Transient Fever Response After ECT in a Patient with Catatonic Schizophrenia: A Case Report

Electroconvulsive therapy (ECT) is an effective and safe treatment method for many psychiatric disorders. In general medical practice, ECT may cause side effects as most other treatment methods do. Headache, myalgia, nausea, vomiting, confusion, anterograde amnesia are common side effects of electroconvulsive therapy. Fever; in addition to general medical conditions such as infection, malignancy, connective tissue diseases, drug treatments, malignant hyperthermia, convulsions, it can also occur due to conditions such as neuroleptic malignant syndrome (NMS), serotonin syndrome, catatonia, malignant catatonia, which are frequently encountered in psychiatry clinics. In the literature, transient fever response due to electroconvulsive therapy application have been described, albeit rarely. Although there are many proposed mechanisms for the emergence of a fever response, regardless of its cause, it is still not understood why some fever responses occur. In this article, we present the differential diagnosis of the fever response, possible causes, and the mechanisms that may reveal the secondary fever response to electroconvulsive therapy in a case with a diagnosis of catatonic schizophrenia, who developed a fever response during electroconvulsive therapy sessions and no fever response was observed at times other than electroconvulsive therapy sessions. In this case, postictal benign fever response associated with electroconvulsive therapy was considered after excluding other medical conditions that may cause a fever response after electroconvulsive therapy. Keywords: ECT, Fever, Catatonia, NMS.

Treatment of schizophrenia with catatonic symptoms: A narrative review

Catatonia is a neuropsychiatric syndrome consisting of psychomotor abnormalities caused by a broad range of disorders affecting brain function. While the nosological status of catatonia is no longer restricted to a subtype of schizophrenia in standardized diagnostic systems, the character, course, and clinical significance of catatonia in people with schizophrenia remain unclear. Evidence suggests that catatonia could be a nonspecific state-related phenomenon, a fundamental core symptom dimension of schizophrenia, or a subcortical variant of schizophrenia. Either way, the validity of catatonia in schizophrenia is clinically significant only insofar as it predicts prognosis and response to treatment. Most contemporary clinical trials of antipsychotics have targeted schizophrenia as an overly broad unitary psychosis neglecting any differential response defined by phenomenology or course. However, early naturalistic studies showed that catatonia predicted poor response to first-generation antipsychotics in chronic schizophrenia and case reports cautioned against the risk of triggering neuroleptic malignant syndrome. More recent studies suggest that second-generation antipsychotics, particularly clozapine, may be effective in schizophrenia with catatonic symptoms, while small randomized controlled trials have found that the short-term response to ECT may be faster and more significant. Based on available data, conclusions are limited as to whether antipsychotics are as effective and safe in acute and chronic schizophrenia with catatonic symptoms compared to other treatments and compared to schizophrenia without catatonia. Further studies of the pathophysiology, phenomenology, course and predictive value of catatonia in schizophrenia are worthwhile.

Treatment of Paroxysmal Perceptual Alteration in Catatonic Schizophrenia by Switching to Aripiprazole from Risperidone: A Case Report

Paroxysmal perceptual alteration (PPA) is the occurrence of brief and recurrent episodes of perceptual changes. It is mainly caused by the treatment of schizophrenia patients with antipsychotics. However, diagnosis of PPA is not very prevalent among psychiatrists, partly due to underrecognition or misunderstanding that it is a worsening of psychiatric symptoms. If psychiatrists do not understand PPA, they cannot treat it appropriately, and the patient's quality of life is impaired. We present a case of PPA in catatonic schizophrenia that was successfully treated by switching to aripiprazole from risperidone. We suggest that the disappearance of PPA in our case was due to both discontinuing risperidone, which completely blocks D2 receptors, and replacing it with aripiprazole, which is characterized as a partial agonist of D2 receptors. Treatment of PPA will improve medication adherence and quality of life. It is important to recognize PPA as a possible side effect of treatment with antipsychotics.

[Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases]

Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases remain a topical problem in modem psychiatry. The author describes psychopathologcal features of oneiroid depending on the form of the affect and presents new data on its relation to peculiarities of the development of attacks.

[Dissolution of the wakefulness-sleep cycle in patients with catatonic form of schizophrenia]

Polysomnograms of two patients with catatonic form of schizophrenia of different duration of the disease were recorded and analyzed. Pronounced disorders of the wakefulness-sleep cycle (WSC) were revealed. Apart from differences connected with duration of the disease and treatment with corresponding medications, there were detected the general features indicating dissolution of the central nervous system and the very wakefulness-sleep cycle. A certain similarity of the found WSC disturbances with the earlier shown WSC disturbances in rats with predisposition to catalepsy was noted. The conclusion is made about domination of diencephalic influences over the telencephalic one in the studied patients.

Neuroleptic induced tardive dyskinesia in a patient on treatment for schizophrenia: case report

In this case, a thirty six year old patient on treatment for schizophrenia is described with severe tardive dyskinesia. The most likely cause is long term treatment with two highly potent typical antipsychotic medications. The patient was initially treated with Benzhexol, an anticholinergic agent with the potential to induce or aggravate the disorder. This case discusses the common presentation and management of neuroleptic induced tardive dyskinesia.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'). II. Factor analysis of the catatonic syndrome

Previous factor analyses of catatonia have yielded conflicting results for several reasons including small and/or diagnostically heterogeneous samples and incomparability or lack of standardized assessment. This study examined the factor structure of catatonia in a large, diagnostically homogenous sample of patients with chronic schizophrenia using standardized rating instruments. A random sample of 225 Chinese inpatients diagnosed with schizophrenia according to DSM-IV criteria were selected from the long-stay wards of a psychiatric hospital. They were assessed with a battery of rating scales measuring psychopathology, extrapyramidal motor status, and level of functioning. Catatonia was rated using the Bush-Francis Catatonia Rating Scale. Factor analysis using principal component analysis and Varimax rotation with Kaiser normalization was performed. Four factors were identified with Eigenvalues of 3.27, 2.58, 2.28 and 1.88. The percentage of variance explained by each of the four factors was 15.9%, 12.0%, 11.8% and 10.2% respectively, and together they explained 49.9% of the total variance. Factor 1 loaded on "negative/withdrawn" phenomena, Factor 2 on "automatic" phenomena, Factor 3 on "repetitive/echo" phenomena and Factor 4 on "agitated/resistive" phenomena. In multivariate linear regression analysis negative symptoms and akinesia were associated with 'negative' catatonic symptoms, antipsychotic doses and atypical antipsychotics with 'automatic' symptoms, length of current admission, severity of psychopathology and younger age at onset with 'repetitive' symptoms and age, poor functioning and severity of psychopathology with 'agitated' catatonic symptom scores. The results support recent findings that four main factors underlie catatonic signs/symptoms in chronic schizophrenia.

Deficit in decision making in catatonic schizophrenia: an exploratory study

Catatonic schizophrenia can be distinguished from paranoid schizophrenia by prominent behavioral and motor anomalies. As demonstrated in recent imaging studies, behavioral symptoms may be related to dysfunction in the ventral prefrontal cortex. However, the neuropsychological correlates of ventral prefrontal cortical dysfunction remain unclear. In an exploratory study, we investigated eight patients with catatonic schizophrenia and compared them with 19 patients with paranoid schizophrenia and 26 healthy subjects. The Iowa Gambling Task (IGT) and the Object Alternation Task (OAT) served as measures of ventral prefrontal cortical function. In addition, other prefrontal cortical tests such as a visual working memory task, a Go-NoGo task, and the Wisconsin Card Sorting Test, as well as attentional tasks, were included in the test battery. Catatonic patients showed significant deficits in the IGT characterized by an inability to shift from the initial preference for high-risk cards to a more advantageous strategy with low-risk cards. Moreover, catatonic patients showed significant deficits in the OAT. In conclusion, our preliminary results suggest a specific deficit in catatonic schizophrenia in those neuropsychological measures that are associated with ventral prefrontal cortical function.

[The application of electroconvulsive therapy in neuroleptic malignant syndrome treatment in patient with catatonic schizophrenia]

The above article presents a case report of a 28-year-old patient, primarily treated with a diagnosis of catatonic schizophrenia, in who in the course of hospitalization developed neuroleptic malignant syndrome (NMS). The patient presented unawareness, hyperthermia, respiratory insufficiency, muscle rigidity, CK increased activity. The patient required tracheotomy and oxygen therapy and then was subjected to a series of electroconvulsive therapy (ECT). Since the fifth ECT treatment we noted a gradual recovery to a completely normal mental status. We did not make an attempt to introduce neuroleptic maintenance treatment.

Are we witnessing the disappearance of catatonic schizophrenia?

The decrease in the frequency of diagnosed catatonic subtypes among schizophrenic disorders as a whole during the last 50 years has long been regarded as an established fact. Until now the factors responsible for this development have been under discussion. As it is not clear if there is a true decrease or an ostensible one due to other factors such as changed diagnostic habits or neuroleptic treatment, we examined 174 consecutively admitted schizophrenic patients from three different psychiatric institutions diagnosed according to DSM-IV and Leonhard's criteria. It turned out that-depending on the diagnostic system-the rates of diagnosed catatonias were 10.3% (DSM-IV) and 25.3% (Leonhard's criteria). Comparison of the two original Leonhard cohorts (1938 to 1968, 1969 to 1986) with our own (1994 to 1999) shows a decrease in the frequency of catatonias from 35% to 25%, which-albeit statistically significant-is much less pronounced than in studies that used a narrower definition of catatonia. Here, besides sociocultural developments, the use of neuroleptics seems to effect the decrease in the frequency of catatonias in two ways: on one hand, they cause a decrease of hyperkinesia, excitement, or impulsivity; while on the other hand, they themselves produce motor abnormalities like rigidity, effects that favor the attribution of motoric symptoms to neuroleptics.

Acute and longer-term effects of risperidone in a case of first-episode catatonic schizophrenia

This case report documents the response of a young, first-episode, neuroleptic naive male with severe catatonic schizophrenia to the novel antipsychotic, risperidone. Initial assessments included the Positive and Negative Syndrome Scales, Global Assessment of Function and the Extrapyramidal Symptom Rating Scale. These were repeated at discharge from hospital and during a 3.5 year outpatient follow-up. Neuroimaging (computed tomography, magnetic resonance imaging and single photon emission tomography) along with electroencephalogram and laboratory examinations were completed. Response to risperidone was prompt, dramatic and sustained over the follow-up period. Possible neurochemical brain mechanisms resulting in catatonia and the role of serotonin/dopamine antagonists such as risperidone are discussed. No other literature on the effect of risperidone in the treatment of severe catatonic schizophrenia in a first-episode patient has been reported.

Case series: catatonic syndrome in young people

This article reviews all recent (1977-1997) reports on catatonic adolescents and summarizes the 9 consecutive cases seen at the authors' institution during the past 6 years. Catatonia occurs infrequently in adolescents (0.6% of the inpatient population), but it appears to be a severe syndrome in adolescents of both sexes. Diagnoses associated with catatonia are diverse, including in this series: schizophrenia (n = 6), psychotic depression (n = 1), mania (n = 1), and schizophreniform disorder (n = 1). Two patients had a previous history of pervasive developmental disorder. In the literature, catatonia was also reported in children with organic condition (e.g., epilepsy, encephalitis). Therapeutic management depends on the specific causes, but several points need to be stressed: (1) the frequency of neuroleptic-induced adverse effects; (2) the potential efficacy of sedative drugs on motor signs; (3) the possible use of electroconvulsive therapy; and (4) the necessity to manage family reactions and fears, which are frequent causes of noncooperation. It is concluded that catatonia is an infrequent but severe condition in young people. While symptomatology, etiologies, complications, and treatment are similar to those reported in the adult literature, findings differ with regard to the female-male ratio and the relative frequencies of associated mental disorders.

[The catatonic dilemma]

In discussing some clinical cases the paper suggests an interpretation of catatonic syndrome based on the original and main characteristics of this psychopathological condition. Kahlbaum described this disease underlining the "affective" symptoms, but since then, catatonia has been considered a schizophrenic syndrome. The paper proposes a definition of catatonia based on Kahlbaum's earlier view in which the complex of psychomotor disturbances can be seen as the expression of schizophrenia, bipolar psychoses or of a specific cyclic disease.

Long standing trismus as the initial presentation of acute catatonic schizophrenia

A case is reported where long standing trismus was the presenting factor in a case of catatonic schizophrenia. The investigations and treatment are described.

Disappearance of tardive dyskinesia during catatonic stupor

A 61-year-old man diagnosed as having catatonic schizophrenia was treated with neuroleptics for many years. From 1983 he showed tardive dyskinesia on trunk and limbs as well as orofacial dyskinesia. In September 1985 he displayed a catatonic stupor several times. With the outbreak of the stupor the dyskinesia disappeared and vice varsa. This finding induces the hypothesis that the dopaminergic system is suppressed during catatonic stupor in such a way that tardive dyskinesia is no longer visible.

DSM-III implications of the diagnoses of catatonia and bipolar disorder

Although catatonia has traditionally been thought of as a type of schizophrenia, the author presents studies indicating that catatonia may be at least as common in bipolar disorder as it is in schizophrenia. He points out that changing definitions of schizophrenia and affective disorder require a reassessment of catatonia and its incorporation in modern diagnostic systems. The discussion represents material presented at the Affective Disorders Advisory Committee of the American Psychiatric Association Work Group to Revise DSM-III.

Systemic lupus erythematosus presenting as catatonic schizophrenia

A patient fulfilling the diagnostic criteria for systemic lupus erythematosus and presenting with catatonic schizophrenia is described. Psychiatric features of the disease and their management are discussed.

The syndrome of self-induced water intoxication in psychiatric patients

This is a report on six psychiatric patients who indulged in excessive ingestion of water and subsequently developed tonic-clonic seizures in the course of the underlying mental disorders. On the basis of the DSM-III criteria, they were diagnosed as follows: schizophrenic disorder, 4; schizo-affective disorder, 1; borderline personality disorder, 1. The levels of serum electrolytes were estimated during five episodes of seizures in three patients. Hyponatremia was a consistent finding (serum sodium: mean = 120.6 mEq/liter). Plasma osmolality and plasma levels of arginine vasopressin (AVP) were determined during two episodes in two patients. The inappropriately high circulating levels of AVP relative to plasma hypoosmolality were documented. However, the response to the overnight fluid deprivation and acute water load during the period of no seizures in two patients revealed no evidence of the persistent SIADH, suggesting the temporal association of hyponatremic encephalopathy with inappropriate AVP secretion. It is not conclusive whether the transient SIADH is the cause or the consequence of hyponatremic encephalopathy, although a delusion or an auditory hallucination could play a critical role in drinking water excessively in three patients.

[Dantrolene in the treatment of life-threatening psychiatric disease pictures. A contribution to the therapy of the malignant neuroleptic syndrome and acute febrile catatonia]

The malignant neuroleptic syndrome and acute febrile catatonia are life-threatening psychiatric disorders which frequently are treated in intensive care units outside psychiatric departments. Their manifestations are very similar to those of anaesthesia-specific malignant hyperthermia. The three syndromes have in common signs of increased muscle metabolism. Dantrolene, a specific drug in the treatment of malignant hyperthermia, has been used successfully several times recently in the treatment of the malignant neuroleptic syndrome. One such case is reported. In a 23-year-old man with signs of acute febrile catatonia parenteral dantrolene and electroconvulsive shocks succeeded in counteracting the symptoms of the abnormally raised muscle metabolism.

Stupor: a review of 25 cases

Twenty-five cases of stupor referred to a psychiatric teaching hospital over 15 years are reviewed. Ten cases presented with a depressive syndrome, four cases with catatonic phenomena and a further 10 cases with established organic aetiology; one case was considered to be psychogenic in origin. The overall mortality was high (16%), attributable to the basic pathology. Compared with earlier series there was a reduction in cases with catatonic features with a corresponding increase in the proportion of organic cases.

Fever, tachycardia, and hypertension with acute catatonic schizophrenia

Fever, tachycardia, and hypertension developed concurrently with the administration of thiothixene during an acute episode of agitation in a case of catatonic schizophrenia. No cause for the fever or hyperkinetic state was found, and the syndrome resolved spontaneously one week after antipsychotic drug therapy was halted. This case appears to be an example of "acute lethal catatonia" or the neuroleptic "malignant" syndrome, both of which may be due to disturbances of dopamine function within the CNS. Such cases are rare, but may be dramatic in their presentation; however, antipsychotic drugs must be withheld during the duration of the disorder.

Legal aspects of electrotherapy in a catatonic renal transplant patient

The treatment of a case of catatonic schizophrenia in a renal transplanted patient is presented and demonstrates that electrotherapy can be life-saving and that there are already adequate legal controls which guarantee the patient's rights. Yet zealots are attempting to have legislators pass laws preventing the use of electrotherapy even in voluntary patients. To help prevent these resolutions from being passed, psychiatrists must become more active in the legislative process.

[Mutism as permanent catatonic condition]

The history of a case of mutism, where the patient had been silent for more than twenty-five years, caused by the author to study and discuss this relatively infrequent catatonic symptom which is a type of schizophrenia, with frequent references being made to the results of psychiatric studies made by authors ranging from Kahlbaum to Leonhard. Permanent mutism as a possible phenomenal form was logically classified, by Leonhard, as a type of mannered catatonia.

Catatonia, gastric hyperacidity, and fatal aspiration: a preventable syndrome

Sudden death from aspiration pneumonitis during acute catatonia is a generally recognized but poorly understood occurrence. The author describes a case in which a schizophrenic patient died following aspiration of gastric contents. In view of findings that suggest that the acidity of gastric contents is related to morbidity following aspiration, he recommends that liquid antacid medication be given routinely to catatonic patients.

Heterogeneity of schizophrenia

One of the difficulties in defining schizophrenia is the possibility of its heterogeneity. Schizophrenia may be divided into organic and idiopathic on the basis of precipitating factors; the difference between the two is supported by evidence from family studies and differences in symptomatology. A further division of idiopathic schizophrenia may be made into typical and atypical schizophrenia based on differences in clinical features, family history, mode of inheritance, and prognosis. There is suggestive evidence that within typical schizophrenia, paranoid and nonparanoid subtypes may be idstinguished due to clinical and family differences. Within nonparanoid schizophrenia, simple, catatonic, and hebephrenic schizophrenia may also prove to be distinct entities. The available evidence for differentiating the subtypes of typical schizophrenia is inconclusive to date. However, several recent developments in the methodology of family research may lead to more convincing findings for differentiating subtypes within typical schizophrenia.

Stress in schizophrenics and normals

This paper presents findings related to the measure of stress in 641 schizophrenics(125 acutes and 516 chronics) and 95 comparable normals. Stress was defined as an imbalance between environmental demands and the respondent's ability to meet that demand successfully, and was measured in terms of level of stress experienced in relation to specific problem situations. Twenty-one dimensions of stress were measured, subsumed under thefollowing four general areas: social performance, family interaction, social interpersonal interaction, and social maladaptive activities. Results indicated that, in general,normals experience significantly less stress in dealing with life events than do schizophrenics. Within the schizophrenic group, the pseudoambulatory chronic patients evidenced more stress than did their acute counterparts, a finding not previously described in the literature. Implications of these findings do not support the present community after-care concepts. Discharged chronic schizophrenics appear unable to remain in the community for any reasonable period of time because of the high level of stress under which they function.