Acute neuropsychiatry:a confused patient and a puzzled doctor

BACKGROUND: Anti-NMDA-receptor-encephalitis is a progressive autoimmune disease with significant mortality if left untreated.CASE DESCRIPTION: A 58-year-old man without previous psychiatric or neurologic history presented at the emergency department after brief loss of consciousness at work. Within a few hours, the patient developed acute neuropsychiatric symptoms, including altered levels of consciousness, aggression, incoherence, change in behaviour, and psychomotor agitation. Initially, additional blood, cerebrospinal fluid and EEG tests showed no abnormalities. Over the course of the following days, catatonia, orofacial dyskinesia and autonomic-function disorder developed, eventually with respiratory insufficiency, necessitating transfer to the intensive-care unit. At this stage, the EEG did show abnormalities, and cerebrospinal fluid analysis showed marginal pleocytosis. The patient was treated with intravenous methylprednisolone and immunoglobins. Anti-NMDA-receptor antibodies were present in the blood and cerebrospinal fluid. Screening for malignancy identified small-cell lung carcinoma, for which the patient was treated with cytostatic agents.CONCLUSION: Acute neuropsychiatric symptoms in a middle-aged patient with no psychiatric medical history are suggestive of an underlying somatic cause. Timely recognition and treatment of anti-NMDA-receptor encephalitis is essential to improve the prognosis.</p

Temporal dynamics of depression, cognitive performance and sleep in older persons with depressive symptoms and cognitive impairments:a series of eight single-subject studies

OBJECTIVES: To investigate the presence, nature and direction of the daily temporal association between depressive symptoms, cognitive performance and sleep in older individuals. DESIGN, SETTING, PARTICIPANTS: Single-subject study design in eight older adults with cognitive impairments and depressive symptoms. MEASUREMENTS: For 63 consecutive days, depressive symptoms, working memory performance and night-time sleep duration were daily assessed with an electronic diary and actigraphy. The temporal associations of depressive symptoms, working memory and total sleep time were evaluated for each participant separately with time-series analysis (vector autoregressive modeling). RESULTS: For seven out of eight participants we found a temporal association between depressive symptoms and/or sleep and/or working memory performance. More depressive symptoms were preceded by longer sleep duration in one person (r = 0.39; p < .001), by longer or shorter sleep duration than usual in one other person (B = 0.49; p < .001), by worse working memory in one person (B = -0.45; p = .007), and by better working memory performance in one other person (B = 0.35; p = .009). Worse working memory performance was preceded by longer sleep duration (r = -.35; p = .005) in one person, by shorter or longer sleep duration in three other persons (B = -0.76; p = .005, B = -0.61; p < .001; B = -0.34; p = .002), and by more depressive symptoms in one person (B = -0.25; p = .009). CONCLUSION: The presence, nature and direction of the temporal associations between depressive symptoms, cognitive performance and sleep differed between individuals. Knowledge of personal temporal associations may be valuable for the development of personalized intervention strategies in order to maintain their health, quality of life, functional outcomes and independence

The importance of personality and life-events in anxious depression:From trait to state anxiety

Objectives: Anxious depression is associated with severe impairment and bad prognoses. We hypothesize that recent life-events are associated with more anxiety in late-life depression and that this is conditional upon the level of certain personality traits. Method: Baseline data of the Netherlands Study of Depression in Older Persons (NESDO) were used. In 333 patients (>= 60 years) suffering from a major depressive disorder, anxiety was assessed with the BAI, personality traits with the NEO-FFI and the Mastery Scale, and life-events with the Brugha questionnaire. Multiple linear regression analyses were applied with anxiety severity as dependent and life-events and personality traits as independent variables. Results: 147 patients (44.1%) had recently experienced one or more life-events. The presence of a life-event is not associated with anxiety (p = .161) or depression severity (p = .440). However, certain personality traits interacted with life-events in explaining anxiety severity. Stratified analyses showed that life-events were associated with higher anxiety levels in case of high levels of neuroticism and openness and low levels of conscientiousness or mastery. Conclusions: In the face of a life-event, personality traits may play a central role in increased anxiety levels in late-life depression

Psychometric Concerns in the Assessment of Trauma-related Symptoms in Older Adults

Assessment of PTSD in older adults is still in its infancy despite reflections on this subject in past literature. Factors that influence assessment are: traumas that occurred long in the past, lower prevalence, the fact that older people complain less, more misinterpretation of avoiding and intrusion, more somatic comorbidity and higher risk of cognitive impairment. The Clinician Administered PTSD Scale (CAPS) is mostly used to diagnose PTSD, but less researched in older age. Only two screening instruments have been validated, the PTSD Checklist (PCL) and the Self Rating Inventory for PTSD (SRIP), but cross-validation has still to be done. The PCL scale has been used more often and is also suitable for clinician rating, which is considered more appropriate for older adults. Biological measures have not yet been adapted for assessment in the complex biological systems of older age. Multimethod assessment is becoming more important and can address many of the difficulties in this field. Finally, much can be learned from knowledge already acquired from younger adults

Psychometric Concerns in the Assessment of Trauma-Related Symptoms in Older Adults

Assessment of posttraumatic stress disorder (PTSD) in older adults is still in its infancy despite reflections on this subject in past literature. Factors that influence assessment are traumas that occurred long in the past, lower prevalence, the fact that older people complain less, more misinterpretation of avoiding and intrusion symptoms, more somatic comorbidity, and higher risk of cognitive impairment. The Clinician Administered PTSD Scale is mostly used to diagnose PTSD, but is less researched in older individuals. Only two screening instruments have been validated specifically for older adults, the PTSD Checklist (PCL) and the Self-Rating Inventory for PTSD. The PCL scale has been used more often, has been translated in various languages, and is also suitable for clinician rating, which is considered more appropriate for older adults. The PCL-5, based on the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria was researched in older veterans but needs further validation. Biological measures have not yet been adapted for assessment in the complex biological systems of older age. Multimethod assessment and computerized screening are becoming more important and can address many of the difficulties in this field. Finally, much can be learned from knowledge already acquired from younger adults