CPCP: Catatonia Update By Trainee Experts

We got a very helpful update on assessment and management of catatonia in medical and psychiatric illness from medical students, Nicholas Bormann and Christopher Tam, and neurology senior resident (and soon to move on to a movement disorders fellowship in the Big Apple), Dr. Sarah O’Shea, MD. I suppose you could call them this month’s Three ConsulTeers:

Three Musketeers with swords out

From left to right: Christopher Tam, Nicholas Bormann, Dr. Sarah O’Shea MD

Anyway, this neuromotor syndrome appears more frequently in bipolar disorder than in schizophrenia as research has shown. We also have to remain alert for it in certain medical syndromes. It turns out that in many cases, electroconvulsive therapy (ECT) can be life-saving in that it can stop catatonia, often (though not always) whether the cause is medical or psychiatric.

The intravenous (IV) lorazepam challenge test can be diagnostic and therapeutic. It can even work in a  synergistic way with ECT. I’m not so sure about the very high doses of scheduled lorazepam recommended in the literature. We don’t use doses as high as the ConsulTeers identified. Incidentally, the IV lorazepam challenge test has been challenged by some. The answer provided by the person answering the question in the hyperlink is correct.

An intriguing question that comes up for me is whether or not the so-called Telephone Effect identifies a different population of catatonic patients than the IV lorazepam test. The Telephone Effect was described by a neurologist, Dr. C. Miller Fisher in the 1980s relative to patients with akinetic mutism (what I consider a description of catatonia):

  • Telephone Effect

–Identifies stimulus bound behaviors in brain injured patients

–Call pt from outside the room; mute pt may then answer simple questions; less often spontaneous

  • Fisher, C.M., Honored guest presentation: abulia minor vs. agitated behavior. Clin Neurosurg, 1983. 31: p. 9-31.
  • Hastak, S.M., P.S. Gorawara, and N.K. Mishra, Abulia: no will, no way. J Assoc Physicians India, 2005. 53: p. 814-8

I sometimes use this because I’ve found it positive in catatonic patients, and when I’m hesitant for medical reasons to use the IV lorazepam challenge test.

It’s important to remember the catatonic variant of delirium as well. One interesting study showed almost 40% of 205 patient met criteria for both delirium and catatonia;

–Assessed using Delirium Rating Scale-Revised-98 and the Bush Francis Catatonia Rating Scale

–Also compared the Bush Francis Catatonia Screening Instrument and (at the time) proposed DSM-5 criteria—32% and 12.7% were catatonic

–More common in women and those who were delirious prior to admission to hospital; hypoactive delirium more commonly associated with catatonia [Grover, S., et al. (2014). “Do patients of delirium have catatonic features? An exploratory study.” Psychiatry Clin Neurosci 68(8): 644-651.]

Benzodiazepine and alcohol withdrawal can also lead to catatonia and may involve gamma-aminobutryric (GABA) transmission changes [Amos, J. J., M.D., (2012). “Lorazepam withdrawal-induced catatonia.” Annals of Clinical Psychiatry 24(2).].

As a historical note, we used to use amobarbital sodium as the challenge test for catatonia. I think my residency cohort might have been the one of the last to employ it. It wasn’t that long ago!

–Medical risks were higher than with the benzodiazepine challenge test due to respiratory depression with barbiturates

–Had to obtain informed consent (usually from family member as the catatonic patient was obviously incapable)

–Stricter rules about vital sign monitoring

–Administered as a slow IV infusion rather than a bolus [Tollefson, G. D. (1982). “The amobarbital interview in the differential diagnosis of catatonia.” Psychosomatics 23(4): 437-438.]

–Abandoned when benzodiazepines were preferred because of their greater benefit to risk ratio

Here are a few take home points about catatonia:

  • Clarifying the underlying cause is essential
  • Catatonia may be one final common pathway for many kinds of pathology, both medical and psychiatric
  • Catatonia treatments usually have a favorable benefit/risk ratio and should be used promptly
  • Learning how to assess catatonia means keeping it in mind whenever faced with bizarre presentations
  • Assessment should be a regular part of psychiatric diagnostic evaluation and research

Good luck to Dr. O’Shea in the city that never sleeps!

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