Developing a Clinical Workflow for Early Recognition and Diagnosis of Autoimmune Encephalitis in Patients Presenting With Atypical Psychosis

Abstract

Background and Objective

Atypical psychosis is often difficult to diagnose and treat, and delays in identifying the underlying etiology can worsen patient outcomes. We present a novel clinical workflow for patients presenting to the emergency department with features of atypical psychosis to standardize the diagnostic process with the goal of earlier recognition and diagnosis of autoimmune encephalitis.

Methods

Through literature review and multidisciplinary discussions, we developed a clinical workflow to direct patient management and diagnostic testing using the following identified “red” and “yellow” flags of atypical psychosis: unexplained seizures, focal neurologic deficits, autonomic instability, movement disorder in the absence of antipsychotics, hyponatremia, age greater than 40 years, psychosis refractory to 2 appropriate treatment trials, infectious or systemic prodrome, and history of malignancy. We then reviewed electronic medical records to assess the disposition and outcomes of patients who underwent the workflow.

Results

From January 2022 to September 2023, 38 patients presenting with atypical psychosis were assessed using our new workflow in the Comprehensive Psychiatric Emergency Program. Most patients (23/38) entered the workflow due to one yellow flag, and age greater than 40 years was the most frequent flag feature (31/38). Ultimately, 57.9% (22/38) were diagnosed with primary psychiatric disorders, while 15.8% (6/38) had primary neurological diagnoses, including 3 immune-mediated cases. A survey of neurology and psychiatry team members showed the workflow was generally viewed as straightforward and effective.

Conclusions

Our novel clinical workflow facilitated early neurologic consultation and management of patients presenting with atypical psychosis, identifying both immune-mediated and nonimmune-mediated neurologic disorders.