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Connell J, Oldham M, Pandharipande P, Dittus RS, Wilson A, Mart M, Heckers S, Ely EW, Wilson JE. Malignant Catatonia: A Review for the Intensivist. J Intensive Care Med 2023; 38:137-150. [PMID: 35861966 DOI: 10.1177/08850666221114303] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Catatonia is a clinical syndrome characterized by psychomotor, neurological and behavioral changes. The clinical picture of catatonia ranges from akinetic stupor to severe motoric excitement. Catatonia can occur in the setting of a primary psychiatric condition such as bipolar disorder or secondary to a general medical illness like autoimmune encephalitis. Importantly, it can co-occur with delirium or coma. Malignant catatonia describes catatonia that presents with clinically significant autonomic abnormalities including change in temperature, blood pressure, heart rate, and respiratory rate. It is a life-threatening form of acute brain dysfunction that has several motoric manifestations and occurs secondary to a primary psychiatric condition or a medical cause. Many of the established predisposing and precipitating factors for catatonia such as exposure to neuroleptic medications or withdrawal states are common in the setting of critical illness. Catatonia typically improves with benzodiazepines and treatment of its underlying psychiatric or medical conditions, with electroconvulsive therapy reserved for catatonia refractory to benzodiazepines or for malignant catatonia. However, some forms of catatonia, such as catatonia secondary to a general medical condition or catatonia comorbid with delirium, may be less responsive to traditional treatments. Prompt recognition and treatment of catatonia are crucial because malignant catatonia may be fatal without treatment. Given the high morbidity and mortality associated with malignant catatonia, intensivists should familiarize themselves with this important and under-recognized condition.
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Affiliation(s)
- Jennifer Connell
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mark Oldham
- University of Rochester Medical Center, Rochester, NY, USA
| | - Pratik Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Division of Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert S Dittus
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of General Internal Medicine and Public Health, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Wilson
- Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Mart
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan Heckers
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wes Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA.,Department of Psychiatry and Behavioral Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.
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Lloyd JR, Silverman ER, Kugler JL, Cooper JJ. Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives. Neuropsychiatr Dis Treat 2020; 16:2191-2208. [PMID: 33061390 PMCID: PMC7526008 DOI: 10.2147/ndt.s231573] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022] Open
Abstract
Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.
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Affiliation(s)
- Jenifer R Lloyd
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Eric R Silverman
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | - Joseph L Kugler
- Department of Psychiatry, University of Texas-Dell Medical School, Austin, TX, USA
| | - Joseph J Cooper
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
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Abstract
OBJECTIVE Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century. METHOD We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia. RESULTS Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms. CONCLUSION Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.
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Affiliation(s)
- Max Fink
- Department of Psychiatry and Neurology Emeritus, Stony Brook University, Long Island, NY, USA.
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