Lorazepam and diazepam rapidly relieve catatonic signs in patients with schizophrenia

Catatonia

Catatonia is a neuropsychiatric disorder characterized by motor, affective and cognitive-behavioural signs, which lasts from hours to days. Intensive research over the past two decades has led to catatonia being recognized as an independent diagnosis in the International Classification of Diseases, 11th Revision (ICD-11) since 2022. Catatonia is found in 5-18% of inpatients on psychiatric units and 3.3% of inpatients on medical units. However, in an unknown number of patients, catatonia remains unrecognized and these patients are at risk of life-threatening complications. Hence, recognizing the symptoms of catatonia early is crucial to initiate appropriate treatment to achieve a favourable outcome. Benzodiazepines such as lorazepam and diazepam, electroconvulsive therapy, and N-methyl-D-aspartate antagonists such as amantadine and memantine, are the cornerstones of catatonia therapy. In addition, dopamine-modulating second-generation antipsychotics (for example, clozapine and aripiprazole) are effective in some patient populations. Early and appropriate treatment combined with new screening assessments has the potential to reduce the high morbidity and mortality associated with catatonia in psychiatric and non-psychiatric settings.

Lorazepam in catatonia - Past, present and future of a clinical success story

The effect of lorazepam in the treatment of catatonia is outstanding and almost immediate. Clinicians are familiar with its effects: mute patients can speak again, akinetic patients can move again and patients with negativism can eat and drink again within usually a short duration of about 10 min to 1-2 h. Fear is often gone after lorazepam administration. While not always effective, the introduction of lorazepam into clinical practice represented a breakthrough and was often life-saving for many patients suffering from catatonia. It is rare to observe such rapid therapeutic effects in other domains of psychiatry. In this narrative review we will briefly look at the past, present and future of lorazepam in the treatment of catatonia. It is gratifying to reflect on the fact that clinicians using the age-old medical practice of observation and empirical treatment succeeded in advancing the management of catatonia 40 years ago. The present evidence shows that the clinical effect of lorazepam in catatonia treatment is excellent and more or less immediate although it remains to be explicitly tested against other substances such as diazepam, zolpidem, clozapine, quetiapine, amantadine, memantine, valproate and dantrolene in randomized clinical trials. In addition, future studies need to answer the question how long lorazepam should be given to patients with catatonia, months or even years? This narrative review promotes the rapid use of lorazepam in the treatment of acute catatonic patients and stipulates further scientific examination of its often impressive clinical effects.

Increased serum anti-N-methyl-D-aspartate receptor antibody immunofluorescence in psychiatric patients with past catatonia

OBJECTIVE

Anti-N-methyl-D-aspartate receptor (NMDAR) antibody was thought to be the cause of anti-NMDAR encephalitis, with manifestations similar to catatonia and schizophrenia. Anti-NMDAR antibody in neuropsychiatric patients who had catatonia before were investigated in a follow-up evaluation. The intensity of antibody immunofluorescence was quantified and compared with healthy controls.

METHOD

Nineteen patients (eight males and eleven females) agreed to be followed-up. Thirteen had the diagnosis of schizophrenia, two had the diagnosis of major depressive disorder, two had bipolar disorder, one had postpartum depression, and one had herpes simplex encephalitis. No patient had catatonia during the follow-up. Nineteen sex-matched healthy controls were recruited.

RESULTS

Using Mann-Whitney U test, patients had greater intensity of anti-NMDAR antibody immunofluorescence than the healthy controls (121,979 ± 86,526 vs. 47,692 ± 26,102, p = 0.003). No correlation was found between immunofluorescence intensity and catatonia scales or symptom severity scores. Neuropsychiatric patients with past catatonia showed greater anti-NMDAR antibody response than the healthy controls.

CONCLUSION

NMDAR dysfunction might play a role in the mechanism underlying catatonia. Further studies are needed to confirm this finding.

Periodic catatonia with long-term treatment: a case report

BACKGROUND

Periodic catatonia has long been a challenging diagnosis and there are no absolute guidelines for treatment when precipitating factors are also unclear. We report a schizophrenia patient with periodic catatonia with a 15-year treatment course. A possible correlation between decreased daylight exposure and periodic attacks has been observed.

CASE PRESENTATION

We describe a 49-year-old woman with periodic catatonia associated with schizophrenia with 15 years of follow-up. The patient was treated with the antipsychotics risperidone, haloperidol, loxapine and quetiapine, but catatonia still relapsed once per year during the first few years of her disease course. The treatment was consequently been switched to clozapine due to fluctuated psychotic illness, and a longer duration of remittance was achieved. Lorazepam-diazepam protocol was used for rapid relief of catatonic symptoms, and was able to significantly shorten the duration of the symptoms. In addition, we observed a possible correlation between catatonic episodes and decreased daylight exposure during the 15-year duration.

CONCLUSIONS

Successful treatment of acute periodic catatonia was achieved with a lorazepam-diazepam protocol, and the patient remained in remission for a longer duration under clozapine treatment. Besides, the possibility of decreased daylight exposure acting as a precipitating factor was observed during our 15 years of follow-up.

The Lorazepam and Diazepam Protocol for Catatonia Due to General Medical Condition and Substance in Liaison Psychiatry

OBJECTIVE

The lorazepam-diazepam protocol had been proved to rapidly and effectively relieve catatonia in patients with schizophrenia or mood disorder. This study aims to investigate the efficacy of lorazepam-diazepam protocol in catatonia due to general medical conditions (GMC) and substance.

METHOD

Patients with catatonia that required psychiatric intervention in various settings of a medical center were included. The lorazepam-diazepam protocol had been used to treat the catatonia due to GMC or substance according to DSM-IV criteria. The treatment response had been assessed by two psychiatrists.

RESULTS

Eighteen (85.7%) of 21 catatonic patients due to GMC or substance became free of catatonia after the lorazepam-diazepam protocol. Five (23.8%) of the 21 patients had passed away with various causes of death and wide range of time periods after catatonia.

CONCLUSION

Our results showed that the lorazepam-diazepam protocol could rapidly and effectively relieve catatonia due to GMC and substance.

Relapses and recurrences of catatonia: 30-case analysis and literature review

OBJECTIVE

Relieving catatonia helps identify the underlying etiology and its treatment. However, catatonia may reemerge after some time, but there are few data on the relapses and recurrences of catatonia. We aimed to investigate the characteristics of patients with relapses or recurrences of catatonia as well as the efficacy of the lorazepam-diazepam protocol on them.

METHODS

Patients with catatonia who had more than one episode of catatonia and were treated with the lorazepam-diazepam protocol were identified. Their medical charts were reviewed, and interview was conducted.

RESULTS

Thirty patients were identified. Nineteen (63.3%) were diagnosed with schizophrenia, five (16.7%) with major depressive disorder, two (6.7%) with bipolar disorder, and four (13.3%) with general medical conditions. In the 68 relapses and relapses the lorazepam-diazepam protocol was used, full response was reported in 54 (79.4%) of them. Twelve of 19 (63.2%) patients with schizophrenia were treated with clozapine. Twenty (66.7%) out of 30 patients were maintained on oral lorazepam by the time of discharge. Literature review showed similar prevalence of schizophrenia in patients with more than one episode of catatonia, and a wide variety of treatment options.

CONCLUSION

The lorazepam-diazepam protocol was mostly effective in managing relapses and recurrences of catatonia. Maintenance clozapine and oral lorazepam were beneficial in a significant number of patients.

Benzodiazepine treatment of catatonia

The mechanisms of catatonia may involve the GABA system, dopamine system, glutamate/N-methyl-D-aspartate receptor system and brain-derived neurotrophic factor. In this article we will share our experiences in treating catatonia with benzodiazepines in Taiwan. We will look at catatonia and its association with anti-N-methyl-D-aspartate receptor encephalitis, and lastly, reports on predicting outcome of patients with catatonia will also be discussed.

Successful treatment of treatment-resistant schizophrenia in a 10-year-catatonic patient by augmentation of selective serotonin reuptake inhibitors: a case report

Although catatonia is a well defined syndrome, the treatment of chronic catatonia remains an unresolved issue. Here, we report a successful treatment of a 30-year-old patient with treatment-resistant catatonic schizophrenia in 10 years by augmentation of selective serotonin reuptake inhibitors (SSRIs).We present a 30-year-old man with treatment-resistant catatonic schizophrenia who failed to respond to the treatment of benzodiazepines and antipsychotics for 10 years. He markedly improved after taking SSRIs. Now, he does not hold odd postures and begins to talk and show more facial expressions.We postulate that the therapeutic effect is related to the enhancement of 5-HT neurotransmission. SSRIs can be a considerable choice to treat chronic catatonia.

A clinical review of the treatment of catatonia

Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome, apart from thorough and repeated observation, a clinical examination is needed. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination. Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines, such as lorazepam, and electroconvulsive therapy.

Lorazepam-diazepam protocol for catatonia in schizophrenia: a 21-case analysis

OBJECTIVES

Catatonia is a unique clinical phenomenon characterized by concurrent motor, emotional, vegetative and behavioral signs. Benzodiazepines (BZD) and electroconvulsive therapy (ECT) can rapidly relieve catatonic signs. The lorazepam-diazepam protocol presented here has been proven to relieve catatonia in schizophrenia within a day.

METHODS

From July 2002 to August 2011, schizophrenic patients requiring psychiatric intervention for catatonia in Kaohsiung Chang Gung Memorial Hospital were studied by medical chart review. The study used the Bush-Francis Catatonia Rating Scale (BFCRS). Patients receiving the lorazepam-diazepam protocol were identified.

RESULTS

The survey included 21 patients (eight males and 13 females) with a mean age of 30.3 ± 12.6 years. Mean duration of schizophrenia was 4.7 ± 5.6 years. Thirteen (61.9%) patients responded within 2 h, 18 (85.7%) responded within one day, and all became catatonia-free within a week. Mean BFCRS score was 9.9 ± 3.0 before treatment. Patients that responded with a single intramuscular lorazepam injection had mean BFCRS score of 8.9 ± 2.8, significantly lower than the mean score (11.6 ± 2.5) of the rest of the patients (p = 0.034).

CONCLUSIONS

The lorazepam-diazepam protocol can rapidly relieve retarded catatonia in schizophrenia. Most patients became catatonia-free within one day but some may require up to a week. ECT should be considered if the protocol fails.

Response rate of catatonia to electroconvulsive therapy and its clinical correlates

Electroconvulsive therapy (ECT) is an important treatment for catatonia. We aimed to study the response rate of catatonia treated with ECT and its clinical correlates in a large sample of inpatients. The ECT parameters of all patients (n = 63) admitted with catatonia between the months of January and December 2007 were examined. The number of ECTs administered, seizure threshold, failure to achieve adequate seizures and clinical signs pertaining to catatonia were analyzed. Response was considered as complete resolution of catatonic symptoms with Bush Francis Catatonia Rating Scale (BFCRS) score becoming zero. ECT was mostly started after failed lorazepam treatment except in 6 patients where ECT was the first choice. Patients who responded in 4 ECT sessions were considered fast responders (mean session number for response is 4 sessions) and response with 5 or more ECTs was considered slow response. Fast responders had significantly lower duration of catatonia (19.67 ± 21.66 days, P = 0.02) and higher BFCRS score at presentation (17.25 ± 6.21, P = 0.03). Presence of waxy flexibility and gegenhalten (22.60% vs. 0%, P = 0.01) predicted faster response, whereas presence of echophenomena (3.2% vs. 24.0%) predicted slow response. The response rate to catatonia appears to be associated with the severity and duration of catatonia, and the presence of certain catatonic signs.

Clinical predictors of response to treatment in catatonia

OBJECTIVE

This study aims at identifying predictors of treatment response to lorazepam in catatonia.

METHODS

The clinical charts of 107 inpatients, admitted over duration of 2 years, with a primary diagnosis of catatonia were examined for response to lorazepam trial. Trial was considered as having received 3-6 mg per day of lorazepam for at least 3 days.

RESULTS

Out of these 107 patients, 99 received lorazepam and 8 received electroconvulsive therapy as the first line of management. There were 32 responders and 67 nonresponders to lorazepam. The nonresponders were characterized by rural background (85.1% vs. 62.5%, P=.01), longer duration of catatonic symptoms (108.88 vs. 25.12 days, P=.018), mutism (63.6% vs. 31.3%, P=.02) and presence of first-rank symptoms like third-person auditory discussing-type hallucinations (16.4% vs. 12.0%, P=.03) and made phenomena (7.5% vs. 0%, P=.04). The presence of waxy flexibility (12.5% vs. 4.5%, P=.03) predicted good response.

CONCLUSIONS

This study identifies that longer duration of illness, presence of catatonic sign of mutism and certain specific phenomena like third-person auditory hallucinations and made phenomena predicted poor response to lorazepam in catatonia. This could provide insight into the prediction and planning of the appropriate treatment strategies in this psychiatric emergency.

Response rate of lorazepam in catatonia: a developing country's perspective

BACKGROUND

Catatonia is a syndrome characterized by concurrent motor, emotional, and behavioral symptoms. Short-term benzodiazepine administration and electroconvulsive therapy have proven to be safe and useful for treatment of this syndrome.

AIMS

This study aimed to explore the evidence of effectiveness of lorazepam as a first line treatment for catatonia in a tertiary psychiatry centre in India given the lack of facilities for ECT in primary care centers of developing countries. We examined the response rate of lorazepam in Catatonia.

METHODOLOGY

Clinical charts of 107 inpatients, admitted over a duration of two years, with a primary diagnosis of catatonia were examined for response with lorazepam trial. Trial was considered as having received 3-6 mg per day of lorazepam for at least 3 days.

RESULTS

Among the patients who were given lorazepam treatment, 32 out of 99 (32.3%) showed response (with complete resolution of catatonic symptoms). Improvement in catatonic symptoms was seen in 68 out of 99 (68.7%) patients.

CONCLUSIONS

Lorazepam is cost effective and could rapidly relieve catatonic signs, even without the use of ECT in a significant proportion of catatonic patients. Its early use can prevent disease progression and complications.

An intercalation mechanism as a mode of action exerted by psychotropic drugs: results of altered phospholipid substrate availabilities in membranes?

Patients respond differently to psychotropic drugs, and this is currently a controversial theme among psychiatrists. The effects of 16 psychotropics on cell membrane parameters have been reported. These drugs belong to three major groups used in therapeutic psychiatry: antipsychotics, antidepressants, and anxiolytic/hypnotics. Human platelets, lacking dopamine (D(2)) receptors (proposed targets of most psychotropics), have been used as a cell model. Here we discuss the effects of these drugs on three metabolic phenomena and also results from Langmuir experiments. Diazepam, in contrast to the remaining drugs, had negligible effects on metabolic phenomena and had no effects in Langmuir experiments. Psychotropic drugs may work through intercalation in membrane phospholipids. It is possible that the fluidity of membranes, rich in essential fatty acids, the content being influenced by diet, could be a contributing factor to the action of psychotropics. This might in turn explain the observed major differences in therapeutic response among patients.

In thrombin stimulated human platelets Citalopram, Promethazine, Risperidone, and Ziprasidone, but not Diazepam, may exert their pharmacological effects also through intercalation in membrane phospholipids in a receptor-independent manner

Intercalation of drugs in the platelet membrane affects phospholipid-requiring enzymatic processes according to the drugs' intercalation capability. We investigated effects of Promethazine, Citalopram, Ziprasidone, Risperidone, and Diazepam on phospholipase A(2) (PLA(2)) and polyphosphoinositide (PPI) metabolism in thrombin-stimulated human platelets. We also examined effects of the drugs on monolayers of glycerophospholipids using the Langmuir technique. Diazepam did not influence PLA( 2 ) activity, had no effects on PPI cycle, and caused no change in mean molecular area of phospholipid monolayers. The remaining psychotropic drugs affected these parameters in different ways and levels of potency suggesting that they act by being intercalated between the molecules of adjacent membrane phospholipids, thus causing changes in substrate availability for phospholipid-hydrolyzing enzymes (PLA(2) and Phospholipase C). We show that several psychotropic drugs can also have other cellular effects than receptor antagonism. These effects may be implicated in the psychotropic effects of the drugs and/or their side effects.

Delirious mania and malignant catatonia: a report of 3 cases and review

Delirious mania is often difficult to distinguish from excited catatonia. While some authors consider delirious mania a subtype of catatonia, the distinction between the two entities is important as treatment differs and effects outcome. It appears that as catatonia is described as having non-malignant and malignant states, the same division of severity may also apply to delirious mania. Non-malignant delirious mania meets the criteria for mania and delirium without an underlying medical disorder. The patients are amnestic, may lose control of bowel and bladder, but still respond to atypical antipsychotics and mood stabilizers. However, with increasing progression of the disease course and perhaps with an increasing load of catatonic features, delirious mania may convert to a malignant catatonic state (malignant delirious mania) which is worsened by antipsychotics and requires a trial of benzodiazepines and/or ECT. Three case reports are presented to illustrate the diagnostic conundrum of delirious mania and several different presentations of malignant catatonia.

Treatment of catatonia with olanzapine and amantadine

Catatonia is a disorder characterized by mutism, posturing, echophenomena, and negativism. The preferred treatment for non-malignant catatonia is benzodiazepines, which often produce a reduction in symptoms within 24 hours. Presented here is a case report of a 19-year-old woman appearing in a catatonic state that did not respond to lorazepam. On the basis of emerging evidence that atypical antipsychotics and weak N-Methyl-D-Aspartate (NMDA) receptor-antagonists may effectively treat catatonia, we treated our patient with olanzapine and amantadine, which resulted in a dramatic reduction in her catatonic symptoms.

Transient splenial lesion of the corpus callosum after acute withdrawal of antiepileptic drug: a case report

Transient lesions at the splenium of the corpus callosum (SCC) have been reported after withdrawal of specific antiepileptic drugs (AED), though the pathophysiology of the lesions remains unclear. We examined and treated a schizophrenic patient who developed a transient SCC lesion after withdrawal of the AED, carbamazepine. Interestingly, the SCC lesion was accompanied by the onset of diabetes insipidus, a state of arginine-vasopressin (AVP) insufficiency. Because carbamazepine is shown to potentiate the effect of AVP, our case suggests that an insufficiency of AVP followed by withdrawal of AED could contribute to the pathogenesis of a transient SCC lesion.

Benzodiazepines in catatonia associated with systemic lupus erythematosus

Neuropsychiatric disturbances are found in 50-70% of systemic lupus erythematosus (SLE) patients. However, there are rare cases of catatonia being described in SLE. Some studies have shown the effectiveness of high-dose steroid, plasma exchange and electroconvulsive therapy (ECT) in lupus catatonia. Herein are described two SLE patients with catatonia who had good response to i.v. diazepam (i.e. relief of catatonia symptoms). Patient 1, with mild cortical atrophy, had great improvement in catatonia symptoms on i.v. diazepam 150 mg during a period of 5 days. Patient 2, without cortical atrophy, had quick response to i.v. diazepam 10-20 mg. Both patients had no recurrence during 6-month follow up. In conclusion, benzodiazepines may play an important role in the treatment of catatonia associated with SLE if patients refuse ECT treatment.

Lorazepam and diazepam rapidly relieve catatonic features in major depression

We have proved that a modified strategy (ie, lorazepam intramuscular injection [IMI] or diazepam intravenous drip [IVD] if lorazepam IMI fails) can rapidly relieve catatonic features in patients with schizophrenia. During a period of 3 years, we identified 7 major depressive patients with catatonic features in the emergency unit of a general hospital. The patients were treated with lorazepam IMI (dose, 2 mg/mL.per ampule) once or twice during the first 2 hours. If lorazepam IMI failed, diazepam IVD (dose, 10 mg/2 mL.per ampule) in 500 mL normal saline every 8 hours for 1 day would be administered. The total complete remission rate to lorazepam IMI within 2 hours was 6 (85.7%) per 7 patients, and the total complete remission rate to benzodiazepines (lorazepam IMI and diazepam IVD) within 1 day was 7 (100%) of all 7 patients. These results highly suggest that this modified strategy can also rapidly relieve catatonic features in major depression within 1 day and attain a high complete remission rate, even without electroconvulsive therapy.

Clozapine in schizophrenia patients with recurrent catatonia: report of two cases

Prolonged catatonia can be a source of extremely serious morbidity and mortality. Lorazepam is effective in rapidly relieving most cases of catatonia. Reports have also shown that second-generation antipsychotic drugs are also efficacious in relieving catatonia. This report describes two schizophrenia patients who demonstrated recurrent catatonic features mutism and stupor. Both patients were treated with lorazepam, diazepam or electroconvulsive therapy (ECT). Patient 1 responded well and rapidly to lorazepam each time catatonia happened; but catatonia recurred once a year under treatment with many antipsychotic drugs. Patient 2 had catatonia features associated with discontinuing or decreasing clozapine. With each recurrent episode, the duration of catatonia increased, requiring an increased dosage of benzodiazepine. The patient's response to lorazepam and ECT gradually decreased, until the patient had almost no response to lorazepam, diazepam or ECT. Both patients had no recurrence during a period of 2-year follow up with continuous clozapine therapy.

Catatonic schizophrenia and the use of memantine

OBJECTIVE

To report a case of catatonic schizophrenia treated with memantine that resulted in a rapid reduction of catatonic symptoms.

CASE SUMMARY

A 68-year-old male with catatonic schizophrenia presented with bizarre and catatonic behavior manifested by mutism, waxy flexibility, immobility, staring, nonresponsiveness to verbal commands, grimacing, rigidity, and posturing. During the course of his hospitalization, he was treated with memantine up to 10 mg/day. The catatonia responded rapidly and significantly to memantine.

DISCUSSION

Few treatment options are available for the management of catatonia. Lorazepam is generally the agent that has been used most often and has had varying degrees of success. Our report adds to a recently published case that also suggested that memantine might be useful for the management of catatonic behaviors in a patient with schizophrenia. While its mechanism of action is unknown, it has been thought that glutamate antagonists, such as memantine, may be beneficial in catatonic schizophrenia due to a glutamatergic dysfunction present in catatonic patients. It also has been hypothesized that there is a decrease in gamma-aminobutyric acid released to the supplementary motor areas, resulting in less glutamate inhibition. This results in a net effect of glutamatergic hyperfunction in the striatum, which may produce catatonia. Based on this hypothesis, memantine would be beneficial as an N-methyl-D-aspartic acid antagonist to decrease the amount of glutamate in the striatum and thereby relieve symptoms of catatonia. However, these potential benefits must be weighed against recently reported adverse reactions associated with memantine use, namely, psychosis and seizures.

CONCLUSIONS

Memantine produced a rapid and significant reduction in catatonic symptoms in our patient with catatonic schizophrenia.