Paralyzed by Fear?-A Case Report in the Context of Narrative Review on Catatonia

In ICD-11, catatonia is a complex syndrome that includes psychomotor disorders (negativity, catalepsy, wax flexibility, mutism, automatism, mannerisms, or echolalia) and volitional processes affect modulation and action planning, which leads to hypofunctional, hyperfunctional, or parafunctional motor action. This is a very important clue that this state can be associated with both mental and somatic diseases. In order to create a narrative review, authors analyzed the diagnostic criteria of ICD-10 and ICD-11 and searched the PubMed medical base for articles on the diagnosis and different approaches to the treatment of catatonia. The treatment of catatonia is not standardized. It is based on the use of benzodiazepines, GABAa receptor antagonists, NMDA receptor antagonists, D2 receptor antagonist, and electroconvulsive therapy (ECT). The authors also would like to present the case of a patient in whom the diagnosis of catatonia was not so clear according to the diagnostic criteria, emphasizing the importance of the key diagnosis for the patient's recovery. The authors would also like to point out that the topic of catatonia should be of interest not only to psychiatrists, but also to doctors of other specialties, who may encounter cases of catatonia complicating somatic states in hospital wards.

Multimodal neurometabolic investigation of the effects of zolpidem on leukoencephalopathy-related apathy

BACKGROUND AND PURPOSE

The symptomatic effect of zolpidem on apathy has been reported in neurological disorders such as strokes and post-anoxic brain injuries, but not in white-matter disease of the brain.

METHODS

A 38-year-old patient presenting with severe apathy related to a genetic leukoencephalopathy but showing marked improvement of apathy after taking 10 mg of zolpidem was studied. To understand what may mediate such a clinical effect, a multimodal neurometabolic approach using ¹⁸ F fluorodeoxyglucose positron emission tomography (FDG-PET) and a dedicated magnetic resonance spectroscopy (MRS) sequence for gamma aminobutyric acid (GABA) and glutamine + glutamate metabolism was undertaken.

RESULTS

Pre-zolpidem FDG-PET showed hypometabolism in the orbitofrontal cortex, dorsolateral cortex and basal ganglia compared to healthy controls. Post-zolpidem, FDG-PET displayed increased metabolism in the orbitofrontal cortex together with improvement in the emotional and auto-activation domains of apathy. There was no improvement in the cognitive domain of apathy, and no change in metabolism in the dorsolateral frontal cortex. Post-zolpidem, MRS showed increased GABA and glutamine + glutamate levels in the frontal cortex and pallidum.

CONCLUSION

Our multimodal neurometabolic study suggests that the effects of zolpidem on apathy are related to increased metabolism in the orbitofrontal cortex and basal ganglia secondary to GABA modulation. Zolpidem may improve apathy in other white-matter disorders.

Catatonia revived: a unique syndrome updated

Catatonia was buried within the confines of schizophrenia for over a century- deterring study, appropriate diagnosis and treatment for many years. With revised changes in the classification of this distinct neuropsychiatric syndrome, it is becoming more recognized clinically and in ongoing research. Catatonia occurs among various psychiatric, metabolic or neurologic conditions. It may present in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy usually produces dramatic and rapid response, although systematic, randomized trials are lacking. The role of antipsychotic agents in treatment is controversial as they may worsen the syndrome. An important unresolved clinical question is the diagnosis and treatment of catatonia in the setting of delirium.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

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.

Zolpidem test and catatonia

WHAT IS KNOWN AND OBJECTIVE

There is no consensus regarding treatment of catatonia and the main recent therapeutic progress has been the development of the zolpidem diagnostic and therapeutic test. We report on the use of this test in one of our patients.

CASES SUMMARY

Mr. S. suffered from a paranoid schizophrenia. Three episodes of catatonia are described to illustrate the effect of zolpidem in a patient for whom lorazepam was ineffective or inadequate.

WHAT IS NEW AND CONCLUSION

Zolpidem with appropriate testing appears to be a credible alternative to electroconvulsive therapy or increased lorazepam dosing and allows continuation of antipsychotic administration.

Catatonia vis-à-vis delirium: the significance of recognizing catatonia in altered mental status

BACKGROUND

Catatonia is seldom considered in evaluation of altered mental status (AMS) in medical settings. Furthermore, catatonia often meets delirium criteria due to incoherence, altered awareness and behavioral change. Catatonia may co-occur with or be preferentially diagnosed as delirium.

METHODS

We conducted a systematic literature review of MEDLINE, EMBASE and PsycINFO on the relationship between catatonia and delirium. We also juxtapose clinical features of these syndromes and outline a structured approach to catatonia evaluation and management in acute medical settings.

RESULTS

These syndromes share tremendous overlap: the historical catatonia-related terms "delirious mania" and "delirious depression" bespeak of literal confusion differentiating them. Only recently has evidence on their relationship progressed beyond case series and reports. Neurological conditions account for the majority of medical catatonia cases.

CONCLUSIONS

New-onset catatonia warrants a medical workup, and catatonic features in AMS may guide clinicians to a neurological condition (e.g., encephalitis, seizures or structural central nervous system disease). Lorazepam or electroconvulsive therapy (ECT) should be considered even in medical catatonia, and neuroleptics should be used with caution. Moreover, ECT may prove lifesaving in malignant catatonia. Further studies on the relationship between delirium and catatonia are warranted.

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.

[Acute catatonia: Questions, diagnosis and prognostics, and the place of atypical antipsychotics]

INTRODUCTION

Acute catatonia is a non-specific, relatively frequent syndrome, which manifests itself through characteristic motor signs that enables its diagnosis. It occurs in association with mood disorders, psychotic disorders and several somatic or toxic diseases. Its short-term prognosis is of paramount importance. Without effective treatment, it is associated with high mortality. Despite the vital risk inherent in this disorder, it is not recognized as an independent diagnostic category by international rankings, which makes its diagnostic detection difficult and consequently does not allow adequate therapeutic care. However, if benzodiazepines and electroconvulsive therapy have proved effective in the treatment of acute catatonia, the role of atypical antipsychotics remains controversial. In fact, despite the progress made by the DSM-IV-TR and CIM 10 by the recognition of the etiologic diversity of catatonia, we deplore the absence to date of a consensus on clinical management and therapy of catatonia, which constitutes a source of confusion for practitioners in their approach to catatonic patients. To illustrate the difficulty in supporting these patients, we report here a clinical vignette.

CLINICAL FEATURES

Mr. M. aged 21, without psychiatric history, has shown a functional acute psychotic episode involving a delirious and hallucinatory syndrome associated with a marked catatonic dimension. Olanzapine was initiated at a dose of 10mg/d on the nineth day of hospitalization; the clinical picture was complicated by a malignant catatonia justifying the halt of olanzapine and the institution, in intensive units, of 15mg per day of lorazepam. After 72hours, the patient has not responded to this treatment. ECT was expected, but the patient died on the 12th day.

DISCUSSION

This case raises a threefold question: the crucial issue of immediate vital prognosis, that of the truthfulness of the positive diagnosis of this psychotic table and finally the issue of therapeutic care, primarily the well-founded or otherwise use of an atypical antipsychotic for the treatment of this type of psychotic disorder. For Mr. M., the clinical diagnosis that he has shown, according to the DSM IV-TR, is brief psychotic disorder "temporary diagnosis". This diagnosis - brief psychotic disorder - does not actually allow for a specific clinical approach to this type of psychotic table. The immediate vital prognosis inherent in the catatonic dimension may not be properly evaluated and the therapeutic conduct may miss the application of the specific treatment of the catatonic syndrome. The proper diagnosis for this type of psychotic disorder would be "catatonia" as proposed by Taylor and Fink, instead of "brief psychotic disorder" if the international rankings have included this disorder as a separate and independent diagnosis. The identification by international rankings of the catatonic syndrome as an independent diagnostic category seems essential for clinicians to allow: its clinical detection, the establishment of a syndromic diagnosis of catatonic disorder, appropriate prognostic evaluation and finally, the application of a suitable therapeutic strategy. Conventional treatment, benzodiazepine- and/or ECT-based, can solve the catatonic episode in a few days, irrespective of its etiology and its severity. Moreover, while all authors agree that conventional antipsychotics may induce a catatonic state or worsen a preexisting catatonia into a malignant catatonia and should thus be avoided for catatonic patients or with prior catatonic episodes, recent data from the literature emphasize the frequent and successful use of atypical antipsychotics, including olanzapine, in various clinical forms of benign catatonia. However, our patient did not respond to treatment with olanzapine and got even more complicated. Was the malignant catatonia that this patient has shown induced by olanzapine ? The answer to this question seems difficult since some authors report the efficacy of olanzapine in malignant catatonia. We wonder if we should have kept olanzapine and strengthen its dosage like Cassidy et al. in 2001 and Suzuki et al. in 2010 for the treatment of the malignant form constituted in this patient rather than having stopped it and used lorazepam as indicated by Taylor and Fink in 2003.

IN CONCLUSION

The non-recognition of catatonia as an independent entity, the lack of a therapeutic consensus and the pending issue on the safety and efficacy of atypical antipsychotics in the treatment of catatonia are at the origin of the difficulties of therapeutic support of catatonic patients.

Catatonia: diagnosis, classification, and treatment

Catatonia is a distinct neuropsychiatric syndrome that is becoming more recognized clinically and in ongoing research. It occurs with psychiatric, metabolic, or neurologic conditions. It may occur in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy leads to a dramatic and rapid response, although systematic, randomized trials are lacking. An important unresolved question is the role of antipsychotic agents in treatment and their potential adverse effects.

Catatonia and consultation-liaison psychiatry study of 12 cases

Nowadays, catatonia is no more considered as a subtype of schizophrenia. Catatonia seems more frequently associated to mood disorders as well as general medical conditions. It is sometimes difficult to associate formally a medical etiology to this syndrome. But we found, in the literature, three groups of associated general medical conditions: neurological disorders, drug induced and toxic induced conditions, metabolic conditions. We present a prospective study of 12 clinical cases of catatonia due to general medical conditions we realized in the Consultation-Liaison Psychiatry Department of the University Hospital of LILLE (France) during a period of 5 months. We find coherent data with the literature. However, our results suggest that if medical conditions precipitate the catatonia syndrome, they are rarely its only etiology. We think that if somatic factors are co-morbid with psychiatric conditions they do not necessarily predominate as the target of treatment. The treatment of the catatonia must be a priority and remain symptomatic, to allow in parallel the specific treatment for the somatic disorder or the psychiatric disorder.