February 23, 2023 – In 2017, during a 12 months of studying abroad in Paris, Michelle Cano Bravo began to suffer from hallucinations, insomnia, and paranoia. She also had problems together with her considering skills – she often got lost, even in places she knew.
“I had no idea what was happening,” says the 25-year-old. “I was lying under a house like a dying dog, just looking for solitude.”
During this time, Bravo, who's now studying law and lives in New York, attempted suicide twice.
After returning to the United States in early 2018, she began experiencing increasingly troubling symptoms. One time, while visiting Times Square, “I thought the people on the big screens were talking to me,” she says.
She panicked and couldn't find her strategy to the subway. She doesn't remember how she got home, but when she did, she collapsed and screamed that she was dying. She was taken to the hospital, where she was placed within the psychiatric ward.
Days later, her condition worsened. She was now not responsive and fell right into a coma. She was eventually diagnosed with encephalitis and multiple organ failure.
Unfortunately, individuals with Bravo symptoms are sometimes suspected of getting a mental illness slightly than encephalitis, says Dr. Jesús Ramirez-Bermúdez of the National Institute of Neurology and Neurosurgery in Mexico City.
Caring for patients with encephalitis is “difficult,” he says, because patients can experience sudden and severe mental disorders.
“They are often wrongly diagnosed with a primary psychiatric disorder, such as schizophrenia or bipolar disorder, but their condition does not improve with the use of psychotropic drugs or psychotherapy,” says Ramirez-Bermudez. Rather, the disease requires “specific treatments,” similar to antiviral drugs or immunotherapy.
What is encephalitis?
Encephalitis is an inflammation of the brain caused either by an infection that invades the brain (infectious encephalitis) or by an erroneous attack by the immune system on the brain (post-infectious or autoimmune encephalitis).
The disease can affect anyone of any age. In the United States, over 250,000 people have been diagnosed with it within the last decade. Worldwide, 500,000 individuals are affected by it every 12 months.
Unfortunately, about 77% of individuals have no idea what encephalitis is, and even some medical professionals are unaware that psychiatric symptoms in encephalitis could also be signs of an acute illness.
In addition to psychiatric symptoms, encephalitis may include flu-like symptoms, fever, headache, sensitivity to light and/or noise, stiff neck, weakness or partial paralysis of the limbs, double vision, and speech or hearing problems.
Suicidality in individuals with encephalitis
Between 2014 and 2021, Ramirez-Bermúdez and his colleagues studied 120 patients affected by anti-NMDA receptor encephalitis—a condition during which antibodies produced by the patient's body attack a receptor within the brain—at a neurological treatment center in Mexico.
This receptor is especially vital in the best way the body signals itself and is required for several processes that result in complex behaviors, he explains. Dysfunction of this receptor could cause these processes to change into disrupted, which might result in psychosis.
“In recent years, we have observed that some patients with autoimmune encephalitis … exhibited suicidal behavior, and a previous study conducted in China suggested that the problem of suicidal behavior is not uncommon in this population,” he says.
Ramirez-Bermúdez and his colleagues wanted to investigate how often patients have suicidal thoughts and behavior, which neurological and psychiatric features could also be related to suicidality, and what the final result could be after treatment of encephalitis.
All patients underwent magnetic resonance imaging (MRI) of the brain, a lumbar puncture (spinal tap) to search for signs of infection within the brain or spinal cord, an electroencephalogram (EEG) to detect possible seizures or abnormal electrical brain activity, and interviews with the patient and relations to evaluate mental capability, mood, and suicidal thoughts.
Of the 120 patients, 15 had suicidal thoughts and/or suicidal behavior. These patients showed symptoms similar to delusions (e.g. paranoia or megalomania), hallucinations, delirium and catatonia.
After medical treatment that included immunotherapy, neurological and psychiatric medications, rehabilitation, and psychotherapy, 14 of the 15 patients experienced remission of their suicidal thoughts and behavior.
The patients were followed for between one and almost nine years after their discharge from the hospital and remained freed from suicidality.
“The good news is that in most cases, suicidal thoughts and behavior, as well as the features of psychotic depression, improve significantly with specific immunological therapy,” says Ramirez-Bermúdez.
Fighting stigmatization, breaking taboos
Study co-author Dr Ava Easton, chief executive of the Encephalitis Society, says mental health issues related to encephalitis, thoughts of self-harm and suicidal behaviour “can arise for a number of reasons. And the stigma that comes with discussing mental health can be a real barrier to talking about symptoms – but it's an important barrier to overcome.”
Easton, an honorary fellow on the University of Liverpool within the UK, said her study “provides a platform to break the taboo, to demonstrate concrete data-based links between suicide and encephalitis and to call for greater awareness of the risks of mental health problems during and after encephalitis.”
Ramirez-Bermúdez agrees. “The conventional approach to mental health issues is linked to many cultural problems, including prejudice, fear, myths, stigma and discrimination,” he says. “This is present in popular culture, but also in the culture of medicine and psychology.”
Bravo, the law student who suffered from encephalitis and its psychological consequences, didn't tell anyone about her suicidal thoughts.
“It was a cultural issue,” she says.
Although her mother is a physician, she was afraid to inform her about her suicidal tendencies. In her South American family, “the subject of mental illness is not a pleasant topic of conversation. And the message is: 'If you think about killing yourself, you'll end up in an institution.'”
Unfortunately, these attitudes contribute to a “delay in recognition” of the diagnosis, says Ramirez-Bermúdez.
After treatment and because the acute illness subsided, Bravo slowly regained her every day functions. But even now, greater than 5 years later, she still struggles with some symptoms related to her mental abilities in addition to depression – although she is studying law and manages to maintain up together with her responsibilities. She is just not actively suicidal, but still has fleeting moments when she feels it could be higher to not be alive anymore.
Bravo, alternatively, goes to a psychotherapist and finds the therapy helpful because “therapy refocuses and recontextualizes everything.” Her therapist reminds her that things could possibly be much worse. “And she reminds me that my very presence is proof of my will to live.”