ArticlePDF Available

Catatonia and Cannabis Withdrawal: a case report

DOI:10.1080/08897077.2015.1052869
Authors:
Mathieu Caudron at EPSM Lille Métropole
Mathieu Caudron
  • EPSM Lille Métropole
Benjamin Rolland at Claude Bernard University Lyon 1
Benjamin Rolland
Sylvie Deheul at Centre Hospitalier Régional Universitaire de Lille
Sylvie Deheul
Pierre Alexis Geoffroy at Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine)
Pierre Alexis Geoffroy
Show all 6 authorsHide
Download full-text PDF
Read full-text
Download citation

Abstract

Catatonia is a severe motor syndrome found in approximately 10% of all acute psychiatric hospital admissions. It can occur in various psychiatric diseases. We report the first case report of catatonia during cannabis withdrawal. Mr. A, a 32-year-old man, reported to have daily smoked approximately 20 grams of cannabis since aged 11 years. Mr. A was incarcerated and was reported three weeks later to the medical department for having completely ceased talking and eating. At admission in our department, the patient presented with classical catatonia symptoms (Bush-Francis Catatonia Rating Scale (BFCRS) score = 39/69). All laboratory results and brain MRI were normal. Six weeks after his admission and treatments by lorazepam and memantine, his BFCRS score was 0/69. This single-case study highlights the previously under-reported emergence of physical and motor symptoms following cannabis withdrawal. Pathophysiological aspects of abrupt cannabis cessation contributing to GABA/glutamate balance dysregulation and to catatonia are discussed.
Content uploaded by Ali Amad
Author content
All content in this area was uploaded by Ali Amad on Aug 13, 2015
Content may be subject to copyright.
This article was downloaded by: [King's College London]
On: 10 August 2015, At: 02:19
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: 5 Howick Place,
London, SW1P 1WG
Click for updates
Substance Abuse
Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/wsub20
Catatonia and Cannabis Withdrawal: a case report
Mathieu Caudron M.D.
a
, Benjamin Rolland M.D. PhD
bc
, Sylvie Deheul M.D.
d
, Pierre Alexis
Geoffroy M.D.
efg
, Pierre Thomas M.D. PhD
a
& Ali Amad M.D. PhD
a
a
Pôle de psychiatrie, Univ Lille Nord de France, CHRU de Lille, F-59000 Lille, France
b
Addiction Consultation-Liaison Service, Department of Addiction Medicine, University
Hospital of Lille, France
c
Department of Pharmacology, INSERM U1171, University of Lille, France
d
Department of Addictovigilance, University Hospital of Lille, France
e
Inserm, U1144, Paris, F-75006, France
f
Université Paris Descartes, UMR-S 1144, Paris, F-75006, France & Université Paris Diderot,
UMR-S 1144, Paris, F-75013, France
g
AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences, 75475 Paris
Cedex 10, France
Accepted author version posted online: 06 Aug 2015.
To cite this article: Mathieu Caudron M.D., Benjamin Rolland M.D. PhD, Sylvie Deheul M.D., Pierre Alexis Geoffroy M.D.,
Pierre Thomas M.D. PhD & Ali Amad M.D. PhD (2015): Catatonia and Cannabis Withdrawal: a case report, Substance Abuse,
DOI: 10.1080/08897077.2015.1052869
To link to this article: http://dx.doi.org/10.1080/08897077.2015.1052869
Disclaimer: This is a version of an unedited manuscript that has been accepted for publication. As a service
to authors and researchers we are providing this version of the accepted manuscript (AM). Copyediting,
typesetting, and review of the resulting proof will be undertaken on this manuscript before final publication of
the Version of Record (VoR). During production and pre-press, errors may be discovered which could affect the
content, and all legal disclaimers that apply to the journal relate to this version also.
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained
in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and
are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and
should be independently verified with primary sources of information. Taylor and Francis shall not be liable for
any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever
or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of
the Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
1
Catatonia and Cannabis Withdrawal: a case report
Mathieu CAUDRON
1
M.D., Benjamin ROLLAND
2,3
M.D. PhD, Sylvie DEHEUL
4
M.D.,
Pierre Alexis GEOFFROY
5,6,7
M.D., Pierre THOMAS
1
M.D. PhD, Ali AMAD
1
M.D. PhD
1) Pôle de psychiatrie, Univ Lille Nord de France, CHRU de Lille, F-59000 Lille, France
2) Addiction Consultation-Liaison Service, Department of Addiction Medicine, University
Hospital of Lille, France
3) Department of Pharmacology, INSERM U1171, University of Lille, France
4) Department of Addictovigilance, University Hospital of Lille, France
5) Inserm, U1144, Paris, F-75006, France
6) Université Paris Descartes, UMR-S 1144, Paris, F-75006, France & Université Paris Diderot,
UMR-S 1144, Paris, F-75013, France
7) AP-HP, GH Saint-Louis - Lariboisière - Fernand Widal, Pôle Neurosciences, 75475 Paris
Cedex 10, France.
Correspondence should be addressed to Ali Amad, MD, PhD, Unité d'Hospitalisation,
Spécialement Aménagée (UHSA) Lille-Seclin, Chemin du bois de l'hôpital, 59113 SECLIN,
France. Email : ali.amad@outlook.com
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
2
ABSTRACT. Background: Catatonia is a severe motor syndrome found in approximately 10%
of all acute psychiatric hospital admissions. It can occur in various psychiatric diseases. We
report the first case report of catatonia during cannabis withdrawal. Case presentation: Mr. A, a
32-year-old man, reported to have daily smoked approximately 20 grams of cannabis since aged
11 years. Mr. A was incarcerated and was reported three weeks later to the medical department
for having completely ceased talking and eating. At admission in our department, the patient
presented with classical catatonia symptoms (Bush-Francis Catatonia Rating Scale (BFCRS)
score = 39/69). All laboratory results and brain MRI were normal. Six weeks after his admission
and treatments by lorazepam and memantine, his BFCRS score was 0/69. Discussion: This
single-case study highlights the previously under-reported emergence of physical and motor
symptoms following cannabis withdrawal. Pathophysiological aspects of abrupt cannabis
cessation contributing to GABA/glutamate balance dysregulation and to catatonia are discussed.
Keywords: Cannabis withdrawal, catatonia, gaba/glutamate balance
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
3
INTRODUCTION
Catatonia is a severe motor syndrome found in approximately 10% of all acute psychiatric
hospital admissions
1
. It can occur in various psychiatric diseases, including mood disorders and
schizophrenia, as well as substance intoxication/withdrawals and other medical conditions
1,2
.
This is the first published case report of catatonia during cannabis withdrawal.
CASE DESCRIPTION
Mr. A was a 32-year-old man incarcerated for interrupting a chase related to a drug
trafficking. His medical history showed evidence of mild intellectual disability (IQ = 67) and a
polyneuropathy at the age of sixteen, which affected his cranial nerves. Full recovery was
obtained with corticosteroid therapy. Family and general practitioner (GP) reports showed no
personal or family psychiatric history, nor notable personal medical history.
Mr. A. reported to have daily smoked approximately 20 grams of cannabis (resin and
marijuana), since aged 11 years. During three previous incarcerations for drug trafficking, he
reported using far lower amounts, without any complications. Due to religious and cultural
beliefs, Mr. A never consumed alcohol or other illicit drugs, confirmed by his GP and family.
Mr. A's family described his behavior as normal on the day before his imprisonment. Both the
GP and the psychiatrist who examined him on his arrival in jail did not report any medical
symptoms. During his current incarceration the patient was unable to obtain cannabis due to a
lack of money. Three weeks later the patient was reported to the medical department, having
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
4
completely ceased talking and eating for several days, as well as having set his coat on fire,
without any skin damage thanks to intervention of the prison staff. The patient was then
transferred from jail to the emergency medical department due to confusion and mutism. Blood
tests were normal and after examination, the psychiatrist decided on compulsory admission to
our forensic psychiatry department.
At admission the patient presented with classical catatonia symptoms, including apathy,
mutism, disorientation in time and space, psychomotor agitation, catalepsy, waxy flexibility,
impulsivity, ‘mitgehen’ (movement in any direction in response to a very light finger pressure),
plastic hypertonia and cogwheel. On the Bush-Francis Catatonia Rating Scale
3
(BFCRS) the
patient scored 39/69, suggesting a diagnosis of catatonia. No psychotic symptoms, including
delusions or disorganization were evident.
Due to catatonic symptomatology, we attempted a zolpidem test
4
, but the patient refused
any oral treatment. We then decided to administer 1 mg of clonazepam by intramuscular
injection, which allowed for treatment with oral lorazepam, starting at 10mg per day
5
. By
gradually increasing the lorazepam dose, his symptomatology improved. At 25 mg per day, the
improvement in his catatonic symptoms stagnated. We then added oral memantine
5
, starting at 5
mg per day, which further decreased his catatonic symptomatology.
During this hospitalization, and given the patient’s history, many examinations were performed.
All laboratory results were normal, including: toxicological analyses (cannabis, amphetamines,
cocaine, opiates/opioids), full blood count, electrolyte panel, liver function panel, coagulation
panel, serum protein electrophoresis, C reactive protein, fibrinogen, blood glucose, thyroid
function tests, B9 vitamin, albumin, hepatitis panel, angiotensin converting enzyme, salivary
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
5
gland biopsy, HIV and syphilis. The involvement of autoimmune and paraneoplastic processes
were also excluded by the analysis of a variety of factors, including: homocystein, anti-nuclear
antibodies, anti-transglutaminase antibodies, antineutrophil cytoplasmic antibodies and onco-
neural antibodies, which were all negative. The tuberculin skin test and quantiferon level were
also negative. Vitamin B12 and iron levels were normal. Brain MRI showed two minor non-
specific lesions in the white matter of the left periventricular and insular areas.
Six weeks after his admission, his BFCRS score was 0/69. After a period of consolidation,
his medication was decreased to lorazepam 1.5 mg/week, with no symptom re-emergence. Mr.
A left the hospital on his release from jail, with treatment continued in a psychiatry outpatient
department.
DISCUSSION
To our knowledge, this is the first reported case of cannabis withdrawal-induced catatonia.
Laboratory and imagery investigations were within normal limits and excluded delirium,
toxicological, neurological, systemic and paraneoplastic causes of his catatonic symptoms. We
hypothesize that the patient experienced catatonia following sudden heavy cannabis use
cessation. According to the WHO-UMC Causality Assessment
6
, derived from clinical-
pharmacological aspects of the case history, the causality between cannabis cessation and
catatonia was "probable", given that the event appeared with reasonable temporal relationship to
drug withdrawal and being unlikely to be attributable to disease or other drugs.
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
6
Physical and motor symptoms are generally lower, compared with other symptoms, after
cannabis cessation
7
and the relation between cannabis dose and the magnitude of abstinence
effects is still being debated
8
. However, these symptoms are included in the DSM-5 cannabis
withdrawal syndrome
9
. Such physical symptoms occur more frequently from day 5 following
cannabis cessation
7
. However, given Mr. A's initial incarceration, there is no certainty as to the
sequence of symptom emergence, being only reported when clearly visible after at least two
weeks incarceration.
Pathophysiologically, abrupt cannabis cessation can dysregulate the GABA/glutamate
balance, contributing to catatonia. Indeed, chronic consumption of cannabinoids, like Δ9
tetrahydrocannabinol, decreases extracellular glutamate and increases extracellular GABA, as
well as enhancing dopamine release in both the striatum and mesolimbic system
10
. This pattern is
reversed by abrupt cannabis cessation, leading to a typical catatonia pattern of GABA-A and
dopamine D2 receptor hypoactivity and glutamate NMDA receptor hyperactivity
5
. Interestingly,
GABA-ergic regulating drugs, such as the selective GABA-B agonist, baclofen, show promise in
the management of cannabis dependence
11
.
In conclusion, the single-case study detailed here highlights the previously under-reported
emergence of physical and motor symptoms following cannabis withdrawal. This case report
further highlights how sudden cessation due to incarceration can be extremely dangerous,
without appropriate management. This common clinical situation requires careful monitoring
and more research on abrupt heavy cannabis cessation is needed in order to improve patient care
and management.
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
7
FUNDING
The authors received no funds for this research. The authors declare no conflicts of
interest.
AUTHOR CONTRIBUTIONS
MC and AA managed the case, MC, BR and AA wrote the first draft, SD, PAG and PT
were responsible for critical revision of the manuscript. All authors have read and approved the
final version of the manuscript.
Downloaded by [King's College London] at 02:19 10 August 2015
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
8
REFERENCES
1. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am. J.
Psychiatry 2003;160(7):1233-1241.
2. Geoffroy PA, Rolland B, Cottencin O. Catatonia and alcohol withdrawal: a complex and
underestimated syndrome. Alcohol Alcohol. 2012;47(3):288-290.
3. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and
standardized examination. Acta Psychiatr. Scand. 1996;93(2):129-136.
4. Thomas P, Rascle C, Mastain B, Maron M, Vaiva G. Test for catatonia with zolpidem.
Lancet 1997;349(9053):702.
5. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the
treatment of catatonia. Front. Psychiatry 2014;5:181.
6. The use of the WHO-UMC system for standardised case causality assessment.
7. Hesse M, Thylstrup B. Time-course of the DSM-5 cannabis withdrawal symptoms in poly-
substance abusers. BMC Psychiatry 2013;13:258.
8. Budney AJ, Hughes JR, Moore BA, Vandrey R. Review of the Validity and Significance of
Cannabis Withdrawal Syndrome. Am. J. Psychiatry 2015.
9. Association AP. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-
5. 5 edition. Washington, D.C: American Psychiatric Publishing; 2013.
10. Maldonado R, Berrendero F, Ozaita A, Robledo P. Neurochemical basis of cannabis
addiction. Neuroscience 2011;181:1-17.
11. Imbert B, Labrune N, Lancon C, Simon N. Baclofen in the management of cannabis
dependence syndrome. Ther. Adv. Psychopharmacol. 2014;4(1):50-52.
Downloaded by [King's College London] at 02:19 10 August 2015
... Abrupt cannabis cessation can dysregulate GABA/glutamate balance contributing to catatonia [10]. Interestingly, GABAergic regulating drugs such as selective GABA-B agonist Baclofen is postulated in the management of cannabis dependence [10]. ...
... Abrupt cannabis cessation can dysregulate GABA/glutamate balance contributing to catatonia [10]. Interestingly, GABAergic regulating drugs such as selective GABA-B agonist Baclofen is postulated in the management of cannabis dependence [10]. Our patient was unable to recall if he suddenly stopped using cannabis in the days leading to his admission. ...
An Atypical Case of Catatonia, Abnormal Gait and Psychosis in an Adolescent with Chronic Cannabis Use
Article
Full-text available
  • Jul 2021
An association between cannabis and psychosis is well established. Cannabis use is known to precipitate schizophrenia in vulnerable individuals and it can exacerbate existing psychosis. However, there is a paucity of knowledge about the emergence of catatonia and abnormal gait associated with cannabis use. History of cannabis use is associated with long-lasting changes in open-chain elements of walking gait. Cannabinoid receptors are located in movement-related brain regions and cannabis use is suggested to affect gait. This report is a unique case of a 16-year-old male with no known past medical history, no past psychiatric history, with family history significant for psychosis who presented to the hospital for bizarre, disorganized behavior, and decreased oral intake following heavy cannabis use over the past three months in the context of a break-up. Upon arrival, he was found to be in a catatonic state with an impaired gait. As catatonia resolved with treatment, he was able to speak and the psychosis surfaced which was addressed with antipsychotics. This case report highlights an atypical but serious clinical picture observed to be precipitated by chronic, heavy cannabis use.
... This is in line with previous studies reporting a positive correlation between consumption of THC concentrations and risk for psychosis (Di Forti et al., 2009). Nonetheless, it should be mentioned that one case report on catatonia-like symptoms reported that catatonic symptoms were precipitated by cannabis cessation (Caudron et al., 2016). Hence, further studies are needed on how cannabis/SC concentrations are related to catatonic symptoms. ...
... Although the current review was focused on the relationship between cannabis or SC use and catatonia-like symptoms from a clinical perspective, several neurobiological factors that go beyond the scope of this review are also worth highlighting. Important factors to take into account are the gamma-aminobutyric acid (GABA) and the glutamate because both neurotransmitters are related to catatonia, cannabis use disorder and substance-induced disorders (Caudron et al., 2016;Deng et al., 2018;Duggal & Singh, 2005;Manseau & Goff, 2015;Walther et al., 2019). This could be related to the fact that THC may alter the physiological control that the endogenous cannabinoid system has on glutamate and GABA liberation (Deng et al., 2018). ...
Catatonia Related to Cannabis and Synthetic Cannabinoids: A Review
Article
  • Apr 2021
Objective: Cannabis and synthetic cannabinoids (SC) are related to several neuropsychiatric symptoms and disorders, especially psychotic symptoms and disorders. Interestingly, catatonia-like symptoms associated with cannabis and SC have been generally neglected in research and scarcely described despite the clinical repercussions. Hence, this review aims to analyze current clinical publications on catatonia induced by cannabis or SC in a systematized way. Methods: A search using PRISMA guidelines was performed on three databases based on a specific inclusion and exclusion criteria. Results: 11 publications describing 14 patients (10 males; mean age 22.50 ± 6.67 years old) with catatonia apparently precipitated by the use of cannabis (n = 6) or SC (n = 8) were found. Clinical features and treatment are described and discussed. Conclusion: From a clinical perspective, cannabis and SC use may be related to catatonia-like symptoms and catatonia syndrome in the same way these substances (cannabis and SC) are related to induced-psychotic episodes. However, further research will be required to understand the exact nature of that relationship. Additionally, investigations focused on the clinical significance (i.e., prognosis, evolution, and outcomes) of catatonia-like symptoms induced by cannabis and SC use in patients are also needed.
... 3 Such an overview was thus required as Addictovigilance signals have been identified, notably through the descriptions of young, apparently healthy, cannabis users suffering from unexpected cardiovascular disorders. 4 These findings, which corroborated those from other studies conducted in different contexts, [5][6][7][8][9][10][11][12][13] raise concerns as to whether cannabis use could also affect other systems. ...
... | DISCUSSIONWhile the relevance and feasibility of authorizing medical cannabis in France was evaluated, it was important to characterize the number, the type and the severity of AEs related to recreational cannabis, in particular the occurrence of unexpected AEs in this context of increasing THC content of cannabis in the market. The present study was the first to give an overview of these events on a national level.[5][6][7][8][9][10][11][12][13] In our sample these AEs mainly concerned men, with a sex ratio over 3:1, and people aged between 18 and 34 years (range: 12-84 years). ...
Adverse events of recreational cannabis use reported to the French addictovigilance network (2012‐2017)
Article
  • Mar 2021
Aims: To describe the adverse events (AEs) of recreational cannabis use in France between 2012 and 2017. Methods: AEs related to recreational cannabis use, alone or in combination with alcohol and/or tobacco reported to the French Addictovigilance Network were analysed (excluding cannabidiol and synthetic cannabinoids). Results: Reporting of AEs tripled between 2012 (n = 179, 6.3%, 95% confidence interval [CI] = 5.4-7.2) and 2017 (n = 562, 10.1%, 95% CI = 9.3-10.9), reaching 2217 cases. They concerned mainly men (76.4%) and users aged between 18 and 34 years (18-25: 30.9%; 26-34: 26.3%, range: 12-84 years). Cannabis was mainly inhaled (71.6%) and exposure was most often chronic (64.2%). Many types of AEs were reported: psychiatric (51.2%), neurological (15.6%), cardiac (7.8%) and gastrointestinal (7.7%), including unexpected AEs (n = 34, 1.1%). The most common effect was dependence, ranging from 10.1% (95% CI = 7.9-12.3) to 20.3% (95% CI = 17.3-23.2) over the study period. Cannabinoid hyperemesis syndrome (n = 87, 2.8%) emerged from 2015. Deaths accounted for 0.2% of all AEs (4 men and 3 women aged on average 35 years). A chronic pattern of cannabis use was reported in 4 of them (intracranial hypertension in the context of lung cancer, suicide, cerebral haematoma, neonatal death with concomitant chronic alcohol use), while in the other cases the toxicological analysis identified cannabis use (ruptured aneurysm and unknown aetiology). Conclusion: This study showed a multitude of AEs related to recreational cannabis use, including unexpected AEs and deaths. It highlights the problem of dependence and the emergence of cannabinoid hyperemesis syndrome.
... substance-related catatonia has previously been described in a patient with acute amphetamine intoxication (Chern & Tsai, 1993) and in an individual with cannabinoid withdrawal (Caudron et al., 2016). More recently, Palma-Alvarez et al. (2021) conducted a systematic review of catatonia associated with cannabis or synthetic cannabinoid use and identified 11 case series or reports with a total of only 14 patients (Palma-Alvarez et al., 2021). ...
Catatonic Episodes Related to Substance Use: A Cross-Sectional Study Using Electronic Healthcare Records
Article
Full-text available
  • Jan 2022
Objective: Substance use has increasingly been linked to the onset of catatonic episodes; however, no large observational studies have examined this association. This study aimed to identify catatonic episodes temporally associated with acute intoxication, withdrawal or chronic substance use, investigate which substances were involved, and compare clinical characteristics of substance-related and non-substance-related catatonic episodes. Methods: This study retrospectively identified all catatonic episodes recorded in an electronic case register hosted at a large secondary mental health trust in London, UK. Episodes were categorized as substance-related if the clinical record reported either a positive urine drug screen, an ICD-10 diagnosis of a mental or behavioral disorder due to substance use, or documented substance use between two weeks prior to the catatonic episode and the date of the catatonic episode. Results: 108 of 2130 catatonic episodes (5.1%) were deemed substance-related. The number of contemporaneously reported substance-related episodes increased between 2007 and 2016 [r = 0.72, p = 0.02]. Episodes in the context of acute intoxication (n = 54) were most frequently related to cannabis (n = 31) or cocaine (n = 5) use, whilst those in the context of drug withdrawal (n = 8) were most commonly related to alcohol, opioids and benzodiazepines. There were 50 episodes of catatonia associated with chronic substance use without intoxication or withdrawal, of which the majority were related to cannabis use (n = 37). 21 episodes had overlapping intoxication, withdrawal and chronic use of different substances within an episode. Compared to catatonic episodes not related to substance use, episodes of substance-related catatonia occurred in individuals who were younger (mean age 31.3 years [SD 12.2] vs 35.7 years [SD 16.3], p = 0.01) and more likely to be men (74.0% vs 54.3%, p < 0.001). The clinical features of catatonia were similar between the two groups. Conclusions: A relatively small proportion of catatonic episodes were temporally associated with reported substance use within their electronic records. Substance-related catatonic episodes were mostly related to cannabis use, but other substances including cocaine, alcohol, opioids and benzodiazepines were sometimes implicated. This is likely an underestimate of substance-related catatonia use due to issues with documentation and appropriate investigation.
... [14][15][16][17]. ...
Cannabis-Induced Malignant Catatonia: A Medical Emergency and Review of Prior Case Series
Article
  • Aug 2021
Few case reports of catatonia associated with cannabis use are reported. Here, we describe a case of a 35-year-old African American male who developed malignant catatonia following heavy cannabis use. The patient was brought to the emergency department (ED) for altered mental status, hypertension, and erratic behavior. Before his ED presentation, he was smoking cannabis in heavy amounts, confirmed by positive urine toxicology in ED. Initial lab results showed leukocytosis, elevated creatine phosphokinase (CPK) levels. Head CT scans without contrast, including cerebrospinal fluid (CSF) analysis, were nonsignificant. In ED, the patient was agitated, combative, mute, and rigid. He was sedated using 2 mg of intramuscular (IM) midazolam. Psychiatric consultation services suspected catatonia, and the patient scored 12 points on Bush-Francis Catatonia Rating Scale (BFCRS). Although the patient's symptoms responded to 2 mg of IM lorazepam, the patient later relapsed, became tachycardic with blood pressure fluctuations, and his repeat BFCRS score was 18. At this point, the patient was diagnosed as having malignant catatonia, and his lorazepam dosage was increased up to 6 mg IM per day. After a few days of waxing and waning of his symptoms, he finally started to show constant improvement and gradually reduced his symptoms. Our case highlights the first-ever reported case of malignant catatonia associated with cannabis use.
Cannabis withdrawal induced brief psychotic disorder: a case study during the national lockdown secondary to the COVID-19 pandemic
Article
Background: Cannabis Withdrawal Syndrome (CWS) is a key feature of Cannabis Use Disorder (CUD). The CWS causes significant distress and disability. While the relationship between CUD and psychosis has been extensively studied, the potential connection between CWS and psychosis has not received as much attention. Case presentation: The CARE guideline's methodology is followed in the presentation of this case report. During the national lockdown decreed by the Spanish government for the containment of the CoronaVirus Disease 19 (COVID-19) pandemic, a 29-year-old man suffers a CWS and a subsequent psychotic episode. He is admitted to a psychiatric unit, obtaining a rapid and complete response to treatment. Discussion: Clinical and pathophysiological data that support the hypothesis of CWS-induced psychosis are discussed. Due to the increasing use of cannabis worldwide, we believe that more research is needed on the mental disturbances associated with CUD, including CWS and psychosis. On the other hand, the confinement and social distancing measures adopted in the face of the current COVID-19 pandemic could have restricted the availability and consumption of certain drugs, precipitating the emergence of withdrawal syndromes such as CWS.
Cannabinoid hyperemesis syndrome: Definition, pathophysiology, clinical spectrum, insights into acute and long-Term management
Article
  • Dec 2020
Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles ‘classic’ cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50–200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6–12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.
Vaping Cannabis Oil: A Case of Catatonia Associated With Use of High-Potency Cannabis
Article
Several troubling trends in cannabis use have converged in recent years. The average concentration of psychoactive tetrahydrocannabinol in cannabis has steadily increased while the concentration of psychoprotective cannabidiol has fallen.¹ This trend coincides with a wave of legalization as well as novel methods for consuming marijuana, quite often in the form of “vaping” concentrated oils with concentrations of THC up to 80%.⁶ Recent literature also reveals significant psychiatric morbidity with the vaping of high potency cannabis products, similar to those seen with the use of synthetic cannabinoids.²⁶,20, 21, 22, 23,¹⁸ We present a case of catatonia associated with vaping cannabis oil. A 20-year-old man presented after vaping cannabis oil daily for 2 weeks and was diagnosed with catatonia with a Bush-Francis catatonia rating score of 19 and refusal to eat or drink. He responded favorably to a lorazepam challenge and was titrated to a daily dose of 5mg which was then tapered off slowly as an outpatient with no further episodes of catatonia, mania, or psychosis after cessation of cannabis use. This case adds to a limited but growing body of literature associating high potency cannabis use with severe psychiatric symptoms such as psychosis and catatonia. Caution regarding the proliferation of laws legalizing marijuana is encouraged until these dangers can be better understood. Additionally it is important, especially for adolescents and young adults, to receive more education regarding the psychiatric risks of cannabis use especially given the recent development and increased availability of high potency products.
Can Memantine Improve Catatonia and Co-Occurring Cognitive Dysfunction? A Case Report and Brief Literature Review
Article
Full-text available
Background In addition to the motor and behavioral symptoms of catatonia, an emerging literature describes co-occurring cognitive dysfunction with catatonia. Memantine is an NMDA receptor antagonist used for some neurocognitive disorders and off-label for catatonia. Objective The objective of this case report is to demonstrate improvement of catatonic symptoms and co-occurring cognitive dysfunction, measured with serial MOCA testing after the administration of memantine. A literature review was also completed examining the effects of memantine on catatonia and co-occurring cognitive dysfunction. Methods We describe the case of a 66 year old female with catatonia who was prescribed memantine. Her cognition was assessed serially utilizing the Montreal Cognitive Assessment. Ten case reports and 3 case series were reviewed examining the treatment effects of memantine on catatonia and co-occurring cognitive dysfunction. Conclusion This case report suggests improvement of both catatonic symptoms and co-occurring cognitive dysfunction with memantine.
Cingulate-basal ganglia-thalamo-cortical aspects of catatonia and implications for treatment
Chapter
  • Jan 2019
The catatonic syndrome is an example of a multifactorial neurobehavioral disorder that causes much morbidity and mortality but also has the potential to unlock the mystery of how motivation and movement interact to produce behavior. In this chapter, an attempt is made to understand better the catatonic syndrome through the lens of neurobiology and neuropathophysiology updated by recent studies in molecular biology, genomics, inflammasomics, neuroimaging, neural network theory, and neuropsychopathology. This will result in a neurostructural model for the catatonic syndrome that centers on paralimbic regions including the anterior and midcingulate cortices, as they interface with striatal and thalamic nodes in the salience decision-making network. Examination of neurologic disorders like the abulic syndrome, which includes in its extreme catatonic form, akinetic mutism, will identify the cingulate cortex and paralimbic neighbors as regions of interest. This exploration has the potential to unlock mysteries of the brain cascade from motivation to movement and to clarify catatonia therapeutics. Such a synthesis may also help us discern meaning inherent in this complex neurobehavioral syndrome.
Baclofen in the management of cannabis dependence syndrome
Article
Full-text available
  • Feb 2014
Cannabis is the most commonly used illicit drug in the world. However, only few studies have shown the efficacy of pharmacologic agents in targeting cannabis withdrawal symptoms or reducing the reinforcing effects of cannabis. Baclofen has been shown to reduce cannabis withdrawal symptoms and the subjective effects of cannabis. We think that the clinical utility of baclofen for cannabis dependence is a reasonable approach. A case report using baclofen is presented and provides preliminary support for the use of baclofen in the management of cannabis dependence.
Time-course of the DSM-5 cannabis withdrawal symptoms in poly-substance abusers
Article
Full-text available
Evidence is accumulating that a cannabis withdrawal syndrome is common, of clinical significance, and has a clear time course. Up till now, very limited data exist on the cannabis withdrawal symptoms in patients with co-morbid substance use disorders, other than cannabis use and tobacco use. Symptoms of withdrawal were assessed through patient self-reports during detoxification in Danish residential rehabilitation centers. Patients (n = 90) completed booklets three times during their first month at the treatment centre. Self-reported withdrawal symptoms was rated using the DSM-5 Withdrawal Symptom Check List with withdrawal symptoms from all classes of substances, with no indication that the described symptoms should be attributed to withdrawal. Self-reported time since last use of cannabis was used as a predictor of cannabis withdrawal severity. With the exception of loss of appetite, time since last use of cannabis was associated with all types of withdrawal symptoms listed in the DSM-5. Only four of 19 symptoms intended to measure withdrawal from other substances were related to time since last use of cannabis, including vivid, unpleasant dreams. The findings yield strong support to the notion of a cannabis withdrawal syndrome, and gives further evidence for the inclusion of the criterion of vivid, unpleasant dreams. Further, the findings speak against the significance of demand characteristics in determining the course of the symptoms of cannabis withdrawal.
Catatonia and Alcohol Withdrawal: A Complex and Underestimated Syndrome
Article
Full-text available
Catatonia is a neuropsychiatric syndrome characterized by alterations in motor behavior, vigilance, thought and mood. Catatonia syndrome occurs in many neuropsychiatric and medical conditions, but it is very rarely mentioned as occurring during alcohol withdrawal. We think that this co-occurrence could be underestimated in clinics because alcohol withdrawal symptoms may distract from its identification. We report the case of a patient presenting with catatonia during the benzodiazepine reduction period of alcohol detoxification. A 65-year-old woman presented with a 15-year history of alcohol dependence and developed catatonic episodes several times during alcohol withdrawal treatment. Misdiagnosis delayed specific treatment. Symptoms of episodes dramatically improved 48 h after treatment with diazepam and revealed an anxiety disorder. This report confirms that catatonia is a non-specific response to psychological, physical and psychosocial stress factors. Recent alcohol withdrawal may sensitize the patient to benzodiazepine withdrawal catatonia, and this phenomenon is probably underestimated. Catatonia Rating Scales can be useful when diagnosis is complicated as in alcohol and benzodiazepine withdrawal. In that situation, misdiagnosis is common and may delay specific treatment.
Budney AJ, Hughes JR, Moore BA, Vandrey RG. A review of the validity and significance of the cannabis withdrawal syndrome. Am J Psychiatr 161: 1967-1977
Article
Full-text available
  • Nov 2004
The authors review the literature examining the validity and significance of cannabis withdrawal syndrome. Findings from animal laboratory research are briefly reviewed, and human laboratory and clinical studies are surveyed in more detail. Converging evidence from basic laboratory and clinical studies indicates that a withdrawal syndrome reliably follows discontinuation of chronic heavy use of cannabis or tetrahydrocannabinol. Common symptoms are primarily emotional and behavioral, although appetite change, weight loss, and physical discomfort are also frequently reported. The onset and time course of these symptoms appear similar to those of other substance withdrawal syndromes. The magnitude and severity of these symptoms appear substantial, and these findings suggest that the syndrome has clinical importance. Diagnostic criteria for cannabis withdrawal syndrome are proposed.
A Clinical Review of the Treatment of Catatonia
Article
  • Dec 2014
Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome, apart from thorough and repeated observation, a clinical examination is needed. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination. Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines, such as lorazepam, and electroconvulsive therapy.
A clinical review of the treatment of catatonia
Article
  • Jan 2014
Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome , apart from thorough and repeated observation, a clinical examination is needed. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination. Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines, such as lorazepam, and electroconvulsive therapy.
Diagnostic and Statistical Manual of Mental Disorders: DSM-V
Book
  • Jan 1994
Neurochemical basis of cannabis addiction
Article
  • Feb 2011
Cannabis derivatives have become the most widely used illicit substances in developed countries, and constitute a major health concern. The psychoactive compounds contained in cannabis induce their pharmacological effects by the activation of at least two different receptors, CB1 and CB2 cannabinoid receptors. Multiple studies have demonstrated the specific involvement of CB1 cannabinoid receptors in the addictive properties of cannabinoids. Several neurotransmitter systems involved in the addictive effects of other prototypical drugs of abuse, such as the dopaminergic and the opioid system are also involved in cannabis addiction. The participation of other neurochemical systems in behavioural responses of cannabinoids related to their addictive effects has also been reported. This review describes the experimental methods now available to study the pharmacological responses of cannabinoids related to their addictive effects and how these methods have contributed to advance the knowledge of the specific contribution of different neurochemical systems in cannabis addiction.
Catatonia. I. Rating scale and standardized examination
Article
  • Mar 1996
To facilitate the systematic description of catatonic signs, we developed a catatonia rating examination, rating scale and screening instrument. We constructed a 23-item rating scale and a truncated 14-item screening instrument using operationalized definitions of signs ascribed to catatonia in published sources. Inter-rater reliability was tested in 44 simultaneous ratings of 28 cases defined by the presence of > or = 2 signs on the 14-item screen. Inter-rater reliability for total score on the rating scale was 0.93, and mean agreement of items was 88.2% (SD 9.9). Inter-rater reliability for total score on the screening instrument was 0.95, and mean agreement of items was 92.7% (SD 4.9). Diagnostic agreement was high based on criteria for catatonia put forth by other authors. Seven per cent (15/215) of consecutively admitted patients to an academic psychiatric in-patient facility met criteria for catatonia. It is concluded that catatonia is a distinct, moderately prevalent neuropsychiatric syndrome. The rating scale and screening instrument are reliable and valid. Their use facilitates diagnosis, treatment protocols, and cross-study comparisons.
Test for Catatonia with zolpidem
Article
  • Apr 1997