Atypical course in severe catatonic schizophrenia in a cannabis-dependent male adolescent: a case report

Recurrent cannabis-induced catatonia: a case report and comprehensive systematic literature review

Background

Catatonia presents itself as a complex neuropsychiatric syndrome, giving rise to various motor, speech, and behavioral challenges. It is noteworthy that approximately 10% of psychiatric hospital admissions can be attributed to this condition. It is imperative to note that cannabis-induced catatonia, while infrequent, has been linked to the use of marijuana. This connection has the potential to disrupt neurotransmitter systems, necessitating further research for a comprehensive understanding and effective treatment, particularly given the evolving trends in cannabis use. In this context, we shall delve into a unique case of recurrent cannabis-induced catatonia.

Case presentation

A 23-year-old gentleman, who has previously struggled with substance use disorder, experienced the emergence of mutism, social isolation, and a fixed gaze subsequent to his use of cannabis. Remarkably, despite the absence of hallucinations, he exhibited recurrent episodes of catatonia. These episodes were effectively addressed through a combination of electroconvulsive therapy (ECT) and lorazepam administration. Notably, when the lorazepam dosage was gradually reduced to below 2 mg per day, the catatonic symptoms resurfaced; however, they promptly abated upon reinstating the medication. The diagnosis of cannabis-induced catatonia was established, and its management primarily involved a therapeutic approach encompassing ECT and lorazepam. It is pertinent to underscore that this catatonic condition can be directly linked to the individual's cannabis usage.

Conclusion

The connection between cannabis and catatonia is intricate and not entirely comprehended. Although cannabis possesses therapeutic advantages, it can paradoxically trigger catatonia in certain individuals. Multiple factors, such as genetics, cannabinoids, and neurotransmitter systems, contribute to this intricacy, underscoring the necessity for additional research.

A Case of Cannabis-Induced Catatonia and Management With Electroconvulsive Therapy

This is a case of cannabis-induced catatonia in an 18-year-old Hispanic male with no prior psychiatric history. Shortly after consuming marijuana, the patient experienced catatonic symptoms and demonstrated resistance to several medicinal therapies. Electroconvulsive therapy (ECT) proved to be a useful treatment choice, resulting in significant improvement in symptoms. This example emphasizes the potential dangers of cannabis usage, particularly in susceptible individuals, and underscores the importance of recognizing and treating catatonia as a possible side effect of cannabis use.

Catatonia Related to Cannabis and Synthetic Cannabinoids: A Review

Cannabis and synthetic cannabinoids (SC) are related to several neuropsychiatric symptoms and disorders, especially psychotic symptoms and disorders. Interestingly, catatonia-like symptoms associated with cannabis and SC have been generally neglected in research and scarcely described despite the clinical repercussions. Hence, this review aims to analyze current clinical publications on catatonia induced by cannabis or SC in a systematized way. Methods: A search using PRISMA guidelines was performed on three databases based on a specific inclusion and exclusion criteria. Results: 11 publications describing 14 patients (10 males; mean age 22.50 ± 6.67 years old) with catatonia apparently precipitated by the use of cannabis (n = 6) or SC (n = 8) were found. Clinical features and treatment are described and discussed. Conclusion: From a clinical perspective, cannabis and SC use may be related to catatonia-like symptoms and catatonia syndrome in the same way these substances (cannabis and SC) are related to induced-psychotic episodes. However, further research will be required to understand the exact nature of that relationship. Additionally, investigations focused on the clinical significance (i.e., prognosis, evolution, and outcomes) of catatonia-like symptoms induced by cannabis and SC use in patients are also needed.

Emergent Medical Illnesses Related to Cannabis Use

As more states rush to legalize the use of cannabis products, both medically and recreationally, there are more medical harms being seen in emergency departments (ED). The tetrahydrocannabinol (THC) concentration today is much stronger than the concentration from the 90s. In the 1990s most typical "joints" contained 1-3 mg of THC. Today, plants are being raised and modified to produce a higher concentration of THC. In turn, the amount of cannabidiol (CBD) is decreasing. Previously, people would smoke 1-3 mg of THC. The typical joint in Colorado contains 18 mg of THC or more. Currently, in the ED, we see patients who self-report smoking 2,000 mg or more of THC in a day. In 2015, 2.6 million individuals started cannabis use, 45% were 12-17 years of age.3 This brief report includes some of the more common illnesses that have been seen over the last four years of legalization in Colorado, and is by no means inclusive of all the potential problems that can occur. Among the many untoward effects being seen, illnesses that will be discussed are: cannabinoid associated hyperemesis, acute psychosis, cannabinoid catatonia syndrome, acute myo-pericarditis and ingestions.

Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive-compulsive disorder: a case report

BACKGROUND

Comorbidity of bipolar disorder and obsessive-compulsive disorder is common in adolescence. Obsessive-compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive-compulsive disorder is challenging, as pharmacotherapy of obsessive-compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive-compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania.

CASE PRESENTATION

A 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive-compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive-compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported.

CONCLUSIONS

This case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive-compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient's condition from worsening must be addressed, including giving priority to mood stabilization before obsessive-compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.