Wir überwinden Grenzen

It sounds like a horror movie come true: Saskia R.* actually had her life under control. The 30-year-old woman worked successfully in the management of a company. But within a few weeks, everything slips away from her. Her mood suddenly fluctuates to an unusual degree, she reacts impulsively and becomes increasingly aggressive. Two months after the changes began, she suffered the first epileptic seizure of her life. A story of suffering begins that lasts more than a year and a half and takes the patient to various neurological and psychiatric clinics. When the true cause of the change was recognized at Freiburg University Hospital, the woman was cured of all her symptoms within a few weeks after almost two years. A similar, equally real case has been filmed in the USA and will be shown in German dubbing on the online streaming service Netflix from Friday, 22 June 2018 under the title "Feuer im Kopf".

Symptoms of schizophrenia

Even before Saskia R. arrives at Freiburg University Hospital, she is examined intensively in several hospitals and psychiatric clinics. The findings were confirmed several times: schizophrenia. However, the treatment with antipsychotic medication did not work for long. "The psychoses returned and became so severe that the young woman was barely able to eat, drink and look after herself. At this point, she was referred to us at the clinic," says Prof. Dr. Ludger Tebartz van Elst, Deputy Medical Director of the Department of Psychiatry and Psychotherapy at the Freiburg University Medical Center.

An almost 100-year-old idea provides the solution

The doctors at the University Medical Center Freiburg are once again examining all possible causes, including inflammation of the brain. "The idea that inflammation of the brain can cause schizophrenia has been around since the 1930s. But it wasn't until the early 2000s that there was the first evidence that this is really the case," says Prof. Tebartz van Elst, who heads the Freiburg research group "Immunological Encephalopathies".

Misdirected immune system responsible for personality change

In extensive laboratory tests, the Freiburg researchers found that the patient's blood-brain barrier was impaired, allowing substances to enter the brain in an uncontrolled manner. The doctors also found special immune antibodies in the blood that block a docking site for the messenger substance NMDA in the brain. A complex metabolic imaging examination of the brain finally provides evidence: parts of the brain are inflamed. "That was the crucial piece of the puzzle that enabled us to treat the patient successfully and in a targeted manner," says the Freiburg psychiatrist. The new diagnosis: NMDA receptor encephalitis.

Therapy takes effect within weeks

The Freiburg doctors are using high-dose cortisone therapy and other immunotherapies to reduce the inflammation of the brain. "We were able to see a clear improvement after just a few days," says Prof. Tebartz van Elst. After a few weeks, the therapy can be reduced and Saskia R. can be discharged home. Eventually, the patient was able to resume her normal life. "It was fantastic to see that the therapy worked so quickly and convincingly, even with such a long-lasting illness," says Prof. Tebartz van Elst.

Inflammatory processes as the cause of schizophrenic forms

It is difficult to quantify how often schizophrenic symptoms are caused by inflammation of the brain. Diagnosis is currently only routinely carried out in a few clinics and is very complex. "There is a great need for clinical research here," says Prof. Tebartz van Elst.

The cause of inflammatory brain diseases that cause schizophrenic or other psychiatric symptoms cannot always be clearly determined. In some cases, the change in personality is preceded by cancer. One assumption is that the immune system subsequently attacks structures that are present in the tumor and in the brain. If the blood-brain barrier is then permeable, this can lead to inflammation of the brain.

Film "Fire in the head" describes similar case

The film "Fire in the Head", which will be released on Netflix on Thursday, June 22, 2018, describes the equally true story of the young journalist Susanna Cahalan, who develops severe symptoms of schizophrenia within a short period of time. After lengthy stays in hospital and psychiatric wards, she is also diagnosed with NMDA receptor encephalitis and successfully treated.

Overall concept of schizophrenia called into question

Experiences such as these could have far-reaching consequences not only for individual patients, but also for the field of psychiatry. For example, Prof. Tebartz van Elst argues in his latest book "Vom Anfang und Ende der Schizophrenie. A neuropsychiatric perspective on the concept of schizophrenia" (2017), Prof. Tebartz van Elst argues: "We know of numerous different causes for illnesses that we refer to as schizophrenia. In other words, schizophrenia is a collective term for many different illnesses. If we take this into account, we could treat patients more successfully, as in the present case."

* Name changed

Further information:

Specialist consultation for immunological encephalopathies

Contact:
Prof. Dr. Ludger Tebartz van Elst 
Deputy Medical Director 
Department of Psychiatry and Psychotherapy 
Freiburg University Medical Center 
Phone: 0761 270-66030 
tebartzvanelst@uniklinik-freiburg.de