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.

Benzodiazepines for catatonia in people with schizophrenia or other serious mental illnesses

BACKGROUND

Catatonia is a debilitating disorder of movement and volition associated with schizophrenia and some other mental illnesses. People with catatonia are more likely to require hospitalisation and highly supervised care than those without the disorder. They also have an increased risk of secondary complications such as pneumonia, malnutrition and dehydration. The mainstay of treatment has been drug therapies and electroconvulsive therapy.

OBJECTIVES

To compare the effects of benzodiazepines with other drugs, placebo or electroconvulsive therapy for catatonia in people with schizophrenia or other similar serious mental illnesses (SMIs).

SEARCH METHODS

We updated our previous search (28 February 2007) by searching the Cochrane Schizophrenia Group's Study-Based Register of Trials (9 November 2016; 6 February 2019). This register is compiled by systematic searches of major resources (including CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. We also manually searched reference lists from studies selected by the search.

SELECTION CRITERIA

All controlled clinical trials that randomised people who have schizophrenia or other similar SMI and experiencing catatonia to receive benzodiazepines or another relevant treatment. We included studies that met our inclusion criteria and reported usable data. We excluded those not meeting our inclusion criteria or those not reporting usable data. We contacted authors when we required further information; and if we received no response, we put those studies aside as 'awaiting assessment'.

DATA COLLECTION AND ANALYSIS

Review authors extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis using a fixed-effect model. We completed a 'Risk of bias' assessment for the included study and generated a 'Summary of findings' table using GRADE.

MAIN RESULTS

The searches found 130 citations, from which we could identify 22 possibly relevant studies. From these, we could only include one study. This study had a relatively small sample size of 17 participants who received lorazepam or oxazepam and were drug free for one week before the trial started. The only usable data reported by this study were clinically important change in symptoms of catatonia measured as 50% improvement on the Visual Analogue Scale (VAS). There was no difference in the numbers of participants showing a clinically important change in their catatonic symptoms (RR 0.95, 95% CI 0.42 to 2.16; participants = 17; studies = 1; very low quality evidence).No data were reported for other important outcomes of hospital stay, clinically important change in satisfaction with care, global state, adverse effects or general functioningWe did find a few studies meeting our inclusion criteria but they reported no usable data. We had to exclude these. Although poorly reported, these studies do illustrate that relevant studies have been undertaken - they are not impossible to design and conduct.

AUTHORS' CONCLUSIONS

Analysis of the results from this review, which was a head-to-head comparison of two benzodiazepine monotherapies, does not show a clear difference in effect. No data were available for benzodiazepines compared to placebo or standard care. The lack of usable data and very low quality of data available makes it impossible to draw firm conclusions and further studies with a high-quality methodology and reporting are required in order to determine more definitively the outcomes associated with benzodiazepine use in the clinical management of catatonia in persons with schizophrenia and other SMI.

Resurgence of catatonia following tapering or stoppage of lorazepam - A case series and implications

The resurgence of catatonia following tapering of lorazepam is a common clinical phenomenon. However, there is limited evidence on the relationship between tapering method of lorazepam and resurgence of catatonic state. We report seven (0.6%) such patients who were found to have resurgence of catatonia. The mean age is 35.7 years; five of them had schizophrenia and other psychotic spectrum disorders. Five of them had resurgence within one week of stoppage, and three of them had multiple resurgences and required maintenance treatment with lorazepam. So gradual tapering and maintenance treatment with lorazepam might be effective in preventing resurgence of catatonia.

[Catatonia and neuroleptic malignant syndrome in view of a psychopathological and pathophysiological overlap: a brief review]

Catatonia was first described in the 19th century as a syndrome with motor, affective and behavioral symptoms. During the 20th century it was rather regarded as a rare motoric manifestation of schizophrenia and that classification has almost resulted in the disappearance of catatonia among patients outside of the schizophrenia spectrum. With the introduction of neuroleptics, the incidence of catatonic schizophrenia also declined which was attributed to effective treatment. Simultaneously, neuroleptic malignant syndrome was described, which shows many similarities with catatonia. Recently, several researchers suggested a common origin of the two disorders. In this paper we review case reports of the last five years, in which both neuroleptic malignant syndrome and catatonia had emerged as a diagnosis. Additionally, based on the relevant literature, we propose a common hypothetical pathomechanism with therapeutic implications for the two syndromes. Besides underlining the difficulties of differential diagnosis, the reviewed cases demonstrate a transition between the two illnesses. The similarities and the possible shifts may suggest a neuropathological and pathophysiological overlap in the background of the two syndromes. Electroconvulsive therapy and benzodiazepines seem to be an effective treatment in both syndromes. These two treatment approaches can be highly valuable in clinical practice, especially if one considers the difficulties of differential diagnosis.

[The use of acatinol in the treatment of stable patients with schizophrenia with predominance of behaviour disorganization and subcatatonic features]

Our study was based on the hypothesis that a non competitive antagonist of NMDA receptors can improve clinical effects of antipsychotic therapy in a subgroup of patients with schizophrenia with clinical signs of glutamatergic hyperfunction such as catatonic symptoms and disorganization. The study design was open and non-comparative. The duration of the study for each patient was 6 months, the target dosage of acatinol was 20 mg. Forty stable patients with schizophrenia with predominance of signs of disorganization and subcatatonic symptoms were included. The following instruments were used: PANSS, NSA, CGI, BACS, UKU. Adding of acatinol to the antipsychotic treatment improved clinical symptoms, cognitive functioning and social functioning and decreased the number of side effects. The drug was well-tolerated.

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.

Amineptine treatment of persistent catatonic symptoms in schizophrenia: a controlled study

BACKGROUND

Data on the treatment response of enduring catatonic phenomena accompanying chronic schizophrenia are few and far between. The aim of this study was to explore the therapeutic effects of add-on amineptine, a dopamine agonist antidepressant in chronic catatonia occurring in schizophrenia.

METHOD

Fifteen subjects with DSM-IV schizophrenia presenting with persistent catatonic features underwent a 15-week, double-blind, placebo-controlled cross-over trial; they were treated for 6 weeks each with amineptine and a placebo, with a 3-week wash-out period in between. The primary outcome measures were the sum scores of the Bush-Francis Catatonia Rating Scale and the Modified Rogers Scale. Changes in other aspects of psychopathology and extrapyramidal side effects (EPS) constituted the secondary outcome measures.

RESULTS

Amineptine augmentation of antipsychotic treatment had no appreciable effect on either of the catatonia ratings. Apart from a statistically significant but clinically negligible improvement in the negative symptom scores, there were no changes in the psychopathology and EPS ratings.

CONCLUSION

The lack of a therapeutic effect of the dopamine agonist amineptine on persistent catatonic signs and symptoms suggests that the dopamine system may not have a decisive role in the pathophysiology of chronic catatonic syndrome arising in the context of schizophrenia.

Secondary enuresis & body dysmorphic disorder in a caucasian male with catatonic schizophrenia: a case report

We describe a patient with Schizophrenia and secondary enuresis. The enuresis settled with resolution of his psychotic symptoms but later remerged after starting Clozapine. We explore the mechanisms of incontinence in Schizophrenia and those due to Clozapine. This case highlights the need to inquire about incontinence in patients with schizophrenia prior to prescribing clozapine.

[Use of aripiprazole in the treatment of catatonia]

INTRODUCTION

Successful aripiprazole treatment of catatonia was reported in some recent case reports.

METHOD

Review of the literature and three case reports.

RESULTS

In the presented cases it was demonstrated that aripiprazole was effective in the treatment of catatonia in patients with schizophrenia, major depression or brief psychotic disorder.

CONCLUSION

Besides benzodiazepines and electroconvulsive therapy, aripiprazole might be an alternative treatment for catatonia, however randomized controlled trials are required to prove the effectiveness of aripiprazole in patients with catatonia.

Amenorrhoea - consequence of combined treatment with sulpiride and risperidone in a patient suffering from schizophrenia

It is well documented that sulpiride causes hormonal adverse events, like amenorrhoea and galactorrhea, due to its mechanism of action. Furthermore, risperidone can produce amenorrhoea and galactorrhea also, due to its mechanism of action, which differs from that of sulpiride. This case report is of a patient that was treated with large doses of sulpiride, but did not develop an adverse event like amenorrhoea. However, when risperidone was introduced into therapy it leads to the onset of amenorrhoea. Gynecologist saw it as the beginning of menopause. General practitioner questioned the existence of an intra-cerebral process that could produce amenorrhoea as well. Therefore, the patient was sent to perform an MRI of the brain, under work diagnosis of pituitary adenoma, which was later ruled out as a cause of the illness. Well experienced psychiatrist linked the loss of menstruation with the adverse event profile of sulpiride and therefore gradually discontinued sulpiride from therapy, while risperidone was left and subsequently menstrual cycle was restored. Good knowledge of adverse events profile of antipsychotic medication used, especially when used in a combination, allows us to correctly question appearance of adverse events, to adequately treat them and lowers the cost of unneeded medical procedures.

[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.

Benzodiazepines for catatonia in people with schizophrenia and other serious mental illnesses

BACKGROUND

Catatonia is a debilitating disorder of movement and volition associated with schizophrenia and some other mental disorders. People in a catatonic state have increased risk of secondary complications such as pneumonia, malnutrition and dehydration. The mainstay of treatment has been drug therapies and electroconvulsive therapy.

OBJECTIVES

To compare the effects of benzodiazepines with other drugs, placebo or electroconvulsive therapy for people with catatonia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (March 2007) and manually searched reference lists from the selected studies.

SELECTION CRITERIA

All relevant randomised controlled clinical trials.

DATA COLLECTION AND ANALYSIS

We (RCG, GW) extracted data independently. For dichotomous data we would have calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis using a fixed-effect model.

MAIN RESULTS

No studies could be included. We did find studies reporting no usable data that we had to exclude or assign to those awaiting assessment. These studies, although poorly reported, do illustrate that relevant studies have been undertaken, and are not impossible.

AUTHORS' CONCLUSIONS

Studies have been justified and undertaken in the past. This justification remains as relevant as ever. Further studies with a high-quality methodology and reporting are required and it may be for countries where catatonia is seen often to take a lead in this area.

Successful use of olanzapine in adolescent monozygotic twins with catatonic schizophrenia resistant to electroconvulsive therapy: case report

We describe a case of monozygotic (MZ) male twins (14.6 years old) who suffered from a severe form of catatonic schizophrenia. On admission, the principal symptoms of the brothers were stupor, mutism, catatonic posturing, rigidity, negativism, and refusal of food and liquids. They were treated with electroconvulsive therapy (ECT) with no effect (twin A) and almost no effect (twin B). Both twins improved with initiation of olanzapine therapy. Twin B showed a marked improvement by week 2 on a dose of 10 mg daily (qd). Improvement in twin A was seen by week 4 on a dose of 15 mg qd. Twin B was discharged after 8 weeks and twin A after 11 weeks of olanzapine treatment. This appears to be the first report on concordant positive responses to olanzapine in MZ twins with catatonic schizophrenia, as well as, the first report on concordant resistance to ECT.

Idiopathic recurrent catatonia needs maintenance lorazepam: case report and review

OBJECTIVES

Catatonia as a phenomenon has been well described with either a schizophrenic illness, severe mood disorders or periodic catatonia disorder. We aim to report a patient who had recurrent catatonia that responded to and required lorazepam for maintenance.

METHODS

We describe the case of a 28 year old woman who had a history of recurrent catatonia that was unresponsive to most anti-psychotics, but who responded to high doses of lorazepam and needed long-term lorazepam for maintenance.

RESULTS AND CONCLUSION

Our patient met the criteria for a diagnosis of idiopathic catatonic disorder. Response to lorazepam suggests that a certain group of patients may require long-term treatment with lorazepam, especially those who may have down-regulation of GABA-A receptors.

Possible antipsychotic effects of minocycline in patients with schizophrenia

We present two cases of patients with schizophrenia treated with minocycline. Minocycline (a second-generation tetracycline) is an established and safe broad-spectrum antibiotic that crosses the blood-brain barrier, with additional efficacy for diseases such as acne and rheumatoid arthritis. Animal studies have suggested that minocycline may prevent progression of some neurological disorders. Moreover, it has been reported that minocycline might have antidepressant effects. We report two cases of acute schizophrenia with predominant catatonic symptoms that responded to minocycline.

Topiramate effect in catatonia: a case series

The authors describe four cases of catatonia in which topiramate treatment was used. Commonly effective therapies, including benzodiazepines and divalproex, were proven refractory. In all four cases, subjects experienced complete remission of catatonic symptoms and tolerated treatment well. In one case, all psychotropic medications were discontinued because the patient became delirious. The delirium resolved after discovery and treatment of a urinary tract infection. Catatonic agitation relapsed when topiramate was withdrawn but remitted again when topiramate and lorazepam therapy was restored. In two cases, continued topiramate therapy was accompanied by sustained remission. These case reports present a novel approach to the treatment of catatonia.

Adjusting the frequency of continuation and maintenance electroconvulsive therapy to prevent relapse of catatonic schizophrenia in middle-aged and elderly patients who are relapse-prone

The purpose of the present paper was to study the effect of continuation electroconvulsive therapy (ECT) on the prevention of relapse in middle-aged and elderly patients with intractable catatonic schizophrenia. It was found that continuation ECT is efficacious to sustain remission for patients who suffer relapse after response to acute ECT despite continuation neuroleptics. However, three patients suffered relapse during continuation ECT, therefore the effect of adjusting the frequency of continuation ECT and maintenance ECT was investigated in these patients with catatonic schizophrenia who relapsed during continuation ECT. These patients with DSM-IV catatonic schizophrenia who relapsed during continuation ECT were treated with more frequent continuation ECT and subsequent maintenance ECT after response to acute ECT. The patients' Brief Psychiatric Rating Scale (BPRS) scores were prospectively evaluated until relapse. Patients were considered to be relapsers if they had a BPRS score >or=37 for 3 consecutive days. The three patients with catatonic schizophrenia who relapsed during continuation ECT were treated successfully with more frequent continuation ECT and subsequent maintenance ECT. No patient experienced a severe adverse effect from continuation or maintenance ECT. More frequent continuation ECT and maintenance ECT deserves consideration in middle-aged and elderly patients with intractable catatonic schizophrenia who suffer relapse during continuation ECT. Large-scale systematic studies are warranted to investigate the optimum use of continuation and maintenance ECT in patients with catatonic schizophrenia.

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.

A prospective study of serum ghrelin levels in patients treated with clozapine

We investigated serum ghrelin levels (SGL) in 12 patients with schizophrenia over a 10-week period after initiation of clozapine treatment. In contrast to increments of body mass indices (BMI, kg/m2) and serum leptin levels (SLL), no significant change in SGL was detected. Inverse correlations between delta SGL and delta SLL did not reach statistical significance. Linear mixed model analysis could not detect effects of age, sex, BMI, SLL and serum clozapine levels on SGL. Our results do not support a causal involvement of ghrelin in clozapine-related weight gain.

Lorazepam and diazepam rapidly relieve catatonic signs in patients with schizophrenia

The uses of lorazepam and electroconvulsive therapy (ECT) have been proven to be effective in treating catatonia. In the present study a modified treatment strategy (i.e. lorazepam i.m. injection or diazepam infused i.v. if lorazepam failed, not with ECT) was proposed to rapidly relieve catatonic signs in patients with schizophrenia. During a 3-year period, 14 patients with catatonic schizophrenia in Chinese ethnic background Taiwanese were brought to the emergency unit of a general hospital. First, the patients were immediately treated with lorazepam 1 or 2 ampules (2 mg/mL per ampule) i.m. injection (IMI) during 2 h. Second, if the previous 2 ampules of lorazepam IMI failed, diazepam infused i.v. (10 mg/2 mL per ampule) in normal saline 500 mL every 8 h would be done during 1 day. The response rate of catatonic signs in these 14 patients with lorazepam IMI during the first 2 h was 85.7% (12/14). However, according to the results of this method, the total response rate to benzodiazepines during 1 day was 100%(14/14). These results suggested that this modified treatment strategy could rapidly and completely relieve catatonic signs, even without the use of ECT.

[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.

Un trouble rare et peu étudié : la schizophrénie chez l’enfant. À propos d’une observation

Childhood-onset schizophrenia is rare: its prevalence is about 50 times lower than the one observed in adulthood. It is also frequently unrecognized, notably because its clinical aspect varies with age. The authors report the case of a prepubertal girl who developed a typical clinical picture of schizophrenia (paranoid subtype) by age 9.

CASE REPORT

The patient was 10 years old when she was hospitalized for a relapse of a suspected childhood-onset schizophrenia. Several significant mental disorders were found in her family history: her mother was treated for mood disorders (including dysthymia and major depression with postpartum onset), while her father and a aunt exhibited schizophrenic disorders. In addition, prenatal and perinatal events (including probable prenatal maternal infection and obstetric complications) were reported by her mother. Demonstrable impairments were already present in her premorbid development: from the age of 3.5, she showed significant manifestations of behavioural inhibition and separation anxiety, severe difficulties in social adaptation, and language abnormalities (qualified by her general practitioner as selective mutism). At the age of 9, when her mother was hospitalized for a diabetes mellitus, she suddenly showed auditory and visual hallucinations associated with delusions. Their content included filiation, somatic, and persecutory themes. Grossly disorganized behaviour (and more particularly catatonic motor behaviours including catatonic rigidity and negativism and bizarre postures) was also observed. Negative symptoms (eg anhedonia, affective flattening, and alogia) were noted. Her IQ scores were 74 in the verbal subtests and 53 in the performance subtests. Because the diagnostic of childhood-onset schizophrenia was suspected, a neuroleptic treatment, haloperidol 3 mg/day, was tried. After a partial remission during a few months period (characterized by a decrease in delusions, anxiety and sleep difficulties), she showed a relapse leading to her hospitalization. At the time of her admission, she showed severe manifestations of separation anxiety including agitation, anger, crying, and insomnia, for which she received a short-lived treatment by lorazepam. When sedation was obtained, the clinical picture proved similar to the one previously observed: hallucinations, delusions, grossly disorganized behaviour, and thought disorder were noted. As soon as the diagnostic of childhood-onset schizophrenia was confirmed, she was administered a new antipsychotic agent, amisulpride, at dose of 600 mg/day. This treatment was going on during several weeks with no significant clinical effect. Because the early onset of the disorder, the family history of schizophrenia, and the lack of effectiveness of the two previously administered antipsychotic agents, a treatment with clozapine was started at the dose of 12,5 mg/day. From the outset of this treatment, clinically significant reductions in hallucinations and disorganized behaviours were noted. Dose was then progressively increased until 200 mg/day, resulting in significant improvement in cognitive and motor functioning. The patient is now in an educational institute. Her adaptation is considered satisfactory, in spite of regular exacerbations of delusions in response to stressful life events. Treatment with clozapine is going on, without any significant undesirable clinical effects.

DISCUSSION

If an abrupt onset is rarely observed in prepubertal children, all the authors report that patients with very early onset schizophrenia show to have demonstrable impairments in their premorbid language as well as in their motor and social development. In addition, several studies suggest that more pronounced early developmental abnormalities are usually associated with a poor outcome in schizophrenia. The clinical picture also agrees with recent studies showing that in children paranoid subtype is as frequent as seen in adult disorders. If genetic factors play a significant role in the pathogenesis of schizophrenia, the notion that such factors may be more salient in very early onset and more severe cases is now usually accepted. However, a number of environmental factors, including prenatal maternal infections and perinatal complications, may also be implicated in the pathogenesis of schizophrenia, in addition to genetic factors. Because a significant relationship between stressful life events and exacerbations in positive symptoms was found in the case reported, the authors examine the role of such stress factors in the pathogenesis of schizophrenia and in the course of illness. A brief review of studies that have examined the effects of antipsychotic agents in children with schizophrenia underscores the paucity of data available to guide clinicians in this area. However, these data suggest that children who receive conventional neuroleptics experience significant adverse effects, primarily sedation and extrapyramidal symptoms. In addition, they suggest that new antipsychotic agents, such as clozapine, may be more effective than conventional neuroleptics, particularly in negative symptoms. Lastly, the authors emphasize the poor outcome usually reported in childhood-onset schizophrenia, highlighting the need of a long-term pharmacological and behavioural treatment.

CONCLUSION

This case report, such as others, supports the hypo-thesis that there is a clinical continuity between early and later onset schizophrenia. It also suggests that very early onset schizophrenia is a more severe form of the disorder and may be secondary to greater familial vulnerability. Consequently, systematic studies of these patients may be particularly informative and may provide important informations for understanding the etiologic processes involved in the pathogenesis of schizophrenia.

Catatonic features noted in patients with post-partum mental illness

The purpose of the present study was to investigate the prevalence, distribution of psychiatric diagnoses, and treatment responses of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung in Taiwan. During a 1 year period a total of 636 Taiwanese women received psychiatric consultation on their visits to the emergency room. Fifteen of these were noted to have post-partum mental illnesses. All subjects were followed up for a minimum of 3-6 months. The prevalence of patients with post-partum mental illness at an emergency unit at Chang Gung Memorial Hospital at Kaohsiung was 2.4% (15/636). The distribution of psychiatric diagnoses according to Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) criteria included eight cases of major depressive disorders (53.3%), three cases of bipolar I disorder (20%), three cases of schizophrenia (20%), and one case of psychotic disorder due to a general medical condition (6.7%). Four subjects manifested catatonic features. Of these four, three had complete remission in catatonic symptoms after receiving intramuscular injection of lorazepam. The fourth subject died of multiple medical diseases. The treatment results suggest that most of the clinical presentations in patients with post-partum mental illness could be relieved by antipsychotics, mood stabilizers or antidepressants. In addition, it was found that intramuscular injection of lorazepam was also effective in patients with catatonic features and post-partum depression or psychosis.

Negative symptoms and neuroleptics in catatonic schizophrenia

The association between neuroleptic treatment and the negative symptom dimension (ND) was evaluated in 1528 schizophrenia patients. In patients receiving more than 820 mg chlorpromazine (CPZ), those with catatonic-type disorder had significantly (p<0.05) higher ND scores than those in any of the other diagnostic subtypes. Even in patients receiving 450 mg CPZ or more, catatonic patients had significantly (p=0.046) higher ND scores than other patients. Patients with catatonic schizophrenia are highly vulnerable to negative symptoms related to neuroleptic drugs, probably because of a defect in their dopaminergic neuronal pathways.

An efficacy analysis of olanzapine treatment data in schizophrenia patients with catatonic signs and symptoms

Thirty-five patients suffering from schizophrenia, as diagnosed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were preselected from 7 clinical trials according to a priori criteria of catatonic signs and symptoms based on 3 Positive and Negative Syndrome Scale (PANSS) items: scores for PANSS item 19 (mannerism and posturing) and either item 4 (excitement) or item 21 (motor retardation) had to exceed or equal 4 at baseline. This particular patient population represents a severely psychotic sample: mean +/- SD PANSS total scores at baseline were 129.26 +/- 19.76. After I week of olanzapine treatment, mean PANSS total score was decreased significantly (-13.14; p < .001), as was mean PANSS total score after 6 weeks of olanzapine treatment (-45.16; p < .001); additionally, the positive subscale, negative subscale, and mood scores improved significantly. A significant improvement in the catatonic signs and symptoms composite score was also observed at week 6 (-4.96; p < .001). The mean +/- SD daily dose of olanzapine was 18.00 +/- 2.89 mg after 6 weeks of treatment. The present data analysis suggests the efficacy of olanzapine in the treatment of severely ill schizophrenic patients with nonspecified catatonic signs and symptoms.

Acute and long-term treatment of catatonia with risperidone

Catatonia is a rare but difficult-to-treat disorder. Here, we report on the case of a schizophrenic patient who developed several episodes of severe catatonia after suffering from adequately treated Lyme disease with encephalitis. The catatonic stupor was not responsive to typical neuroleptics and benzodiazepines. After the medication was changed to risperidone, there was a dramatic and persistent improvement of the patient's condition. Two relapses during the follow-up period over five years were caused by dose reductions. Risperidone might be a promising drug in the treatment of acute catatonia and in preventing further episodes.

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.

Dopamine D4 receptor 48-bp repeat polymorphism: no association with response to antipsychotic treatment, but association with catatonic schizophrenia

The dopamine D4 receptor (DRD4) may play a role in the pathogenesis of neuropsychiatric disease and in the action of dopaminergic drugs. The 48-bp repeat polymorphism (48-bp VNTR) coding for a 16-amino acid segment in the third cytoplasmatic loop of the DRD4 was studied as a predictor of the therapeutic response to antipsychotics and as susceptibility factor for schizophrenia. We included 638 in-patients with acute schizophrenic, schizoaffective (mainly schizophrenic), and other nonaffective psychoses, as well as two reference groups: one with 278 in-patients with non-psychiatric diseases, and one with 474 healthy volunteers. Catatonic patients (DSM-IV 295.2) more frequently carried the DRD4 D4.2 and D4.3 allele than did all other schizophrenic cases (P < 0.001; OR: 2.7; CI: 1.5-4.9) and controls (P < 0.004; OR: 2.3; CI: 1.3-4.2). We found no significant difference in the DRD4 allele or in genotype frequencies in our comparison of all schizophrenic patients and controls. The subgroups with affected family members, and the subgroups with early or late onset of disease, also did not differ from the controls in DRD4 allele frequencies. The 48-bp VNTR was not a predictor for therapeutic outcome measured by the positive and negative symptoms scale. A total of 1390 subjects showed between 1 and 10 repeats (D4. 1 and D4.10), with 25 different genotypes. These data exclude a major role of DRD4 48-bp VNTR in response to antipsychotic therapy and as susceptibility factor for schizophrenia, but catatonic schizophrenia may be associated with the D4.2 and D4.3 alleles.

Negative parkinsonian, depressive and catatonic symptoms in schizophrenia: a conflict of paradigms revisited

BACKGROUND

To study the interrelationship pattern of negative, depressive, parkinsonian and catatonic symptoms over an exacerbation phase of schizophrenia.

METHOD

Forty-five inpatients with a DSM-IV diagnosis of schizophrenia or schizophreniform disorder were assessed at admission and discharge for negative, depressive, parkinsonian and catatonic symptoms. A subsample of patients unmedicated at admission (n=23) was specifically analyzed.

RESULTS

Negative, parkinsonian and catatonic symptoms correlated significantly at both assessment points, as did their mean changes over the episode. At admission, depressive symptoms did not correlate with negative, parkinsonian or catatonic symptoms, but they did at discharge. Changes of depressive symptoms over the episode did not correlate with changes of the other groups of symptoms. In the patients who were unmedicated at admission, ratings of nonakinetic parkinsonism, unlike ratings of akinetic parkinsonism, worsened significantly after neuroleptic treatment.

CONCLUSIONS

While negative, parkinsonian and catatonic symptoms are highly related features, depressive symptoms seem to be a relatively independent dimension of psychopathology in schizophrenia. Non-akinetic parkinsonian symptoms may be more useful than the akinetic symptoms in distinguishing primary from drug-induced negative symptoms.

Reduced activation and altered laterality in two neuroleptic-naive catatonic patients during a motor task in functional MRI

BACKGROUND

Catatonia, a symptom complex with motor, affective and cognitive symptoms seen in a variety of psychotic conditions and with organic disease, was examined using a motor task using functional magnetic resonance imaging (fMRI).

METHODS

Two acute catatonic patients and two age- and sex-matched healthy controls performed sequential finger opposition (SFO) after being medicated with 2 mg of lorazepam (i.v.). Functional magnetic resonance images were collected using a gradient echo pulse sequence (EPI).

RESULTS

Patients with catatonia showed reduced motor activation of the contralateral motor cortex during SFO of the right hand, ipsilateral activation was similar for patients and controls. There were no differences in the activation of the SMA. During left hand activation the right-handed catatonic patients showed more activation in the ipsilateral cortex, a reversal from the normal pattern of activation in which the contralateral side shows four to five times more activation than the ipsilateral side.

CONCLUSIONS

In catatonic patients there is a decreased activation in motor cortex during a motor task compared to matched medicated healthy controls. In addition activation of the non-dominant side, left-handed activity in right-handed patients, results in a total reversal of the normal pattern of lateral activation suggesting a disturbance in hemispheric localization of activity during a catatonic state.

["Catatonic dilemma". Therapy with lorazepam and clozapine]

We are reporting on a patient with a schizoaffective disorder (ICD 10:F25.1), whose catatonic symptoms deteriorated while receiving high-potency neuroleptic drugs in combination with anticholinergic medication. Initially there was a "catatonic dilemma", i.e. it was not possible to differentiate between the morbigenous and pharmacogenic (malignant neuroleptic syndrome) etiology of the catatonic symptoms. Catatonic symptoms were successfully treated with a combination of lorazepam and clozapine. The severe catatonic syndrome was found to be a neuroleptic-induced deterioration of a primary morbogenous catatonic syndrome. Thus, this case also suggests that the malignant neuroleptic syndrome and neuroleptic non-responsive catatonia may not be two different disease entities but that catatonia under neuroleptic medication is caused by the interaction of individual disposition, morbigenous and pharmacogenic factors.

Clozapine: a mimicry of phaeochromocytoma

OBJECTIVE

To report a case of clozapine-induced hypertension with raised urinary catecholamines.

CLINICAL PICTURE

A 27-year-old man fulfilling DSM-III-R criteria for catatonic schizophrenia was treated with clozapine. He later developed both hypertension and raised urinary catecholamines which mimicked phaeochromocytoma.

TREATMENT

Clozapine was withdrawn.

OUTCOME

Both blood pressure and urinary catecholamines normalised.

CONCLUSIONS

Clozapine may induce sympathetic hyperactivity.

[Manneristic catatonia. A psychotropic drug refractory chronic progressive course]

Manneristic catatonia, one form of Leonhard's systematic schizophrenias, is illustrated in nine case notes. The essential syndrome of this rare disorder (described by Leonhard in the preneuroleptic era) consisted in mannerisms and progressive stiffness of psychomotor activity. Mannerisms often developed from obsessive and compulsive ideas; whereas distress disappeared, repetitive behavior developed into a stereotype. Complex movements (e.g. not to shake hands; mutism) became mannerisms. With disease progression stiffness of facial expression and gestures and an impairment of voluntary motor activity became increasingly prominent. There were no signs of (neuroleptic-induced) parkinsonism. Manneristic catatonia affects preponderantly men and exhibits an early age of onset (median: 23 years). In none of the cases a family history of psychiatric illness was noted. Severe obstetric and birth complications as well as the high prevalence of supratentorial and cerebellar CT/MR abnormalities in this patient group point to deviations of prenatal brain maturation. The median yearly dose of neuroleptics was 83.1 g chlorpromazin equivalents. The characteristic psychopathology was not essentially influenced by modern psychopharmacological treatment neither in the beginning nor in the long run irrespective of the time of onset of the disease. Continuous high-dose neuroleptic treatment is not efficacious in this distinct group of systematic schizophrenias. Behavioural training in a rehabilitation unit is the treatment of choice from the early beginning.

[Catatonia, malignant neuroleptic syndrome and myositis ossificans]

Lethal catatonia and the malignant neuroleptic syndrome represent two potentially fatal disorders that require different therapeutic regimens. Clinical differentiation is considered difficult because of a number of similarities with respect to mode of onset, signs and symptoms, and outcome. Recent observations emphasizing similarities between the two disorders, however, suggest that catatonia and the malignant neuroleptic syndrome may not represent separate diagnostic entities. Instead, the malignant neuroleptic syndrome has been hypothesized to be a neuroleptic-aggravated form of catatonia. In the present paper, we report the case of a 22-year-old male who developed different forms of malignant neuroleptic syndromes subsequent to a catatonic episode and overlapping it. In addition, the course was complicated by the occurrence of heterotopic calcification within skeletal muscles. The clinical value of diagnostic criteria that help distinguish catatonia from neuroleptic malignant syndrome and their therapeutic consequences are discussed.