I have been a New England Journal of Medicine (NEJM) subscriber since I left medical school. It was a recommended practice in my first year Biochemistry class by the distinguished professors in that class. We had very close contact with them in my medical school for two reasons – daily seminars where we discussed research papers in the applicable topics and their graduate students talking the same course. It was one of the more intellectually stimulating courses in medical school.
Over the subsequent 43 years of subscribing, I have noticed
a couple of trends. The most significant
one is that psychiatry has been increasingly represented on the pages
especially in the past 10-15 years. It is more likely that authors and
discussants in the weekly case presentations will be psychiatrists. You can also get updates on relevant
psychiatric papers sent by email. If you scan the table of contents each week
it is likely that 2 or 3 papers will be relevant to psychiatric practice – more
if you are a neuropsychiatrist or medical psychiatrist.
That brings me to Case 22-2025 from the July 25, 2025
issue. I will describe the case as
briefly as possible due to copyright considerations and the fact you can read
all the details in your medical library copy or access. I want to focus on the diagnostic process and
what it implies for both psychiatric diagnosis and treatment. I also want to focus on the fact that there
are acute care psychiatrists in intensely medical settings and they are very
knowledgeable and take care of very tough problems that nobody else does. That can get lost on an almost daily basis as
you see provocative headlines and social media posts seeking attention by
distorting what psychiatrists do and what they are capable of.
The patient is a 19-year-old woman admitted with episodic
right arm and leg shaking and unusual behavior.
The symptoms developed over the 10 days prior to admission with episodic
shaking and numbness of the right arm, and slowed speech. A week before
admission she collapsed in public and full body shaking was observed. In the emergency department she was noted to
be drooling, confused, and had bitten her tongue. She gradually became more alert. In the MGH ED her exam was normal and the
only remarkable lab finding was an elevated lactate. CT and MRI of the brain were normal. An EEG was normal. On day 1 she had sudden onset of intense fear
and dread followed by whole body shaking lasting 1-1 ½ minutes. With the last episode she had a decreased
oxygen saturation to 50%. She was
started on lorazepam and levetiracetam.
On day 2 she was started on lamotrigine. She was also seen by a
psychiatrist and was noted to have extension and stiffening of the right arm,
flexion and stiffening of the left arm, turning the head to the right and
whole-body stiffening. The episode lasted a minute and she described feeling
like “brain and mind were disconnected”. She denied hallucinations, suicidal
ideation, and aggressive ideation but did not think that she could return to
college. She became more agitated, tried
to run out of her room, and thought the staff were trying to kill her. She became agitated and required physical
restraint and IM olanzapine.
Additional history was remarkable for a grandfather with
schizophrenia and past treatment for anxiety and depression – most recently
with psychotherapy and no medication.
Following a recent discharge from another hospital and a 5-day admission
she was taking levetiracetam, lamotrigine, melatonin, and folic acid. She was rehospitalized
after she developed symptoms on the way home from that hospitalization.
This is a severe and acute problem that every acute care
psychiatrist should be able to analyze and treat. The patient exhibits seizure like activity,
catatonia, and psychosis in the form of disorganized behavior rather than any
descriptions of hallucinations or delusions.
The concern about hospital staff trying to kill her could be paranoia –
but unless there is corroboration that it was present for some time – it can
also be due to the significant cognitive problems of poor memory and
inattentiveness.
In the subsequent discussion and unfolding events – Judith A. Restrepo, MD – a C-L psychiatrist at MGH presents a refined approach
to the problem as outlined in the graphic at the top of this post. After describing the observed characteristics
of the three syndromes on the left she looks at groups of disorders that may
account for the syndromes and how common they are. Since the emergency screening has already
been done, she can rule out any associated with obvious abnormalities of brain
imaging studies or lab tests. She goes
through each major category and states why a diagnosis is likely of not. For example, in the Rare Disorders Where
Psychotic Sx Are Typical she mentions acute intermittent porphyria and
Creutzfeldt-Jakob disease and how they are unlikely due to the illness pattern,
lack of GI sx, and a normal EEG.
In that same category, Dr. Restrepo discusses autoimmune
encephalitis as a possibility and eventually lands on that diagnosis. In the subsequent evaluation (anti-NMDA
receptor antibodies, CSF studies, abdominal ultrasound and CT) the diagnosis of
anti-NMDA receptor encephalitis secondary to a malignant mixed germ cell tumor
of the left ovary was noted.
The case report is useful to read in full because of the
complicated post diagnostic course and description of what is known about the
treatment of this condition. I am going
to focus on a couple of additional diagnostic issues and the implications for
psychiatrists.
Pattern matching remains a critical aspect of all medical
diagnoses and that includes psychiatry. It
is still a popular trope that psychiatric diagnosis is DSM centric and nothing
could be farther from the truth. The real value of psychiatry is the training and
direct observation and assessment of real problems. Reading a checklist of
symptoms is essentially worthless without knowing those patterns. The obvious examples from this case are
psychosis, seizures, and catatonia and their many variations. The wording in the case report is often stacked
to cause an association to those patterns.
An obvious example is whole body shaking followed by
hypoxemia and an elevated lactate level should lead to an association to
generalized seizures and probably similar patients seen in the past with that
condition. Similarly, the features of
catatonia should be obvious without referring to a catatonia rating scale and
lead to associations to past catatonia patients diagnosed and treated. Superimposed
on these diagnostic patterns should be a general pattern of how to approach
very ill patients – in this case patients who have either serious psychiatric
disorders or psychiatric syndromes secondary to serious medical and
neurological conditions. How should a stuporous or comatose patient be examined (2)? In this specific patient could the arm movements be decorticate or decerebrate posturing? Could they be a movement disorder? That should include a triage pattern of how
that patient needs to be stabilized until the diagnosis is determined.
As an example – what should happen if this patient is
described to you as an admitting psychiatrist?
Should they be admitted to a typical inpatient psychiatric unit? All that I would need to hear is hypoxemia
following seizure like activity and my answer would be no. They need to be in a unit that has telemetry
and critical care nursing and psychiatric units do not.
There are also patterns on the rule-in side. Are there any features of this illness that match
typical patterns of schizophrenia, bipolar disorder, or depression? Are there any features that match acute intoxication
with commonly used substances? Is the
patient medically stable enough to be treated on a psychiatric unit?
How do we prepare acute care psychiatrists who are based in
medical neuroscience? Thomas Insel the
former NIMH director had the idea of a rotating clinical neuroscience
fellowship where neurology, psychiatry, and neurosurgery residents would do a 2
year fellowship before moving on their respective residencies. That is a hard sell when you come out of it
needing to do another 3 – 5 years of residency.
I propose getting ready in medical school. Most MS4 courses are electives and there is
probably room to further modify the MS3 year.
In addition to basic general medicine and surgery I recommend the
following electives: neurosurgery, neurology, endocrinology, infectious disease,
renal medicine, cardiology, emergency medicine, and allergy and
immunology. Just rotating through is not
enough given what I have said about the pattern matching requirement. As many acute care cases and unusual presentations of psychiatric disorders associated
with brain and medical illnesses need to be seen as possible. Only that will get residents ready to make
diagnoses like the one in this case. It helps to have an attitude and interest
in treating the most severe problems in psychiatry.
And once you are out – keep reading the journals including the
NEJM.
George Dawson, MD, DFAPA
Supplementary 1: Thought I would add a couple of supplementary
comments here rather than adding them to the main post.
Psychiatry is not DSM centric: Practically every critic of the field and by
default these days every social media venue and many journals have lengthy
debates about the DSM, what it does or not do, and how it affects the future of
psychiatry. The above post is a shining
example of what I did in over 35 years of practice. At no point in that 35 years did I pull the
old DSM off the shelf and think: “Gee I wonder what the DSM will tell me to diagnose?” Just today I was in a seminar where the
question was: “What diagnosis should we use for psychotherapy?” and reminded
that the primary use of the DSM and why it was invented – initially for statistical
and census purposes and now for billing and coding. In other words, today – you do not get paid
if you don’t have a diagnostic code but that code is technically an ICD-10 code
and not a DSM code.
Should that role lead to protracted debates in journals and
social media. I guess I will take the
lead role is saying emphatically no.
You can take all the debates about the precision and validity of
psychiatric diagnoses and watch it explode in this case report. We see real
psychiatry in action. A psychiatry where
patterns of illness are recognized and critical in making a diagnosis of a
life-threatening condition.
Pathology in a psychiatric case: I did not mention that this case report contains a pathology report including photos of the gross pathology and microscopic pathology of the left ovarian mass and the malignant germ cell tumor. This is reminiscent of late 19th/early 20th century psychiatry looking for neuropathological autopsy correlates of severe mental illness and the famous psychiatrists involved. It was a more intellectually stimulating approach and there were results but not for the major psychiatric disorders leading to asylum care at the time namely bipolar disorder, schizophrenia, and depression/melancholia. Now that the pathology is more specific should psychiatrists be taught the pathology and the pathophysiology of these disorders? Should they be aware of all paraneoplastic syndromes that cause psychiatric symptomatology. Of course they should. It is more important than a DSM and unless the DSM is serious about including real patterns and pathology it will be much less relevant in the future. We have reached a limit when it comes to parsing words about psychiatric diagnoses and need to get back to reality.
References:
1: Restrepo JA,
Mojtahed A, Morelli LW, Venna N, Turashvili G. Case 22-2025: A 19-Year-Old
Woman with Seizure like Activity 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 Diagnosis of Stupor and Coma. FA Davis Company, Philadelphia, 1980.
