Lyme neuroborreliosis

Page most recently updated 7 September 2026

This page focuses on the reported psychiatric associations, which may be the initial presenting manifestation, and on other clinical features that may assist the psychiatrist or primary care physician in identifying the underlying diagnosis, considered through the lenses of the diagnostic lenses framework.

Lyme neuroborreliosis is a neurological manifestation of infection with Borrelia species that can produce neuropsychiatric and multisystemic manifestations. A distinctive presentation may include the combination of new cognitive or behavioural change, headache or meningitic symptoms, painful radiculopathy, cranial neuropathy—particularly facial palsy—and a relevant history of tick exposure or residence in, or travel to, a Lyme-endemic region.

Exposure clues include residence in or travel to a Lyme-endemic area and possible exposure to infected blacklegged (Ixodes) ticks, particularly through outdoor activities in wooded or brushy environments. A recognized tick bite or erythema migrans rash may provide an important clue, but neither is necessary for diagnosis, and many patients do not recall a tick bite.

It can present with psychiatric features such as depression, anxiety, irritability, sleep disturbance, impaired concentration, memory difficulties, behavioural changes, as well as delusions, hallucinations and mania.

Other characteristic features include lymphocytic meningitis, severe headache, neck stiffness, cranial neuropathies—particularly unilateral or bilateral facial palsy—painful radiculitis or radiculoneuropathy, shooting or radicular pain, paresthesias, numbness, and weakness. Encephalitis or encephalomyelitis can occur but is uncommon. Visual disturbances, dizziness, and other cranial-nerve manifestations may also occur.

From a multisystemic lens perspective, clinical features in other body systems include (but are not limited to):

  • Cardiovascular: Lyme carditis, particularly atrioventricular conduction abnormalities or heart block; palpitations, dizziness, syncope, and, less commonly, myocarditis may occur.

  • Hepatobiliary: Mild, usually transient elevations of aminotransferases or other liver enzymes may occur, particularly in early disseminated Lyme disease; clinically significant hepatitis or hyperbilirubinemia is uncommon.

  • Hematologic: Lymphadenopathy may occur, particularly during early disseminated infection.

  • Musculoskeletal: Recurrent episodes of objective arthritis, particularly involving a large joint such as the knee, as well as migratory or intermittent musculoskeletal pain.

  • Dermatologic: Erythema migrans, including multiple lesions with disseminated infection; the rash may be absent or atypical, and a classic “bull's-eye” appearance is not required.

Early diagnosis is important because untreated neuroborreliosis can cause persistent or progressive neurological injury; patients typically respond well to appropriate antibiotic treatment.

Selected references and further reading — Multisystemic lens

Cardinal RN, Bullmore ET. The diagnosis of psychosis. Cambridge: Cambridge University Press; 2011.

Sachdev PS, Keshavan MS, editors. Secondary schizophrenia. Cambridge: Cambridge University Press; 2010.

Levenson JL, editor. The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. 3rd ed. Washington (DC): American Psychiatric Association Publishing; 2019.

Stern TA, Beach SR, Smith FA, Freudenreich O, Vranceau AM, Fava M, editors. Massachusetts General Hospital handbook of general hospital psychiatry. 8th ed. Philadelphia: Elsevier; 2025.

Arciniegas DB, Yudofsky SC, Hales RE, editors. The American Psychiatric Association Publishing textbook of neuropsychiatry and clinical neurosciences. 6th ed. Washington (DC): American Psychiatric Association Publishing; 2018.

Agrawal N, Faruqui R, Bodani M, editors. Oxford textbook of neuropsychiatry. Oxford: Oxford University Press; 2020.

Boland R, Verduin M, editors. Kaplan and Sadock's comprehensive textbook of psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2024.

Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 22nd ed. New York: McGraw Hill; 2025.