Cases That Test Your Skills

The treatment-resistant catatonia patient

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Ms. R develops severe catatonia after being hospitalized with agitation, delusions, and hallucinations. A benzodiazepine does not help. How would you treat her?



Case: Worsening psychosis

Ms. R, age 21, is admitted to our psychiatric facility while experiencing paranoid delusions and auditory hallucinations. Upon admission, she is agitated and her mood is labile.

Ms. R has 4 previous brief psychiatric admissions and was diagnosed with schizoaffective disorder, bipolar type and moderate mental retardation. Her family history is positive for psychiatric illness, as her mother was diagnosed with schizophrenia. Prior to admission, Ms. R was taking ziprasidone, 160 mg/d, and lithium, 450 mg/d, for 11 months. Both were discontinued during the first week of admission because Ms. R was not responding.

During this admission, the treating psychiatrist assesses Ms. R using the Schedules for Clinicians’ Interview in Psychiatry (SCIP), an instrument developed by the lead author (AA) for psychiatrists to use in conjunction with their routine clinical interviews in inpatient and outpatient settings (see Related Resources). The SCIP includes a 25-question screening section and a diagnostic section that consists of 7 modules that represent major psychiatric diagnoses defined by DSM and International Classification of Diseases criteria.1

During the first week of admission, we monitor Ms. R and administer haloperidol as needed, 10 mg total. Eight days after admission, she develops severe catatonia. On the catatonia scale of the SCIP, Ms. R scores the maximum on measures of immobility, catalepsy/waxy flexibility, and mutism (Table).

How would you treat Ms. R’s catatonia?


Patient’s catatonia symptoms: Response to pharmacotherapy

Lorazepam onlyLorazepam + risperidoneRisperidone oral onlyRisperidone long-acting injection only
Dosage(s)7 mg total over 7 daysLorazepam: 4 mg/d Risperidone: 4 mg/d8 mg/d37.5 mg every 2 weeks
Scores on SCIP catatonia scale:*
  Catalepsy/waxy flexibility2100
Total score6200
*Scale of 0 to 2, with 0=none, 1=less than half the time, and 2=more than half the time. Symptoms are evaluated over a 1-day period
†For this category, 0=none, 1=brief (usually 1 minute
SCIP: Schedules for Clinicians’ Interview in Psychiatry

The authors’ observations

DSM-IV-TR recognizes catatonia as a schizophrenia subtype, as a descriptor for mania and major depression, and as being caused by various medical conditions, such as neuroleptic malignant syndrome, encephalopathy, or renal failure.2 Kahlbaum initially described catatonia in 1873 as a brain disease characterized by motor abnormalities such as akinesia, rigidity, negativism, mutism, grimacing, posturing, catalepsy, waxy flexibility, and verbigerations.3 Catatonia is characterized by hypo- and hyperkinetic features. Catalepsy, stupor, rigidity, and catatonic posturing with waxy flexibility might alternate with violent catatonic excitement.4

Catatonia can be life-threatening; patients might not be able to eat or chew food, which puts them at risk for aspiration. Those with immobility might not move to urinate or defecate. During the first half of the 20th century, catatonia was documented in up to 50% of patients with schizophrenia.5 Since then, the incidence of catatonia has decreased, possibly the result of advances in psychopharmacology.6

Two days after Ms. R develops catatonia, we transfer her to a local hospital for evaluation to rule out a medical cause of her catatonic symptoms.

EVALUATION: No medical cause

At the hospital, physical examination, electroencephalography, drug screening, and liver and thyroid function tests are within normal limits, eliminating an organic cause of Ms. R’s catatonia. MRI of the head shows a 3-mm mass at the base of the infundibulum, which is unchanged from a prior MRI. Ms. R received 7 mg total of lorazepam over 4 days without relief of her catatonia. She is transferred back to our facility.

The authors’ observations

Benzodiazepines and ECT are effective treatments for catatonia.7 Benzodiazepines are considered first-line treatment because of their efficacy and favorable side-effect profile.7 Lorazepam frequently is used to treat catatonia in the short term.8 Long-term use of benzodiazepines, however, is associated with tolerance, addiction, and rebound phenomena.8,9

Patients with catatonia who do not respond to benzodiazepines may benefit from ECT.9 ECT can cause serious side effects, however, including memory impairment, confusion, delirium, and cardiac arrhythmias.10

Atypical antipsychotics may alleviate motor symptoms of catatonia by virtue of their 5-HT2A receptor antagonistic action.9 In 2 case reports, risperidone successfully treated catatonia.4,11 Kopala et al11 found risperidone, 4 mg/d, was effective in treating severe, first-episode catatonic schizophrenia in a neuroleptic-naive young man. This efficacy was sustained over a 3.5-year outpatient follow-up.

In another report, risperidone, 6 mg/d, effectively treated catatonia and prevented further episodes in a patient with schizophrenia who developed severe catatonia after receiving adequate treatment for Lyme disease with encephalitis.4 Two relapses of catatonic syndrome occurred when risperidone was reduced to 2 mg/d, and remission occurred after risperidone was increased to 6 mg/d. Risperidone’s antagonistic activity of the 5-HT2/D2 receptors may be relevant to its anticatatonic effect.12

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