CPCP: Treatment of Catatonia by Pharmacy Resident Luke Watson, Pharm.D.

Luke Watson PharmD

Luke Watson, Pharm.D. PGY-2 Psychiatric Pharmacy Resident

So we had this great Clinical Problems in Consultation Psychiatry (CPCP) presentation on drug treatment of catatonia by a really sharp 2nd year Psychiatric Pharmacy Resident, Luke Watson, Pharm.D. This focuses more on specific pharmacotherapy for this complex neuropsychiatric disorder which can be caused by medical or psychiatric disorders.

Luke reminds us that catatonia occurs most often in the setting of primary psychiatric disorders, especially mood disorders and specifically Bipolar Affective Disorders, either manic or depressive states.

Catatonia also occurs in a variety of medical disorders as well, as he points out. About 70% of catatonia episodes due to a medical condition arise from a neurologic cause. The drug treatments, as well as electroconvulsive therapy (ECT) are also effective in these settings. catatonia can even occur as a variant of delirium, Catatonic var delirium andrew francis. Furthermore, the increasingly recognized Anti-NMDA Receptor Encephalitis can present with catatonia and the role of ECT in its treatment has been remarked on in the literature.

According to a presentation by catatonia expert, Dr. Andrew Francis, MD, PhD, Professor of Psychiatry, Penn State Medical School/Hershey Medical Center, Hershey, Pennsylvania, at the Academy of Psychosomatic Medicine (APM) Annual Meeting 2015 last month, the incidence of catatonia in medical illness is approximately 2-3% [1]. There doesn’t appear to be a way to distinguish catatonia from medical causes from psychiatric causes.

You can use the Bush-Francis Catatonia Rating Scale (BFCRS) to assess catatonia. Diagnosis requires 2 of the first 14 symptoms:

Excitement, mutism, posturing/catalepsy, echopraxia/echolalia, mannerisms, rigidity, waxy flexibility, immobility/stupor, staring, grimacing, stereotypy, verbigeration, negativism, withdrawal.

It’s critically important to recognize catatonia from any cause because it’s associated with severe medical complications which can lead to a mortality of 100% in the case of malignant catatonia–and it’s treatable.

Sometimes I’ve used the so-called “telephone effect” instead of or in addition to the standard IV lorazepam challenge test Luke describes. It’s an interesting phenomenon which I asked Dr. Francis about at an APM meeting in 2012. I don’t think he’d ever heard of it and he thought it was more of a stimulus bound effect. I asked Dr. Scott Beach, MD, Assistant Professor of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts who gave a lecture on catatonia at this year’s APM meeting about the telephone effect in the setting of “akinetic mutism” which in my opinion is just another descriptive term synonymous with catatonia. Dr. Beach says it’s related to catatonia but distinct mainly because it has an obvious neurologic cause, usually a structural brain lesion–which may raises more questions than answers, but that’s just me.

Anyway, the author of the paper I’ve seen on akinetic mutism which mentions the telephone effect is by a neurologist, C. Miller Fisher, and it starts on page 22 [2]. The essential feature is calling the patient from outside the room and trying to have a conversation with him. You could be only steps away from a mute patient who won’t speak to you in person but who will answer questions if you just ring him up. They don’t always talk to you and the responses tend to dwindle after a few minutes. Fisher thought the ring of the telephone was essential because the patient would not respond without it. Fisher says: “The examiner’s voice must come over the phone and the patient won’t answer you if the phone rings and the receiver is held against the ear, and the examiner speaks to the patient directly.” And you can’t get away with trying to talk the patient in the dark without being visible.

Dr. Amos on smartphoneI don’t know if it makes a difference if you use a smartphone or not.

I like Luke’s tables and the algorithm on slide 16. I also really like having a clinically oriented psychiatric pharmacist on my team. I’m pretty lucky to have this resource because they sometimes rotate through the consult service at some point during their training. May the Force be with you, Luke.

References

  1. Carroll BT, et al. Catatonic disorder due to general medical conditions. J Neuropsychiatry Clin Neurosci 1994; 6:122-33.
  2. Fisher, C. M. (1983). “Honored guest presentation: abulia minor vs. agitated behavior.” Clin Neurosurg 31: 9-31.

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