Article

Catatonia and consultation-liaison psychiatry study of 12 cases

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  • Centre Hospitalier Universitaire de Lille
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Abstract

Nowadays, catatonia is no more considered as a subtype of schizophrenia. Catatonia seems more frequently associated to mood disorders as well as general medical conditions. It is sometimes difficult to associate formally a medical etiology to this syndrome. But we found, in the literature, three groups of associated general medical conditions: neurological disorders, drug induced and toxic induced conditions, metabolic conditions. We present a prospective study of 12 clinical cases of catatonia due to general medical conditions we realized in the Consultation-Liaison Psychiatry Department of the University Hospital of LILLE (France) during a period of 5 months. We find coherent data with the literature. However, our results suggest that if medical conditions precipitate the catatonia syndrome, they are rarely its only etiology. We think that if somatic factors are co-morbid with psychiatric conditions they do not necessarily predominate as the target of treatment. The treatment of the catatonia must be a priority and remain symptomatic, to allow in parallel the specific treatment for the somatic disorder or the psychiatric disorder.

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... Although catatonia is identified as a type of schizophrenia in the psychiatric classification, it is more often found in patients with mood disorders, systemic medical illnesses and neurotoxicity [2]. The association of the catatonic syndrome with several neurologic and general medical conditions is well documented with a reported frequency of 1.8% in the general hospital setting for patients examined by consultation-liaison psychiatric services [3]. Here we report seven intensive care unit (ICU) cases of catatonia. ...
... In our sample, catatonia was not associated with psychotic disorders. This finding is different from the report by Cottencin et al. [3] in which nine of 12 patients had a current or previous psychiatric disorder. It has been suggested that the majority of patients with catatonia due to general medical condition have in fact multifactorial etiologies that are concurrent medical and psychiatric disorders [9]. ...
... Catatonia has been recognized among general medical patients who receive psychiatric consultations. Three studies attempted to provide estimates of prevalence and were in agreement that 2% to 3% of consultations showed catatonia [25][26][27]. The rates of catatonia may be higher than these estimates in the hospitalized medical patients because withdrawn patients may not be recognized as catatonic, and some hypokinetic delirious patients may be catatonic [28]. ...
... It is becoming increasingly recognized as another pharmacologic treatment option for catatonia. Zolpidem was found to be effective in a series of medical patients [27] and in an open trial with 20 psychiatric patients in which BFCRS scores declined by more than 50% within 30 min of a single oral dose of 10 mg [38••]. ...
Article
Catatonia is a distinct neuropsychiatric syndrome that is becoming more recognized clinically and in ongoing research. It occurs with psychiatric, metabolic, or neurologic conditions. It may occur in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy leads to a dramatic and rapid response, although systematic, randomized trials are lacking. An important unresolved question is the role of antipsychotic agents in treatment and their potential adverse effects.
... Catatonia may be identified in one out of seven patients with psychosis and one out of five patients with a major mood episode [1]. In acute medical settings, catatonia prevalence ranges from 1.6% [2,3] to 6.3% [4,5]. In fact, a recent study of sequential patients with delirium evaluated by a consult psychiatry service found a 12%-37% incidence of catatonia depending on the symptom cutoff [6]. ...
... Whether psychiatric illness associated with catatonia may contribute to a catatonic diathesis remains unexplored. Case series have found that psychiatric illness is common even in presumed medical catatonia [3,11,12], but conflicting reports exist [5,49]. In the retrospective Mayo Clinic review [41] Phencyclidine and ketamine [51] Neuroleptics (particularly as NMS) Serotonergic agents (as SS) Withdrawal from sedative-hypnotics and dopamine agonists (see "Withdrawal" above) Hypertensive encephalopathy ...
Article
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Catatonia is seldom considered in evaluation of altered mental status (AMS) in medical settings. Furthermore, catatonia often meets delirium criteria due to incoherence, altered awareness and behavioral change. Catatonia may co-occur with or be preferentially diagnosed as delirium. We conducted a systematic literature review of MEDLINE, EMBASE and PsycINFO on the relationship between catatonia and delirium. We also juxtapose clinical features of these syndromes and outline a structured approach to catatonia evaluation and management in acute medical settings. These syndromes share tremendous overlap: the historical catatonia-related terms "delirious mania" and "delirious depression" bespeak of literal confusion differentiating them. Only recently has evidence on their relationship progressed beyond case series and reports. Neurological conditions account for the majority of medical catatonia cases. New-onset catatonia warrants a medical workup, and catatonic features in AMS may guide clinicians to a neurological condition (e.g., encephalitis, seizures or structural central nervous system disease). Lorazepam or electroconvulsive therapy (ECT) should be considered even in medical catatonia, and neuroleptics should be used with caution. Moreover, ECT may prove lifesaving in malignant catatonia. Further studies on the relationship between delirium and catatonia are warranted. Copyright © 2015. Published by Elsevier Inc.
... Antipsychotics: Many cases of catatonia related to antipsychotic use in older patients have been published. Of these, there were patients that developed NMS associated with aripiprazole [107] haloperidol [108][109][110][111][112][113] and loxapine [114]. In addition, there are reports of catatonia induced by pipothiazine [115], quetiapine [11,116], and droperidol [117] and cases secondary to exposure to more than one antipsychotic: Haloperidol and trifluperazine [109], risperidone and quetiapine[11], aripiprazole and olanzapine [11], and risperidone, haloperidol and tiapride [8]. ...
... A family history should be taken into account in all cases of rare autosomal-dominant catatonia [11]. Most studies revealed a heavy medical and surgical history including cases such as endocarditis, tuberculosis, cerebral tumor and polytraumatisms [3,12]. ...
... Consequently, the Fink and Taylor criteria (and the earlier version) have been used in screening for catatonia in at least two case series studies. 25,26 ...
Article
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MODERN PSYCHIATRIC NOSOLOGIES SEPARATE CATATONIA ALONG THE LINES OF PRESUMED ETIOLOGY: bipolar, major depression, schizophrenia, and/or due to a general medical condition. Catatonic signs have always possessed significant diagnostic, therapeutic, and prognostic value. Kahlbaum's description of this syndrome in his monograph "Katatonia" included careful documentation of phenomenology. Kahlbaum selected the term katatonia to describe "tension insanity." He felt that the neuromotor signs were more important than the content of delusions (e.g. megalomania). While he felt that he was describing a unitary illness, he did identify mood disturbance, psychosis, and medical factors in this new illness.(1) In modern times, the term catatonia has become limited to describe a specifier of neuropsychiatric illnesses.The authors of this article feel that the term katatonia should be used to describe a group of neuropsychiatric illnesses presenting with catatonic signs. This may prevent the misconception that "catatonia is schizophrenia" and improve the detection of katatonia in patients. Specifically, katatonia is also observed in mood disorders, general medical conditions, and pervasive developmental disorders. The literature also supports the view of Dr. Leo Kanner and his description for neuromotor and neuropsychiatric signs in autistic disorder. This scale is named in honor of Dr. Kanner. It was developed by the authors and includes some of Dr. Kanner's core concepts. This paper will identify the clinical features of katatonia and introduce the KANNER scale (see Appendix 1) to improve conceptualization, detection, and measurement of this important clinical syndrome.
... (2) Recently, Cottencin et al suggest that the treatment of catatonia must hold priority over the treatment of a somatic disorder or other psychiatric disorders. (17) Although a detailed understanding of the mechanism associated with benzodiazepines in catatonia associated with renal failure remains to be explored, this report demonstrates that intramuscular lorazepam is a safe, effective and rapid relief to catatonia associated with renal function impairment in order to avoid the possible complications of catatonia including aspiration pneumonia and ventricular arrhythmia. In conclusion it should noted that patients receiving a continuous infusion of high dose lorazepam (10 mg/h) should be monitored for propylene glycol toxicity. ...
Article
Cases of catatonia in patients with renal failure have been rarely reported. In this report, we describe two renal-insufficient patients with catatonia who had a good response to intramuscular lorazepam whereby the catatonic symptoms were relieved. Case 1 involved a patient with end-stage renal disease and severe pneumonia related respiratory failure. He responded well to intramuscular lorazepam (total dose, 4 mg) whereby the catatonia was elieved. Case 2 involved a patient with alcoholic liver cirrhosis and rhabdomyolysis-related acute renal failure. He showed great improvement with intramuscular lorazepam (2 mg) whereby the catatonia was subsequently relieved. This report demonstrates that intramuscular lorazepam is safe, effective and rapid in relieving catatonia associated with renal function impairment. Neither of the patients had a recurrence of catatonia during a period of 6- months follow-up. In conclusion, intramuscular lorazepam may play an important role in the treatment of catatonia associated with renal insufficiency.
... Seçici GABA agonisti olan zolpidem katatoni semptomlarında en az %50 azalma sağlamıştır. [64] Çalışmalar transkranial manyetik stimulasyonun (TMS) da tedavide bir seçenek olabileceğini göstermiştir. [65,66] Günümüzde malign katatonide özellikle benzodiazepinlerin yararı gösterilmiştir. ...
Article
Full-text available
Catatonia is a syndrome characterized by mutism, immobility, negativism, stereotypy, mannerisms, echophenomena, perseveration and passive obedience. The underlying causes can be psychiatric or may be associated with general medical status or neurological diseases. Additionally catatonia has two subtypes as malignant and nonmalignant catatonia. Main symptoms of malignant catatonia are hyperthermia and autonomic symptoms such as tachycardia, tachypnea and hyperhidrosis. It is important to make the diagnosis as early as possible for an appropriate medical treatment. Clinicians should be aware of the fatal outcome of the disease.
... In addition, clinical practice depends on the possibility of curing the underlying condition. Indeed, catatonia may occur in patients with various psychiatric disorders (usually schizophrenia and severe mood disorders) and medical conditions (e.g., neurological conditions, intoxication, auto-immune diseases, and metabolic conditions) (Cottencin et al., 2007;Lahutte et al., 2008). Some of these conditions have poor prognoses and may result in death (Dimitri et al., 2006). ...
Article
Rare diseases have been associated with more and more genetic and non genetic causes and risk factors. But this has not been systematically assessed in catatonia, one of the psychiatric syndromes, that is most frequently associated with medical condition. We sought to assess the medical and developmental risk factors of catatonia in children and adolescents. From 1993 to 2009, 58 youths aged 10 to 18 years were prospectively admitted for catatonia and were followed up after discharge. A multidisciplinary approach assessed patients' medical condition and developmental history. A causality assessment scored medical risk (maximum score=10; κ=0.91). We compared the prevalence of catatonia in these patients to that of 80 inpatients with bipolar I disorder admitted from 1993 to 2003 who were also followed up. We found that 13 (22.4%) patients had medical conditions and 18 (31%) had a history of developmental disorder in the catatonia group, whereas 1 (1.3%) and 17 (22.6%) patients had the same conditions in the bipolar group (p<0.001; p=0.17, respectively). Medical conditions associated with catatonia included auto-immune encephalitis (systemic lupus erythematosus [N=3] and anti-NMDA-receptor encephalitis [N=1]), seizures (N=1), ciclosporin encephalitis (N=1), post hypoglycaemic coma encephalitis (N=1), and genetic or metabolic conditions (chorea [N=2], 5HT cerebrospinal fluid deficit [N=1], storage disease [N=1], fatal familial insomnia [FFI; N=1], and PRODH mutations [N=1]). Six patients responded to a specific treatment approach related to their medical condition (e.g., plasma exchange in the case of auto-immune encephalitis). Catatonia in children and adolescents is associated with a high prevalence of medical conditions. This needs to be acknowledged as it may greatly delay the treatment of catatonia and the diagnosis of medically related catatonia. Tragically, this may deny patients treatment opportunities.
... Catatonic symptoms in elderly patients can be masked by concurrent medical and neurological conditions [113,114,133,134], such as infectious disease (e.g., pneumonia and advanced syphilis), cardiovascular disease, cerebrovascular disease, renal failure, dementia with Lewy bodies or advanced Parkinson's disease, and dementia. Benzodiazepines are used as first-line treatment for mild-to-moderate catatonia [135]. ...
Article
Full-text available
Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.
... The prevalence is estimated to range 0.6-17.7 % among young inpatients [1,2]. In adults, catatonia is associated with psychiatric disorders (such as affective disorder and schizophrenia) and also medical conditions [3][4][5][6][7]. The clinical presentation of catatonia in children and adolescents is similar to that in adults, but three major differences should be noted. ...
Article
We aimed to (1) describe the treatment used in a large sample of young inpatients with catatonia, (2) determine which factors were associated with improvement and (3) benzodiazepine (BZD) efficacy. From 1993 to 2011, 66 patients between the ages of 9 and 19 years were consecutively hospitalized for a catatonic syndrome. We prospectively collected sociodemographic, clinical and treatment data. In total, 51 (77 %) patients underwent a BZD trial. BZDs were effective in 33 (65 %) patients, who were associated with significantly fewer severe adverse events (p = 0.013) and resulted in fewer referrals for electroconvulsive therapy (ECT) (p = 0.037). Other treatments included ECT (N = 12, 18 %); antipsychotic medications, mostly in combination; and treatment of an underlying medical condition, when possible. For 10 patients, four different trials were needed to achieve clinical improvement. When all treatments were combined, there was a better clinical response in acute-onset catatonia (p = 0.032). In contrast, the response was lower in boys (p = 0.044) and when posturing (p = 0.04) and mannerisms (p = 0.008) were present as catatonic symptoms. The treatment response was independent of the underlying psychiatric or systemic medical condition. As in adults, BZDs should be the first-line symptomatic treatment for catatonia in young patients, and ECT should be a second option. Additionally, the absence of an association between the response to treatment and the underlying psychiatric condition suggests that catatonia should be considered as a syndrome.
... Many clinicians will share the experience that a 'lorazepam test' not only confirms the diagnosis of catatonia, but that it also makes the underlying psychopathology apparent 'by permitting mute patients to speak' (79). Analogous to the lorazepam test, a Zolpidem Challenge Test was proposed (80,81). In this test 10 mg of zolpidem is administered per os and after 30 minutes the patient is examined. ...
Article
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.
... Antipsychotics: Many cases of catatonia related to antipsychotic use in older patients have been published. Of these, there were patients that developed NMS associated with aripiprazole [107] haloperidol [108][109][110][111][112][113] and loxapine [114]. In addition, there are reports of catatonia induced by pipothiazine [115], quetiapine [11,116], and droperidol [117] and cases secondary to exposure to more than one antipsychotic: Haloperidol and trifluperazine [109], risperidone and quetiapine[11], aripiprazole and olanzapine [11], and risperidone, haloperidol and tiapride [8]. ...
Article
Full-text available
BACKGROUND Catatonia is a complex psychomotor syndrome that often goes unrecognized and untreated, even though its classification has evolved in recent years. Prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications. The underrecognition of catatonia in older patients is also frequent, and research in this population is scarce. AIM To conduct a systematic review of the literature on catatonia in older people to ascertain its clinical characteristics across settings. METHODS Following the PRISMA guidelines, MEDLINE, EMBASE, and PsycINFO databases were searched from inception to December 2021, with a strategy aimed at identifying all articles published on catatonia in older adults. Titles and abstracts were scanned and selected independently by two authors. Papers investigating issues related to catatonia and/or catatonic symptoms in older people, with English abstracts available, were included. References of selected articles were revised to identify other relevant studies. RESULTS In total, 1355 articles were retrieved. After removing duplicates, 879 remained. Of the 879 identified abstracts, 669 were excluded because they did not meet the inclusion criteria. A total of 210 articles underwent full text review, and 51 were eliminated for various reasons. Fourteen more articles were selected from the references. Overall, 173 articles were reviewed: 108 case reports, 35 case series, 11 prospective cohort studies, 6 case-control studies, 3 retrospective cohort studies and 10 reviews. We found several particular aspects of catatonia in this population. Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. Older patients, compared to younger patients, have a higher risk of developing catatonia with benzodiazepine (BZD) withdrawal, in bipolar disorder, and in the general hospital. Age, together with other risk factors, was significantly associated with the incidence of deep venous thrombosis, neuroleptic malignant syndrome poor outcome, other complications and mortality. Treatment with BZDs and electrocon- vulsive therapy is safe and effective. Prompt treatment of its cause is essential to ensure a good prognosis. CONCLUSION Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. The risk of developing catatonia in some settings and conditions, as well as of developing complications, is high in this population. Symptomatic treatment is safe and effective, and timely etiologic treatment is fundamental. Key Words: Catatonia; Older adults; Etiology; Phenomenology; Prevalence; Treatment
... Lorsque le lorazépam est administré par voie intramusculaire ou orale, l'intervalle entre les deux doses doit être plus long, soit respectivement de 15 et 30 minutes. Le zolpidem peut également être utilisé comme alternative (40,41). Dans ce cas, on administre 10mg de zolpidem par voie orale et l'on évalue le patient 30 minutes plus tard. ...
... Catatonia also occurs in medical patients with drug-related conditions or seizures. 9 Although there are no controlled treatment studies in catatonia satisfying current standards for evaluating therapies, the literature consistently shows positive effects of anticonvulsant drugs, particularly benzodiazepines, and barbiturates and of ECT, regardless of the severity or etiology of catatonia 10Y12 or age of the patient. 13Y19 ...
Article
Full-text available
Current autism research is historically separated from catatonia and other childhood psychotic disorders, although catatonia and autism share several common symptoms (mutism, echolalia, stereotypic speech and repetitive behaviors, posturing, grimacing, rigidity, mannerisms, and purposeless agitation). Electroconvulsive therapy (ECT) effectively treats catatonia and catatonia-related conditions of intractable compulsions, ties, and self-injury in people with autism. We assess the incidence of catatonic symptoms in autism, examine emerging ECT indications in people with autism and related developmental disorders, and encourage ethical debate and legal-administrative action to,assure equal access to ECT for people with autism.
... Wanneer lorazepam intramusculair of per os wordt toegediend, dient het interval voor de tweede dosis langer te zijn, respectievelijk 15 en 30 minuten. Als alternatief kan ook zolpidem worden gebruikt (40,41). In dat geval wordt 10mg zolpidem per os toegediend en na 30 minuten wordt de patiënt geëvalueerd. ...
... Catatonia, a psychiatric condition, also has several organic etiologies such as infectious diseases, neurological conditions, toxicinduced states, genetic conditions (Cottencin et al., 2007;Lahutte et al., 2008). Organic catatonia may lead to death and should be differentiated first. ...
... Catatonia is a neuropsychiatric syndrome characterized by particular motor and behavioral signs and symptoms 1 that can manifest as a consequence of many neurologic, psychiatric, and/ or general medical conditions. [2][3][4] Research studies have found the prevalence of catatonia to be 5%218% on inpatient psychiatric units, [5][6][7][8] 12% in drug-naïve patients with first episode psychosis, 9 3.3% on a neurology/neuropsychiatric tertiary care inpatient unit, 10 3.8% on the intensive care unit, 11 1.6% to 1.8% on psychiatry consultation-liaison services, 12,13 and 8.9% in elderly patients referred for psychiatric consultation. 14 Depending on which catatonic signs are more prominent on exam, catatonia can be classified into retarded, excited, or mixed type. ...
Article
Catatonia is under-diagnosed in psychiatric settings. No studies have explored the under-diagnosis of catatonia in general hospitals. The authors conducted a retrospective chart review using DSM-5 criteria to diagnose catatonia in medical inpatients between 2011 and 2013. Of 133 case subjects meeting DSM-5 criteria for catatonia retrospectively, 79 had never been diagnosed and 54 had a documented diagnosis. Multiple logistic regression revealed that psychiatry consultation significantly decreased the odds of under-diagnosis of catatonia, whereas presence of agitation, grimacing, or echolalia increased the likelihood of under-diagnosis. Under-diagnosed case subjects received significantly lower doses of lorazepam, and increased mortality during admission and increased length of hospital stay both fell short of statistical significance in this group. Catatonia appears to be frequently under-diagnosed in the general hospital, and psychiatry consultation services play a crucial role in its detection and treatment. Strategies to improve recognition and treatment of catatonia should be implemented.
... Catatonia may accompany several general medical and neurologic disorders, and it is more frequently associated with mood disorders and neurotoxic syndromes than with schizophrenia [2]. Conceivably, catatonic syndrome is encountered in various clinical settings, besides psychiatric wards, such as the consultation-liaison psychiatry [3], the emergency department [4], and the intensive care unit [5,6]. ...
Article
Full-text available
Background Catatonia is a syndrome of altered motor behavior that is mostly associated with general medical, neurologic, mood and schizophrenia-spectrum disorders. The association of newly onset catatonic symptoms with hyponatremia has been rarely reported in the literature. Case Presentation We present a rare case of a young female patient with schizophrenia, who presented with catatonic symptoms in the context of hyponatremia due to water intoxication. The symptoms were eliminated with the correction of hyponatremia. There are only a few reports of hyponatremia-associated catatonia in psychiatric and non-psychiatric patients. Sometimes, catatonic symptoms may co-occur with newly onset psychotic symptoms and confusion, suggesting delirium. In several cases, the catatonic symptoms responded to specific treatment with benzodiazepines or electroconvulsive therapy. Conclusion Hyponatremia may induce catatonic symptoms in patients, regardless of underlying mental illness, but this phenomenon is even more relevant in patients with a psychotic or mood disorder, which may itself cause catatonic symptoms. It is important for clinicians not to attribute newly-onset catatonic symptoms to the underlying psychotic or mood disorder without measuring sodium serum levels. The measurement of sodium serum levels may guide treating psychiatrists to refer the patient for further investigation and appropriate treatment.
... Prevalence has been described around 5% to 18% among patients admitted to mental health wards [5]. Catatonia is commonly underdiagnosed in general hospitals, with estimated prevalences of 1.6% to 1.8% [6][7][8], being usually mistaken with delirium [9][10][11]. ...
... Studies with medical/Neurological patients Psychiatric patients with medical comorbidity Granata et al. [11] Kakooza et al. [12] Jaimes Albornoz [13] Smith et al. [14] Cavanna et al. [15] Carroll et al. [16] Barnes et al. [17] No. of studies=15 [18,19,20,21,22,23,24,25,26,27,28,29,30 associated with catatonia can be hypokinetic or hyperkinetic type [34]. The hypokinetic type movements are mutism, rigidity, waxyflexibility and cataplexy. ...
Article
Catatonia is a well-described clinical syndrome characterized by features that range from mutism, negativism and stupor to agitation, mannerisms and stereotype. Causes of catatonia may range from organic brain disorders to psychiatric conditions. Despite a characteristic syndrome, catatonia is grossly under diagnosed. The reason for missed diagnosis of catatonia in neurology setting is not clear. Poor awareness is an unlikely cause because catatonia is taught among conditions with deregulated consciousness like vegetative state, locked-in state and akinetic mutism. We determined the proportion of catatonia patients correctly identified by neurology residents in neurology emergency. We also looked at the alternate diagnosis they received to identify catatonia mimics. Twelve patients (age 22-55 years, 7 females) of catatonia were discharged from a single unit of neurology department from 2007 to 2017. In the emergency department, neurology residents diagnosed none of the patients as catatonia. They offered diagnosis of extrapyramidal syndrome in 7, meningitis in 2, and conversion reaction, acute psychosis/encephalopathy and non-convulsive status epilepticus in one each. Their final diagnosis at discharge was catatonia due to general medical condition in 6 (progressive supranuclear palsy in 2, post-status epilepticus, uremic encephalopathy, glioblastoma multiforme and tuberculous meningitis in one each), catatonia due to major depression in 4, schizophrenia and idiopathic catatonia in one each. Extrapyramidal syndrome appeared as common mimic of catatonia. The literature reviewed also revealed the majority of organic catatonia secondary to causes that are usually associated with extrapyramidal features. Therefore, we suggest that neurologists should consider catatonia in patients presenting with extrapyramidal syndromes.
... Dans la droite ligne du « test à l'amobarbital » et du « test au lorazepam », l'équipe du Professeur Thomas à Lille a proposé à la fin des années 1990 l'utilisation du zolpidem, permettant souvent une amélioration rapide et spectaculaire du syndrome catatonique. Plus facile d'accès que le lorazepam intraveineux, le « test au zolpidem » est particulièrement utilisé en France, notamment dans les services d'urgence 106,107 . Moins maniable de par sa faible demie-vie, il peut cependant être utilisé comme traitement dans certains cas 108,109 . ...
Thesis
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Brain imaging in catatonia
... Although evidence on zolpidem appears to lack well design, controlled studies with numerous patients, the diagnostic and therapeutic test with zolpidem seems to be a credible alternative to increasing lorazepam doses (Cottencin et al., 2007;Thomas et al., 1997). 10 mg of zolpidem is first administered per os and after 30 min the patient is re-examined. ...
Article
Catatonia is a cluster of motor features that appears in many recognized psychiatric illnesses, that according to the DSM-5 it is not linked as a subtype to schizophrenia anymore. The classic signs are mutism, a rigid posture, fixed staring, stereotypic movements, and stupor, which are all part of a broad psychopathology that may be found in affective, thought, neurological, toxic, metabolic and immunological disorders. Despite the many etiologies, catatonia may be a life-threatening condition with a specific treatment. Benzodiazepines are the first line therapeutic option for catatonia, being lorazepam the first-choice drug. Eighty percent of the patients are relieved by the use of barbiturates or benzodiazepines, while in those who fail, an improvement is achieved by electroconvulsive therapy (ECT). With more than 60 years of use in catatonic patients, ECT has proven to be an effective and safe tool for the treatment of this frequent and sometimes forgotten syndrome.
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Depression is a frequent comorbid condition in Alzheimer’s disease (AD) and is associated with the presence of parkinsonism. Apathy in AD was reported to predict more severe parkinsonism, suggesting that apathy may be an early manifestation of a more aggressive AD phenotype characterized by loss of motivation, increasing parkinsonism, a faster cognitive and functional decline, and more severe depression. Catatonia may be found in a small proportion of patients with AD, but rates are higher in hospitalized patients. Catatonia is significantly associated with more severe parkinsonism and depression and older age. Psychotic symptoms are relatively frequent in the late stages of AD. Current treatment with atypical antipsychotics has a concomitant risk of increased parkinsonism.
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Acute presentation of new movement disorders and acute decompensation of chronic movement disorders are uncommon but potentially life-threatening. Inadvertent or purposeful overdose of many psychiatric medications can result in acute life-threatening movement disorders including serotonin syndrome, neuroleptic malignant syndrome, and malignant catatonia. Early withdrawal of potentiating medications, treatment with benzodiazepines and other diagnosis-specific drugs, and providing appropriate supportive care including airway and breathing management, hemodynamic stabilization, fluid resuscitation, and renal support including possible hemodialysis are the mainstays of acute management. Many of these conditions require admission to the neurologic intensive care unit.
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Riassunto L’agitazione è uno degli stati patologici che più perturbano l’atto medico. La ricerca dell’eziologia è essenziale di fronte a un’agitazione, perché potrebbe essere in gioco la prognosi vitale. La gestione deve, quindi, essere immediata, per evitare violenza e aggressività, che possono mettere in pericolo il paziente e il personale. Le eziologie sono varie e possono essere organiche, tossiche, psichiatriche e, talvolta, intrecciate. La gestione dell’agitazione deve privilegiare gli approcci non farmacologici, come la de-escalation verbale. La contenzione fisica deve essere usata solo se gli altri mezzi di controllo sono inefficaci o inappropriati. Si tratta di una decisione medica di ultima istanza, inquadrata da rigide regole di monitoraggio. Deve esservi associata una gestione farmacologica. I trattamenti sintomatici si basano su benzodiazepine e antipsicotici e dipendono dall’eziologia. Richiedono un monitoraggio ravvicinato.
Article
Catatonia was buried within the confines of schizophrenia for over a century— deterring study, appropriate diagnosis and treatment for many years. With revised changes in the classification of this distinct neuropsychiatric syndrome, it is becoming more recognized clinically and in ongoing research. Catatonia occurs among various psychiatric, metabolic or neurologic conditions. It may present in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy usually produces dramatic and rapid response, although systematic, randomized trials are lacking. The role of antipsychotic agents in treatment is controversial as they may worsen the syndrome. An important unresolved clinical question is the diagnosis and treatment of catatonia in the setting of delirium.
Article
Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.
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A 12-year-old Indian boy presented to a psychiatric unit with catatonia. He was subsequently diagnosed to have Wilson's disease. Symptoms improved on treatment with penicillamine, zinc sulphate, and benzodiazepines.
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Agitation is one of the diagnostic features of catatonia in the DSM IV classification, but permanent forms of agitated catatonia have occasionally been described. We report the case of a 43-year-old man who had already suffered from undifferentiated schizophrenia for 7 years, and in whom we diagnosed agitated catatonia. While our patient was being treated with a neuroleptic during a second episode of paranoia, a state of agitation was observed which persisted for a further 8 months. During this period, he was treated with several different neuroleptics and benzodiazepines, either alone or in association, without any improvement. No organic cause was found. He was then transferred to our electroconvulsive therapy (ECT) unit, with a diagnosis of schizophrenic agitation resistant to drug therapy. ECT was begun, and he was only given droperidol in case of agitation and alimemazine for insomnia, neither of which had any effect. In view of his persistent agitation without any purpose, echolalia and echopraxia, stereotyped movements with mannerisms and marked mimicking and grimacing, we diagnosed him as having agitated catatonia. After the fourth session of ECT, we decided to stop all treatment and gave him lorazepam at a dose of 12.5 mg daily. Twenty-four hours later, all symptoms of agitation had disappeared. In our opinion, permanent catatonic agitation is not rare. In our case, the neuroleptic treatment maintained and may even have worsened the symptomatology. Lorazepam can be used as a therapeutic test for this type of agitation, especially if it does not respond to neuroleptics. This also allows the patient to be sedated rapidly and effectively, thus preventing him from injuring himself further.
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Inhibitory neurotransmission in the brain is largely mediated by GABA(A) receptors. Potentiation of GABA receptor activation through an allosteric benzodiazepine (BZ) site produces the sedative, anxiolytic, muscle relaxant, anticonvulsant and cognition-impairing effects of clinically used BZs such as diazepam. We created genetically modified mice (alpha1 H101R) with a diazepam-insensitive alpha1 subtype and a selective BZ site ligand, L-838,417, to explore GABA(A) receptor subtypes mediating specific physiological effects. These two complimentary approaches revealed that the alpha1 subtype mediated the sedative, but not the anxiolytic effects of benzodiazepines. This finding suggests ways to improve anxiolytics and to develop drugs for other neurological disorders based on their specificity for GABA(A) receptor subtypes in distinct neuronal circuits.
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Zolpidem is a widely used hypnotic agent acting at the GABAA receptor benzodiazepine site. On recombinant receptors, zolpidem displays a high affinity to α1-GABAA receptors, an intermediate affinity to α2- and α3-GABAA receptors and fails to bind to α5-GABAA receptors. However, it is not known which receptor subtype is essential for mediating the sedative-hypnotic action in vivo. Studying α1(H101R) mice, which possess zolpidem-insensitive α1-GABAA receptors, we show that the sedative action of zolpidem is exclusively mediated by α1-GABAA receptors. Similarly, the activity of zolpidem against pentylenetetrazole-induced tonic convulsions is also completely mediated by α1-GABAA receptors. These results establish that the sedative-hypnotic and anticonvulsant activities of zolpidem are due to its action on α1-GABAA receptors and not on α2- or α3-GABAA receptors. British Journal of Pharmacology (2000) 131, 1251–1254; doi:10.1038/sj.bjp.0703717
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All three patients to show catatonia at a teaching veterans' hospital over a 1-year period were over 60 years old. Each experienced delays of 2-5 months in identification of catatonia and adverse events attributable to the delay (e.g., pulmonary embolus, physical restraint, pneumonia, mislabeling as "advanced dementia," Do Not Resuscitate orders, and death). These outcomes suggest that geriatric patients with unrecognized catatonia are at high risk for major adverse events.
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The enhancement of GABA-mediated synaptic transmission underlies the pharmacotherapy of various neurological and psychiatric disorders. GABA(A) receptors are pluripotent drug targets that display an extraordinary structural heterogeneity: they are assembled from a repertoire of at least 18 subunits (alpha1-6, beta1-3, gamma1-3, delta, epsilon, theta, rho1-3). However, differentiating defined GABA(A) receptor subtypes on the basis of function has had to await recent progress in the genetic dissection of receptor subtypes in vivo. Evidence that the various actions of allosteric modulators of GABA(A) receptors, in particular the benzodiazepines, can be attributed to specific GABA(A) receptor subtypes will be discussed. Such discoveries could open up new avenues for drug development.
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Catatonia is a rare but severe condition in adolescents that can be associated with both psychiatric and organic causes. The present report notes that systemic lupus erythematosus should be considered among possible causes of catatonia and shows that plasma exchange could be an efficient treatment option for such neuropsychiatric manifestations of systemic lupus erythematosus, to avoid the use of electroconvulsive therapy in young patients.
Article
Differential diagnosis of motor symptoms, for example, akinesia, may be difficult in clinical neuropsychiatry. Symptoms may be either of neurologic origin, for example, Parkinson's disease, or of psychiatric origin, for example, catatonia, leading to a so-called "conflict of paradigms." Despite their different origins, symptoms may appear more or less clinically similar. Possibility of dissociation between origin and clinical appearance may reflect functional brain organisation in general, and cortical-cortical/subcortical relations in particular. It is therefore hypothesized that similarities and differences between Parkinson's disease and catatonia may be accounted for by distinct kinds of modulation between cortico-cortical and cortico-subcortical relations. Catatonia can be characterized by concurrent motor, emotional, and behavioural symptoms. The different symptoms may be accounted for by dysfunction in orbitofrontal-prefrontal/parietal cortical connectivity reflecting "horizontal modulation" of cortico-cortical relation. Furthermore, alteration in "top-down modulation" reflecting "vertical modulation" of caudate and other basal ganglia by GABA-ergic mediated orbitofrontal cortical deficits may account for motor symptoms in catatonia. Parkinson's disease, in contrast, can be characterized by predominant motor symptoms. Motor symptoms may be accounted for by altered "bottom-up modulation" between dopaminergic mediated deficits in striatum and premotor/motor cortex. Clinical similarities between Parkinson's disease and catatonia with respect to akinesia may be related with involvement of the basal ganglia in both disorders. Clinical differences with respect to emotional and behavioural symptoms may be related with involvement of different cortical areas, that is, orbitofrontal/parietal and premotor/motor cortex implying distinct kinds of modulation--"vertical" and "horizontal" modulation, respectively.
Article
GABAergic interneurons are highly diverse and operate with a corresponding diversity of GABA(A) receptor subtypes in controlling behaviour. In this article, we review the significance of GABA(A) receptor heterogeneity for neural circuit development and central nervous system pharmacology. GABA(A) receptor subtypes were identified as selective targets for behavioural actions of benzodiazepines and of selected intravenous anesthetic agents using point mutations which render a specific receptor subtype insensitive to the action of the respective drugs and also by novel subtype-selective ligands. The pharmacological separation of anxiolysis and sedation guides the development of novel anxiolytics, while inverse agonism at extrasynaptic GABA(A) receptors involved in learning and memory is currently being evaluated as a novel therapeutic principle for symptomatic memory enhancement.
Article
This is a report of an 11-year-old, prepubertal boy with acute-onset urinary urgency and frequency, obsessions and compulsions related to urination, severe mood lability, inattention, impulsivity, hyperactivity, and intermittent periods of immobilization. Fever, cough, otitis, and sinusitis preceded neuropsychiatric symptoms. Antistreptolysin O and DNAse B antibody titers were elevated, and magnetic resonance imaging revealed bilateral diffuse caudate nuclei swelling. Plasmapheresis resulted in significant and rapid clinical improvement of obsessive-compulsive disorder symptoms and a simultaneous decrease in basal ganglia swelling, consistent with an immune-mediated pathophysiological process involving group A beta-hemolytic streptococci. Hyperactivity, impulsivity, and inattention improved with lorazepam, suggesting that the attention-deficit/hyperactivity disorder symptoms could be manifestations of catatonia.
Article
Patients with psychiatric catatonias vs those with medical catatonias may differ in catatonic phenomenology. To determine if these could be distinguished, the following methods were used: 1) a review of the literature; 2) a chart review; and 3) a prospective series. The literature review of 467 reports of medical catatonias yielded 240 cases that met research criteria. A chart review of 47 episodes of catatonia revealed a higher frequency of negativism in patients with medical catatonias. Prospective data obtained from rating scales revealed an increased frequency of echophenomena in patients with medical catatonias; however, no discriminate pattern of catatonic signs for medical catatonias arose. Overall, catatonic signs appear to share a similar distribution. These findings suggest that psychiatric and medical catatonias are indistinguishable based upon catatonic sign.
What catatonia can tell us about " top-down modulation " : a neuropsychiatric hypothesis Case study: effectiveness of plasma exchange in an adolescent with systemic lupus erythematosus and catatonia
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