Psychiatric Clinics of North America
Volume 21 . Number 3 . September 1998
Copyright © 1998 W. B. Saunders Company

THE UNDERDIAGNOSIS OF NEUROPSYCHIATRIC LYME DISEASE IN CHILDREN AND ADULTS

Brian A. Fallon, MD, MPH
The NYS Psychiatric Institute
Lyme Disease Research Program
722 West 168th Street, #13
New York, NY 10032

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[excerpts]

Lyme disease is a tick-borne illness caused by the spirochete Borrelia burgdorferi. Reported throughout the United States, the greatest incidence of Lyme disease occurs in certain areas, such as the Northeast, the upper Midwest, and the Pacific Coastal states. It has been dubbed "The New Great Imitator" because, like another spirochetal illness neurosyphilis -- the original Great Imitator, Lyme disease has a vast array of multisystem manifestations, including neuropsychiatric ones. [18] Failure to recognize Lyme disease early in its course can result in the development of a chronic illness that is only temporarily or partially responsive to antibiotic therapy. The goal of this article is to present the typical and atypical manifestations of Lyme disease in children and adults in order to help the clinician more rapidly unmask the correct diagnosis behind the puzzling presentations of some patients.

Underdiagnosis of Lyme disease, however, is also a problem, particularly when the symptoms are primarily neuropsychiatric. In a survey of 193 patients with seropositive chronic Lyme disease, [7] patients reported having been sick for approximately 1 year and having had to consult with a mean of two doctors before the diagnosis of Lyme
disease was made. Prior to diagnosis, 42.5% of these seropositive patients were thought to have had only a psychiatric disorder. Although this survey sample undoubtedly included some seropositive patients who may not have had Lyme disease, the results do suggest that neuropsychiatric problems are common in chronic Lyme disease, and that mental health professionals can play a critical role in the initial diagnosis.

In this article, the authors describe the typical clinical profile of Lyme disease and the tests that exist to support the diagnosis. They conclude with case studies of three patients who were initially thought to have other diagnoses: attention deficit disorder (ADD), depression, and multiple sclerosis (MS).

Amblyomma americanum~includes lone star tick

The plethora of psychiatric problems associated with Lyme disease were first reviewed in 1990 in the European medical literature by Drs. Kohler [12] and Omasits. [17] Kohler attempted to categorize the psychiatric symptoms by stage, listing depressive mood in early disease, organic personality disorders in mid-stage disease, and organic psychoses, dementia, and anorexia in the later phase of the illness. Omasits stated that psychiatric manifestations can be predominant and that the clinical spectrum of Lyme disease ranges from agitated depressive states with suicidal ideas to the clinical picture of dementia. A review of the medical literature [8] revealed that, in addition to the disorders listed by Kohler and Omasits, Lyme disease appear to be capable of causing syndromes which manifest as personality change, depersonalization, mania, hallucinations (auditory, visual, and olfactory), paranoia, catatonia with stupor and mutism, somatization disorder, obsessive compulsive disorder, violent outbursts, panic attacks and disorientation.

Children and adolescents with neurologic Lyme disease, behavioral or mood disturbances are the second most frequently reported symptom. [1] Common neuropsychiatric symptoms include headaches, fatigue, difficulty with concentration in school, irritability, oppositional behavior, and new onset anxiety disorders. When the onset of illness is not dramatic, but characterized by gradually increasing fatigue, disinterest, and inattention, children may begin to label themselves as incompetent as they realize they can no longer keep up with the rest of their classmates academically. While developmental and family issues always need to be considered when there is a change in a child's behavior or mood, in endemic areas Lyme disease should be considered as well, particularly because delays in diagnosis are associated with greater chronicity.