Examining the influence of cognitive bias delaying the diagnosis and treatment of Anti-NMDA receptor encephalitis

Anti-NMDAR encephalitis is an autoimmune condition that often mimics psychiatric conditions on first presentation. Although immunotherapy can be effective in treatment, delayed recognition and diagnosis prolongs the acute phase of illness which carries higher risk of morbidity. In addition to the complex and varied clinical manifestations, one overlooked factor that may influence clinical judgment, diagnosis, and treatment is a provider's implicit biases, particularly as they pertain to sociocultural preconceptions of patients’ demographics. Here, we describe the clinical presentations, hospital courses, investigations, and treatment in two illustrative cases of anti-NMDAR encephalitis. We discuss the confluence of clinical factors that differentially confounded each clinical picture leading to delayed diagnosis. Additionally, we describe the possible influence of cognitive biases that perpetuated misdiagnoses. We emphasize that clinicians ought to be aware that bias takes different forms and can lead to delayed diagnosis or misdiagnosis resulting in significant morbidity. Consequently, we suggest simple strategies for mitigating the impact of specific biases both generally and specifically for encephalitis.