs is actually nugatory with out realizing these patterns. The apparent examples from this case are
psychosis, seizures, and catatonia and their many variations. The wording within the case report is usually stacked
to trigger an affiliation to these patterns.
An apparent instance is complete physique shaking adopted by
hypoxemia and an elevated lactate stage ought to result in an affiliation to
generalized seizures and doubtless related sufferers seen prior to now with that
situation. Equally, the options of
catatonia ought to be apparent with out referring to a catatonia score scale and
result in associations to previous catatonia sufferers recognized and handled. Superimposed
on these diagnostic patterns ought to be a normal sample of easy methods to strategy
very unwell sufferers – on this case sufferers who’ve both severe psychiatric
problems or psychiatric syndromes secondary to severe medical and
neurological situations. How ought to a stuporous or comatose affected person be examined (2)? On this particular affected person might the arm actions be decorticate or decerebrate posturing? May they be a motion dysfunction? That ought to embrace a triage sample of how
that affected person must be stabilized till the prognosis is set.
For example – what ought to occur if this affected person is
described to you as an admitting psychiatrist?
Ought to they be admitted to a typical inpatient psychiatric unit? All that I would wish to listen to is hypoxemia
following seizure like exercise and my reply can be no. They must be in a unit that has telemetry
and important care nursing and psychiatric models don’t.
There are additionally patterns on the rule-in facet. Are there any options of this sickness that match
typical patterns of schizophrenia, bipolar dysfunction, or melancholy? Are there any options that match acute intoxication
with generally used substances? Is the
affected person medically secure sufficient to be handled on a psychiatric unit?
How will we put together acute care psychiatrists who’re primarily based in
medical neuroscience? Thomas Insel the
former NIMH director had the thought of a rotating scientific neuroscience
fellowship the place neurology, psychiatry, and neurosurgery residents would do a 2
yr fellowship earlier than transferring on their respective residencies. That could be a laborious promote whenever you come out of it
needing to do one other 3 – 5 years of residency.
I suggest preparing in medical faculty. Most MS4 programs are electives and there may be
most likely room to additional modify the MS3 yr.
Along with primary normal medication and surgical procedure I like to recommend the
following electives: neurosurgery, neurology, endocrinology, infectious illness,
renal medication, cardiology, emergency medication, and allergy and
immunology. Simply rotating via just isn’t
sufficient given what I’ve mentioned concerning the sample matching requirement. As many acute care instances and weird displays of psychiatric problems related
with mind and medical diseases must be seen as doable. Solely that can get residents able to make
diagnoses just like the one on this case. It helps to have an perspective and curiosity
in treating essentially the most extreme issues in psychiatry.
And as soon as you’re out – preserve studying the journals together with the
NEJM.
George Dawson, MD, DFAPA
1: Restrepo JA,
Mojtahed A, Morelli LW, Venna N, Turashvili G. Case 22-2025: A 19-Yr-Previous
Lady with Seizure like Exercise and Odd Behaviors. N Engl J Med. 2025 Jul
31;393(5):488-496. doi: 10.1056/NEJMcpc2412531. PMID: 40742263.
2: Plum F, Posner
JB. The Prognosis of Stupor and Coma. FA Davis Firm, Philadelphia, 1980.