The Neuropsychiatric Assessment of Lyme Disease

[minitails2]

Yvonne,
Thanks for all the info. One of these days, through the haze of my recently diagnosed Acquired Deficit Disorder, I will get through all the information you've posted about this topic. Thanks.

[Yvonne]

1: Appl Neuropsychol. 1999;6(1):12-8.Links

Relations among indexes of memory disturbance and depression in patients with Lyme borreliosis.

Barr WB, Rastogi R, Ravdin L, Hilton E.
Department of Neurology and Psychiatry, Long Island Jewish Medical Center, New Hyde Park, New York 11040, USA.

This study examined the relation between complaints of memory disturbance and measures of mood and memory functioning in 55 patients with serological evidence of late-stage Lyme Borreliosis (LB). Patients completed the Self-Ratings of Memory Questionnaire (SRMQ) and the Beck Depression Inventory. Memory functioning was assessed with the California Verbal Learning Test. Depressed patients exhibited more frequent complaints of memory disturbance on the SRMQ, although their pattern of responses did not differ from nondepressed patients. There was a significant correlation between subjective memory ratings and self-reported depression (Spearman rho = -.57, p < .001). No relation was observed between subjective memory ratings and objective memory performance. The results indicate subjective complaints of more severe memory disturbance in patients with LB and depression. Particular attention should be paid to the assessment of depression and subjective symptoms of memory disturbance when administering neuropsychological tests of memory functioning in patients with LB.

PMID: 10382566

[Yvonne]

Fortschr Med. 1990 Apr 10;108(10):191-3, 197. Links

Lyme borreliosis in neurology and psychiatry
[Article in German]


Kohler J.
Neurologische Klinik mit Poliklinik, Universität Freiburg.

Neurological manifestations of Lyme disease are as multifarious as the entire spectrum of this common infection. In stage I, fibromyalgia and, more rarely, painful muscular fasciculation, dominate the clinical picture. In the individual case, mild psychic abnormalities may already be observed. Characteristic of the 2nd stage is lymphocytic meningopolyneuritis. Involvements of the CNS are expressed not so much in focal deficits, as in diffuse psychopathological disorders. In stage 3, CNS manifestations are characterized by chronic, in part multifocal, encephalitides and encephalomyelitides, isolated transverse myelitides and cerebral vasculitic disorders. The clinical symptomatology may be dominated by severe psychiatric syndromes. Connatal and subclinical latent infections of the nervous system with Borrelia represent special forms.

PMID: 2187778

[Yvonne]

Orv Hetil. 1994 Oct 9;135(41):2269-71. Links

Differential diagnostic problems in Lyme disease (Borrelia infection resulting in acute exogenous psychosis)
[Article in Hungarian]


Császár T, Patakfalvi A.
Zala Megyei Kórház, I. Belgyógyászat, Zalaegerszeg.

Case of a 31 years old woman suffering from I and II type atrioventricular heart block, acute exogenic psychosis, intermittent type of fever and arthritis of right knee was described by the authors. The non typical clinical picture, the extremely elevated erythrocyte sedimentation rate and the exogenic type of psychosis caused differential diagnostic difficulties. Besides polysymptomatic autoimmune disorder, Lyme disease as emerged although there were no data of vector bite. In the consequence of steroid and combined antibiotic treatment the patient became immediately apyretic and the sedimentation rate returned to the normal limit. The psychotic symptoms have disappeared only two weeks following Ceftriaxon's and Doxycyclin's management. The high titer Borrelia seropositivity reserved to apply the diagnosis of Lyme disease.

PMID: 7970642

[Yvonne]

Nervenarzt. 1991 Jul;62(7):445-7. Links

Endogenous paranoid-hallucinatory syndrome caused by Borrelia encephalitis
[Article in German]


Barnett W, Sigmund D, Roelcke U, Mundt C.
Psychiatrische Universitätsklinik, Heidelberg.

We describe a case with no neurological signs but marked psychiatric symptoms induced by borrelia burgdorferi, whose clinical picture was indistinguishable from an endogenous schizophrenia. The symptoms within one week under antibiotic treatment with ceftriaxon, but afterwards the patient showed a mild organic brain syndrome. The case demonstrated the aetiologic nonspecificity of paranoid symptoms and hallucinations and emphasizes that in psychotic patients without psychiatric history additional diagnostic measures should be performed.

PMID: 1922585

[Yvonne]

Psychiatric disorders in borreliosis

Psychiatric disorders were observed among patients both in early and late stage of disease.
The most common are: chronic mild confusional stage, Lyme encephalopathy, which is manifested
as impulsiveness, personality changes with irritability and mood swings, hypersomnia, short-term
memory loss. The encephalopathy may develop many years after the acute stage of disease (10,
11). Patients may also experience depression, panic attacks, unrelenting anxiety, paranoia, obsessive
compulsive disorder, manic episodes, psychotic states (6, 11). Depressive stages among patients
with Lyme disease are ranging across studies from 26% to 66% (5). Kohler described 3 stages of
borreliosis with connection to neurologic and psychiatric symptoms: stage I – fibromyalgia and mild
depression, stage II – aseptic meningitis, infectious polyneuritis and organic psychiatric disorders,
stage III – chronic encephalitis and/ or myelitis linked with dementia, organic psychosis and anorexia
nervosa (11).
Reviewing the literature there is but little report on psychiatric manifestations in Lyme disease.
There are a few reports of cases. Hess and colleagues presented the case of a 42-year-old woman
who was diagnosed with schizophrenic disorder. She suffered from paranoid delusions, acoustic and
visual hallucinations, thinking decelerations with thought withdrawals. Neurological examination
showed no focal or meningitic signs. CSF investigation revealed a lymphocytic pleocytosis, higher
level of protein and a B-cell immunoresponse. Antibody-specific indices to Borrelia burgdorferi
were positive. Cranial MRI discovered contrast medium enhancing lesions in thalamus on both
sides and left pallidum. Based on MRI and CSF findings an atypical course of Lyme disease was
diagnosed. Authors noted that the patient did not receive any chronic antipsychotic treatment after
acute intermittent treatment with antibiotic and antipsychotic drugs (12).
Some evidence for linkage between borreliosis and psychiatric symptoms is a report of three
patients who had developed a psychiatric disorder for the first time after infection with Borrelia
burgdorferi. These manifestations include depression, panic disorder and mania. Similar to the case
described above these disorders remitted after adequate antibiotic treatment (4).
Bar et al. described a case of a 61-year-old woman who developed a severe pain syndrome
following tick bites. She was diagnosed with neuroborreliosis. She received various courses of
antibiotics over several years, but without any clinical improvement in her conditions. She was
admitted to a psychiatric ward because of mental symptoms. Neuroleptic treatment led to a dramatic
improvement of her pain symptoms. Although this patient might have suffered from late onset
schizophrenia with painful hallucinations right at the start of her disease, an idea is emerging that
psychiatric complications might be associated with neuroborreliosis (2). In one of the cases psychiatric
disorder occurred as an acute exogenous psychosis, concomitant with polysymptomatic autoimmune
disorder. The psychotic symptoms disappeared after typical treatment (with antibiotics) (3).
Some patients develop a chronic fatigue syndrome with predominant symptoms: fatigue,
headaches, emotional lability, memory impairment, neurasthenia, difficulty in concentration. Often
there are the flulike symptoms of fever, sore throat, unrefreshing sleep, muscle stiffness, tender
lymph nodes (1, 7, 11).
The suggestion that there is liaison between borreliosis and psychiatric disorders in based
on observations upon the frequency of psychiatric disorders among patients with Lyme disease
which is greater than among those with other medical conditions, antibiotic treatment may improve
psychiatric symptoms and many patients who developed neuropsychiatic conditions reported being
psychiatrically healthy prior to the onset of Lyme disease.

DIFFERENTIATING PRIMARY AND SECONDARY DISORDERS
Differentiating neuropsychiatric Lyme disease from primary psychiatric disorders can be
complicated. In the task of differentiating Lyme disease from primary psychiatric disorders clinical
presentation, laboratory testing, neuropsychological testing and functional brain imaging. It is
important if patient has markers of a nonpsychiatric disease, such as an erythema migrans rash,
arthralgias or arthritis, myalgias, increased light or sound sensivity, severe headaches, paresthesias,
diffuse fasciculations, cardiac conduction delay, cranial neuropathies, radicular pains (6). But
diagnosis is made difficult by lack of history or finding of a tick bite and by the fact that the
pathognomonic finding, the rash of erythema chronicum migrans, is seen in only a minority of
causes (1). We should pay attention to any atypical course of disorders. In the case of depression, it is
characterized by marked mood lability, in which the patient bursts into tears for no apparent reason or
in which moods fluctuate from normal to extreme irritability over short periods. In the case of panic
disorder, the acute anxiety last longer than the usual 10-minute interval characteristic of most primary
panic attacks. A poor response to medications that typically would be helpful or that previously had
helped the same patient should alarm the doctor if a diagnosis is apt. And as a general rule, whenever
a patient older than the age of 40 years develops a psychiatric disorder for the first time without
apparent cause, an organic etiology must be suspected (6).
The essential method in the laboratory diagnostics of borreliosis is serologic tests indicating the
presence of antibodies for Borrelia burgdorferi. As each methods as this has some limitations, to use
any laboratory test it is essential to understand its positive and negative predictive values – i.e. in a
given patient, what is the likelihood that a positive result predicts disease or a negative result predicts
its absence. Test ELISA, the Western-blot technique and in some cases auxiliary the PCR test are
used (6, 13).
Neurological tests show that 50–60% of patients with chronic neurological Lyme disease have
evidence of objective impairment. These symptoms include impairment of memory, attention and
concentration, verbal fluency, perceptual motor functioning, conceptual ability. Often, objective
cognitive deficits on neuropsychological testing can be demonstrated despite normal findings from
a neurological examination and of EEG, CFS and MRI studies. And what is important, a routine
clinical examination may not show memory problems. In cases of memory loss accompanied by
mild depression, neuropsychological testing can be extremely valuable. Typically, mildly depressed
patients will show few if any objective memory deficits on neurological testing, while patients with
Lyme disease encephalopathy will show mild to severe levels of impairment, particularly in verbal
fluency and verbal short-term memory (6, 7).
MRI scans of patients with neurological Lyme disease may demonstrate punctate white matter
lesions on T2-weighted images, similar to SM. This is most often the case among patients with
evidence of meningitis or encephalitis. The white matter lesions may resolve after antibiotic treatment.
In late-stage neurological Lyme disease, however, brain MRI scans are generally normal even though
the patient may continue to have neuropsychiatric problems. In patients with Lyme disease, SPECT
scans typically show multifocal areas of decreased perfusion in both the cortex and the subcortical
white matter (6).
However, some investigators claimed that there are no reasons to link borreliosis to psychiatric
disorders (9, 10), Hajek et al. had psychiatric patients tested to look antibodies to Borrelia
burgdorferi. Prevalence of antibodies to Borrelia burgdorferi among psychiatric patients was higher
than healthy subjects. One-third of the psychiatric patients had serological signs of past Borrelia
burgdorferi infection. They speculate that circulating immune complex IgM, with a high rate of
psychiatric patients, might be involved in the pathogenesis of psychiatric symptoms associated with
borreliosis. As far as a relationship between borreliosis and psychiatric disorders is concerned there
are taken two possibilities into account. Patients vulnerable to psychiatric disease may be also more
susceptible to Borrelia burgdorferi infection or perhaps to its neurotoxic effects because of genetic
or intrauterine factors. Or Borrelia burgdorferi infections may cause psychiatric symptoms. Future
research should elucidate this issue (8).

CONCLUSIONS
There are data that nearly one-fifth of a sample of psychiatric outpatients had a medical
conditions as the cause of their psychiatric disorder and that this physical conditions had
been missed by the referring physician in about one-third of the causes (6). It is crucial to
diagnose Lyme disease in its earliest phases, as treatment with antibiotics usually results in
a complete cure. Failure to make an early and certain genetic factors contribute to a pattern
of chronic disease in some patients (1). An early diagnosis affects a selection of treatment,
which in case of borreliosis and concomitant psychiatric disorders should be combined.

http://www.annales.umcs.lublin.pl/D/2006/127.pdf

[Yvonne]

Clinical and demographic characteristics of psychiatric patients seropositive for Borreliaburg dorferi


http://www.hoschl.cz/files/508_en_Hajek ... _Psych.pdf

Abstract
Purpose.–
Borrelia burgdorferi (Bb)infection can affect the central nervous system and possibly lead to psychiatric disorders.We compared clinical and demographic variables in Bb seropositive and seronegative psychiatric patients and healthy controls.

.
Method.– Ninehundredandtwenty-six consecutive psychiatric patients were screened for antibodies to Bband compared with 884 simultaneously recruited healthy subjects.

Results.– Contrary to healthy controls, ,seropositive psychiatric patients were signifcantly younger than seronegative ones.None of the studied psychiatric diagnostic categories exhibited stronger association with seropositivity.There were no differences between seropositive
and seronegative psychiatric patients in hospitalizationlength, proportion of previously hospitalized patients and proportion of subjects withfamily history of psychiatric disorders.


Conclusion.– These findings elaborate on potential association between Bbinfection and psychiatric morbidity,but fail to identify any specific clinical ‘signature’ of Bbinfection.

[Yvonne]

http://psy.psychiatryonline.org/cgi/con ... l/39/3/301


Lyme Disease and Secondary Depression: Universal Lessons From An Uncommon Case

TO THE EDITOR: The pathogenesis and clinical presentation of Lyme disease can be explained by direct invasion of the central nervous system by the Lyme spirochete. This idea was recently supported by a number of clinical and experimental studies showing the presence of neuropathological lesions in different parts of brain tissue in patients with Lyme disease.1–4 We describe a case of Lyme disease in which single photon emission computed tomography (SPECT) functional brain imaging was used to detect the illness for the first time.

Case Report

Mr. H. is a 48-year-old, Caucasian man with no psychiatric history prior to 1989. In the summer of 1988, he camped out with his family in Wisconsin. Shortly thereafter, Mr. H. developed significant pain in his knees and bilateral hip pain radiating to the thighs and back. Mr. H. gradually developed generalized fatigue and malaise. Even small tasks seemed to require significant effort. He would wake up suddenly at night with chest tightness, shortness of breath, palpitations, dizziness, sweating, and a fear of dying. He also had trouble falling and staying asleep. Mr. H. felt depressed and complained of an impaired ability to think, concentrate, or make simple decisions, and he was unable to perform his regular office work, which left him feeling worthless and guilty. He also reported a loss of interest and pleasure in everyday activities and in his hobbies. He had a reduction in his sexual interest and desire. Mr. H. had no drug abuse or family history of psychiatric illness. Mini-Mental State Exam showed no deficits in orientation, language, memory, or praxis. A psychiatrist made a diagnosis of anxiety and dysthymic disorder and started him on Xanax (alprazolam) at a dose of 0.5 mg po bid. Mr. H. reported partial relief from his anxiety symptoms, but his fatigue, malaise, and depression became progressively worse, and his arthritis progressed. He was referred to internal medicine for an evaluation of possible Lyme disease and IFA CSF; (Lyme) titers showed a ratio of 1:2,048. A spinal tap showed an elevated Lyme titer also. A SPECT study revealed decreased perfusion of both temporal lobes. Mr. H. was admitted and treated with intravenous ceftriaxone daily for 3 weeks. He then reported much more energy and less depression

Discussion

The present case addressed several salient aspects of Lyme disease and psychiatric symptomatology. In certain cases, it is difficult to diagnose Lyme disease, particularly when multiple somatic and psychiatric symptoms present without the typical early skin signs. The absence of both a family history of psychiatric illness in Mr. H.'s family and any psychological factors warranted that an acquired infectious disease rather than primary psychiatric illness per se be considered. This conclusion was supported by the finding of an increased IFA titer in the cerebrospinal fluid of this patient, which raised the possibility of direct brain involvement in the infectious process. Additional support for this hypothesis was documented by decreased perfusion of both temporal lobes, identified by SPECT functional brain imaging. The involvement of temporal lobe structures explains the panoply of psychosensory features prominent in this case. Furthermore, a thorough knowledge of brain–behavior relationships—in this case, sensory dysesthesia, and mood changes characteristic of temporal lobe kindling5—is helpful to the diagnostic armamentarium of the modern clinical psychiatrist.

[Yvonne]

Pol Merkur Lekarski. 2001 Nov;11(65):460-2.Links

Mental disorders in Lyme disease

[Article in Polish]


Rudnik-Szałaj I, Popławska R, Zajkowska J, Szulc A, Pancewicz SA, Gudel I.
Klinika Psychiatrii AM w Białymstoku.

From the early 90-ties there is a growing number of patients suffering from Lyme Disease all over the world, including Poland. Lyme Disease is the disorder connecting physicians of various specialties. The authors reviewed literature on mental disorders in Lyme Disease during different stages and in different types of illness. Mental disorders are part of clinical picture of the acute stage of Lyme Disease, and could also be its sequel. The most commonly found mental disorders are: encephalopathy, other cognitive disorders, mood disorders (depression), anxiety disorders and less often: psychotic disorders and eating disorders (anorexia nervosa).

PMID: 11852824

[Yvonne]

http://ccs.sagepub.com/cgi/content/abstract/6/5/430

Treating Depression and Compensatory Narcissistic Personality Style in a Man With Chronic Lyme Disease

The following case study illustrates a client-centered, cognitive-behavioral approach to the psychological treatment of Mr. M, a 41-year-old male diagnosed with chronic Lyme disease, a mood disorder from Lyme disease, and narcissistic personality disorder. Mr. M's personality difficulties are conceptualized as representing compensatory narcissism, a strategic way of coping with feelings of insecurity. The goals of treatment included positively integrating Mr. M's chronic illness into his identity, decreasing depressive symptoms, and improving his interpersonal skills. Treatment was successful in decreasing both Mr. M's depressive symptoms and his narcissistic orientation to thinking and interacting with others