Treating persistent catatonia when benzodiazepines fail

Table 2

WIRED `N MIRED: Mnemonic for detecting catatonia

CASE CONTINUED: MAKING THE DIAGNOSIS

In the medical unit, Mr. C was found to be in a catatonic stupor, with immobility, mutism (monosyllabic speech), catalepsy, intermittent waxy flexibility, withdrawal (refusal to eat and drink), automatic obedience, and mitgehen (exaggerated movements in response to light finger pressure, despite instructions to stay still). ECT workup was started, along with a trial of lorazepam, 1 mg tid.

Laboratory studies revealed high BUN/creatinine (80/2.0) that returned to normal range (BUN 7 to 21 mg/dL; creatinine 0.5 to 1.2 mg/dL) after 3 days of hydration. Because of Mr. C’s earlier excited symptoms and delusional thinking, we considered a diagnosis of bipolar disorder with catatonia. However, his symptoms did not improve with a trial of valproic acid (serum level 64 mcg/mL).

Head CT showed generalized atrophy and EEG showed delta slowing. Single-photo emission computer tomography (SPECT) showed areas of decreased perfusion in the cortex, with no perfusion in the left posterior parietal area (PP).

Mental status exam found Mr. C disoriented with poor short-term memory and unable to complete the Mini Mental State Examination (MMSE). His Bush-Francis Catatonia Rating Scale score was 28 and included many catatonic signs that would not be seen a patient with simple dehydration.

The workup supported a diagnosis of catatonia due to general medical condition (vascular dementia) and ruled out schizophrenia with catatonic features, bipolar disorder, or major depression with catatonia.

EVALUATION AND DIAGNOSIS

Medical causes. A careful history and thorough physical examination are essential for making an accurate diagnosis and ruling out medical conditions that could present with or mimic catatonia (Table 3). Medications that can induce catatonia include antipsychotics, corticosteroids, and disulfiram at therapeutic doses. Drug abuse (such as with phencyclidine), use of the general anesthetic ketamine, and benzodiazepine withdrawal may also lead to catatonia.

Head CT or MRI is indicated for patients being considered for ECT or for localizing neurologic findings. EEG can be useful when patients present with features of seizure activity—such as tongue biting, incontinence, or stupor—or with catatonia as a manifestation of delirium or dementia.

A history of head injury or neurologic disease warrants further neurologic investigation. Also consider a neurology consult when the patient has prolonged stupor or does not respond to initial drug therapy.

Psychiatric causes. The clinical setting may suggest the most likely primary psychiatric disorders to consider, such as:

• bipolar or major depression in acute inpatient psychiatric units
• autism and pervasive developmental disorders (PDD) in pediatric or PDD units
• catatonic schizophrenia in chronic psychotic patients
• somatoform or factitious disorders in forensic settings.

These generalizations are not clinically exclusive, of course, but may provide a starting point for the treatment team confronted with limited history and exam information.

Table 3

Catatonia workup: Recommended lab tests

Initial treatment. Catatonia related to medical and psychiatric causes has been shown to respond to lorazepam and to ECT.^6,7 Lorazepam is preferred because of its specificity for the GABAa receptor and ease of administration (oral, IM, or IV). Other agents that act on GABA—including amobarbital and zolpidem—have also been used. Catatonia’s hallmark features such as mutism and immobility have been shown to respond to lorazepam.^8,9

ECT is a first-line treatment for catatonia with life-threatening conditions and should be considered for refractory cases.

Lorazepam. The starting dosage is usually 1 mg tid for healthy adults; 0.5 mg tid can be used for children and the elderly. Observe the patient for improvement in catatonic signs after the first dose and before giving the second. Dosages of up to 16 mg/d have been used.

In many cases, lorazepam can be tapered off after adequate treatment of the primary psychiatric condition. In severe cases, however—such as when patients refuse to eat or drink—lorazepam may be continued for as long as 1 year. Weigh the risk of benzodiazepine tolerance, dependence, and misuse versus the possibility of relapse and rehospitalization.

Medical catatonias and neuroleptic malignant syndrome (NMS) have responded favorably to ECT.⁸ Addressing the medical cause itself usually does not resolve catatonia, with the possible exception of seizure-induced (“ictal”) catatonia, which may respond to anticonvulsants and lorazepam.^6,7

ECT. An ECT workup can begin as soon as a patient presents with catatonia. If lorazepam produces no response within 24 hours, consider ECT.