A convergent neurological and psychoanalytic view of the concept of regression and mental structure in a case of NMDA receptor encephalitis

Abstract

This is a review of a case of N-methyl-D-aspartate (NMDA) receptor encephalitis looked at from the vantage point of clinical psychoanalysis and clinical neurology. We will describe the events of our patient's illness and attempt to articulate our ongoing clinical thought process, both psychoanalytic and neurological. We will show that our patient demonstrated a massive regression in mental functioning, whose features were consistent with Freud's views on the nature of regression. With neurological treatment our patient made a full recovery in her mental functioning. We will argue that this regression in mental functioning was the result of a six-month-long absence of functional NMDA receptors in her brain. However, in trying to understand what happened to this patient's mental functioning using Freud's structural theory, we came across some insoluble contradictions in accounting for the dynamic interactions of the id, ego, and superego when these entities were viewed as distinct systems, agencies, or structures of the mind. We will argue that this constitutes clinical and neurobiological evidence for the need to modify some aspects of Freud's structural theory. We will propose that reuniting neurological and psychoanalytic thinking can provide psychoanalysts with a conceptual framework necessary to critically evaluate psychoanalytic metapsychology.

Keywords:

• regression
• consciousness
• ego
• id
• NMDA
• encephalitis

Notes

1. The three terms – agencies, systems, or structures – were used interchangeably throughout Freud's writing, including in The Ego and the Id, (Freud, 1923). We will use them interchangeably here to avoid unnecessary repetition for stylistic purposes. However, it should be noted they each have slightly different connotations, even though they all refer to some kind of modularity of the mind.

2. This might have been a case of NMDA receptor encephalitis reported by a psychoanalyst at a time (1981) when the diagnosis and neuropathology of NMDA receptor encephalitis were not yet elucidated (for discussion, see: Florance et al., 2009).

3. The psychoanalytic reader should note here that this is classical clinico-anatomical neurological thinking – “pure culture” clinical neurology, consistent with contemporary standards of practice. The neurologist must first locate where in the nervous system a problem might reside given known anatomical-pathological associations, and then, second, define the type of neuropathology that might render that part of the nervous system dysfunctional. The first is partly accomplished through the neurological examination, and the second relies more on the detailed neurological history. The entire clinical impression is then verified (ruled in or ruled out) by an array of tests chosen to test the clinical impression (serology, cerebral spinal fluid examination, many different kinds of brain scans, EEG, etc.). This kind of anatomical “locating,” as a component of clinical neurological thinking, should not be confused with the localizationist tradition, which struggled with, for example, whether a memory was located inside a neuron. The localizationist tradition posed great problems for Freud's attempts at defining the underlying neurophysiology of mental processes (for discussion see: Solms & Saling, 1986).

4. The first contact in the Canadian ER and the second contact in the American ER and then the psychiatric ward can be looked at retrospectively as the prodromal period of NMDA receptor encephalitis.

5. Henceforth the authors themselves made the clinical observations we report.

6. Experienced neurological nurses who had prior experience on pediatric wards especially confirmed this observation of the mother–child emotional interaction. On pediatric wards, it is commonly observed that infants and young children are generally calmer when their mothers are calm.

7. We could not test this clinical hypothesis with EEGs due to the patient's inability to tolerate excessive stimulation. The implications of this will be discussed below.

8. She did not receive any psychoactive medication prior to this interaction with me [A.W.] because she was now calm and did not require sedation. We continued to have standing pro re nata orders for quetiapine and diphenhydramine, however, it was not used at the time of her dream report. We attributed her being calm to the ongoing presence of her mother – much like one might see when a young child needs to be in the hospital. The mother was present at the bedside during this dream report.

9. We are trying to convey here what we view as the patient's subjective experience of herself. This is a paradigmatically psychoanalytic perspective.

10. Recall that Freud viewed all dreaming as a topographical regression because it entailed the movement of an excitation through the mental apparatus during sleep as proceeding in a backward direction – from thought to hallucination, rather than from thought to motor action (see Chapter VII in Freud, 1900). The patient had a minimum of motor activity in this period, although not the (almost) complete atonia that accompanies rapid eye movement sleep.

11. These behaviors did not recur.

12. Recall that the hallmark of NMDA receptor neurophysiology is its capacity to effect complex integration of neural pathways via the cellular process of synaptogenesis.

13. Prior to hippocampal surgery at the MNI the functionality of the contralateral hippocampus must be shown to be normal. Then the diseased hippocampus can be safely removed without producing a permanent amnesia, as in the case of H.M. (Scoville & Milner, 1957). Following hippocampectomy a healthy contralateral hippocampus can take over all hippocampal functions and there is usually no memory impairment. Anesthetizing only one hemisphere of the brain with the patient awake, and then performing neurocognitive tests, verifies the functionality of the contralateral hippocampus. Amnesia is thought to be associated with bilateral hippocampal dysfunction.

14. For a discussion of the “day residue” and its link to memory, see (Freud, 1900, pp. 560–564)

15. The retrograde amnesia seen in NMDA receptor encephalitis usually does not exceed six months – the period of time thought to coincide with long-term memory consolidation.

16. When the patient was transferred from the ICU to the regular ward at the MNI, there was extensive team discussion about the advisability of ongoing repetition of multiple tests (scans, EEG's, etc.). The decision was taken not to pursue any further investigations of this patient because her eight-month long ordeal was difficult enough as it was, and any further investigations were not going to alter our clinical management of a patient who was recovering. In the immediate post ICU period, for example, the patient would have required general anesthesia in order to have brain imaging studies.

17. This refers to the “localizationist” tradition, not to the anatomical-pathological associations that neurologists utilize in their clinical thinking (Solms & Saling, 1986).