This is a special Clinical Problems in Consultation Psychiatry (CPCP) by Dr. Aubrey Chan, MD, who’s in his second year (soon to be third year) of his residency in our combined Internal Medicine-Psychiatry program here. This is on catatonia and he has a great sense of humor and a command of the humanities which makes him a great teacher even though he’s early on in his career. He actually gave this talk a few years ago when he was a medical student. He has a strong interest in academic medicine, including research.
Usually patients who are catatonic are mute and immobile (although they can also be hyperkinetic). It’s as though they’re choosing not to move, but it’s not a conscious choice. They don’t move and sometimes the only way to get them to move is to administer an injectable sedative, such as a benzodiazepine like lorazepam. And at other times, the only way to unfreeze them is by electroconvulsive therapy (ECT), which can be lifesaving. Catatonia can also be a variant of delirium as well and would be one of the exceptions to the usual caution against using benzodiazepines in the setting of delirium, another being alcohol or sedative-hypnotic withdrawal.
And it’s important to remember that abruptly stopping a patient’s benzodiazepine can result in catatonia as well as a substance withdrawal state:
Amos, J. J., M.D., (2012). “Lorazepam withdrawal-induced catatonia.” Annals of Clinical Psychiatry 24(2).
Catatonia can be associated with a number of medical and psychiatric disorders including sedative-hypnotic withdrawal. The mechanism is unclear but may involve γ-aminobutyric acid (GABA) transmission changes. I report a case of lorazepam withdrawal-induced catatonia in a postsurgical patient who had been taking lorazepam at home as prescribed by her psychiatrist. This case begs the question of whether to continue previously prescribed benzodiazepines in the intensive care unit (ICU) postoperatively in light of a recent study showing that lorazepam administration in this context is an independent risk factor for delirium.
There was a slide with an embedded video of catatonic catalepsy, which is better shown below:
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