Table 1.
Included publications and brief notes from their findings
| Author | Type of study | Patient/sample | Diagnostic test | Level of evidence | Past medical and psychiatric history | Short clinical notes |
|---|---|---|---|---|---|---|
| Blum et al7 | Case report | A man in his 60 s | BFCRS | 4 | History of hypertension and psychotic episode (20 years ago) | Patient presented to the emergency department with 3 days of altered mental state: muteness, staring, perseveration, ambitendency, rigidity, gegenhalten agitation, verbigeration, insomnia and refusal of food and water. Fifteen minutes following a lorazepam challenge, BFCRS score decreased from 27 to 9 |
| Kopishinskaia et al8 | Case series | A 12-year-old male | Clinical examination | 4 | History of perinatal encephalopathy, brief febrile seizures at 6 months; nil previous psychiatric history | Summer 2020: showed slowness in movement and weight loss owing to reduced appetite and spontaneous fluid intake. Admitted on 10 December 2020 because of neurological sequalae of COVID-19 inflammatory diseases. During admission, the patient demonstrated the pillow sign within catatonic rigidity, posturing and slow gait with festination gait |
| A 17-year-old male | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric history | May 2020: patient experienced psychiatric and neurological symptoms. January 2021: admitted to a psychiatric hospital, where he was treated with risperidone. No psychiatric diagnosis was conveyed, but he tested positive for IgM antibodies to SARS-CoV-2. 26 January 2021: the patient was sitting in a hunched posture, showed understanding of the conversation and replied appropriately to questions, but answered rapidly and abruptly, in telegraphic speech |
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| Tyler Torrico et al9 | Case series | A 36-year-old Black female | Clinical examination | 4 | Past medical history of hypertension, type 1 diabetes and incidental pancreatic head mass; nil previous psychiatric history | Patient presented with multiple symptoms of catatonia 26 days after developing symptoms of COVID-19. Initial treatment with methylprednisolone resulted in no improvement. Catatonia was suspected and 2 mg lorazepam trial was initiated. Within 10 min after the first dose of lorazepam, the patient sat up at the bedside and was seen calling her family members |
| A 64-year-old White female | Clinical examination | 4 | Nil previous medical history; past psychiatric history of unspecified bipolar disorder | Two months of symptoms of waxing and waning mentation problems, selective mutism, minimal engagement with others and staring. Refusal to eat or drink, resulting in 20-pound weight loss. COVID-19 RNA was detected by RT-PCR 6 weeks before presentation. The patient was given 2 mg intravenous lorazepam for suspected seizure. Shortly thereafter, she was entirely alert and oriented. Her physical health deteriorated and was treated with methylprednisolone, with no benefit. A lorazepam trial was re-initiated, starting at 0.5 mg lorazepam three times daily. Over the next 3 days, the patient resumed speech |
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| Mulder et al10 | A case report | A 40-year-old male | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric health history | Patient presented with multiple sever catatonic symptoms after 3 weeks history of COVID-19; no hospital admission needed. Signs of autoimmune encephalitis. Treatment was initiated with 1 g methylprednisolone daily. On day 28, the patient showed dramatic improvement |
| Kwon et al11 | A case report | A 62-year-old woman | BFCRS | 4 | Past medical history of hypertension; past psychiatric history of schizoaffective disorder and bipolar disorder | Patient presented to the emergency department with shortness of breath and weakness for 1 week; a COVID-19 test was positive. On hospital days 6–9, the patient displayed extreme mutism and negativism. On hospital day 10, a single 1 mg trial of lorazepam was administered for a presumed diagnosis of catatonia with no improvement. On hospital day 18, patient was started on intravenous lorazepam every 8 h. After 48 h of starting the lorazepam challenge, the patient had a significant improvement. Patient died because of sudden cardiac arrest refractory to resuscitation efforts; likely secondary to a massive pulmonary embolism |
| Vazquez-Guevara et al12 | A case report | A 43-year-old female | BFCRS | 4 | Nil previous physical health history; nil previous psychiatric health history | Patient presented with 3-day history of cationic symptoms. BFCRS: 19 points. Diazepam infusion for the catatonic syndrome was started, with no good response. Serum IgG, IgM and PCR were positive for COVID-19. Methylprednisolone for 5 days was given for encephalitis because of a lack of diagnostic certainty, followed by oral prednisone. Remarkable improvement was shown with the boluses of steroids |
| Scheiner et al13 | Case series and systemic review | A female in her 50 s | BFCRS | 4 | History of hypertension and osteoarthritis; nil previous psychiatric history | Patient presented with self-inflicted stab wounds, catatonic features and positive SARS-CoV-2 nasopharyngeal swab. BFCRS score of 11. She was challenged with 2 mg intravenous lorazepam, with lysis of catatonia (BFCRS severity 0) after ~45 minutes |
| A female in her 50 s | BFCRS | 4 | History of chronic kidney disease stage 3; history of chronic schizophrenia | Patient brought to the emergency department from a local jail twice for refusal to eat; 50-pound weight loss over 2 months. SARS-CoV-2 swab was positive. BFCRS severity of 12. Symptoms included withdrawal, mutism, staring and negativism. Patient was administered a 2 mg intramuscular lorazepam challenge, with good response (BFCRS severity 2) |
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| Zain et al14 | A case report | A 69-year-old female | Clinical examination | 4 | Past medical history of chronic obstructive pulmonary disease, type 2 diabetes and hypertension; nil previous psychiatric history | Patient presented with confusion and paranoid thoughts for 4–6 weeks, worsening over the past 2 weeks. PCR test for COVID-19 at the time of admission was negative. Antibody test was done on day 6 of admission, which was positive. She displayed extreme agitation and aggression, poor eye contact and had a flat affect with echolalia and loose associations. Excited catatonia was considered as a possible delayed catatonic reaction to COVID-19 after 2 months, with differential diagnosis of delirium and dementia. She was treated with lorazepam; agitation and paranoia appeared to improve |
| Jaber et al15 | Report of two patients | A 39-year-old male | DSM-5 diagnostic criteria | 4 | Nil previous physical health history; nil previous psychiatric history | Patient presented with delirium and catatonic features. Admitted to the ICU. MRI and CSF were normal, but the patient tested positive for SARS-CoV-2 and was treated successfully with lorazepam |
| A 56-year-old female | DSM-5 diagnostic criteria | 4 | Nil previous physical health history; history of schizoaffective disorder | Patient presented with delirium, and catatonic features. Admitted to the ICU. MRI and CSF were normal, but the patient tested positive for SARS-CoV-2 and was treated successfully with lorazepam |
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| Jaber et al16 | A case report | A 36-year-old female | Clinical examination | 4 | History of diabetes; nil previous psychiatric history | Patient presented with slurred speech, which progressed to catatonia, and tested positive for COVID-19. The patient received intravenous methylprednisone out of concern for autoimmune or paraneoplastic encephalitis; showed no clinical improvement. Symptoms quickly resolved in response to lorazepam |
| Johnson et al17 | A case report | A 27-year-old male | Clinical examination | 4 | A history of benign pressure hydrocephalus and polycythaemia; nil previous psychiatric history | Patient presented with depression and catatonia, and was transferred to a tertiary care centre for ECT. Upon admission, patient was found to be COVID-negative but tested positive on day 40 of the admission, after exposure to a COVID-19-positive visitor, and catatonia progressed to malignant catatonia. Patient initially improved with scheduled lorazepam and ECT, with partial regain in motor function. However, overnight on hospital day 40, patient acutely spiked fevers to 40 degrees Celsius, had acute worsening in rigidity and rapidly rising CPK level from 166 to 3200 in just over 48 h |
| Fiaschè et al18 | A case report | A 59-year-old male | Clinical examination | 4 | Nil previous physical health history; a history of schizotypal personality disorder | Patient presented with acute symptoms of COVID-19 and catatonic behaviour manifested by stuporous state, catalepsy, immobility, rigidity and mutism. Treated with successfully with asenapine 20 mg/day; symptoms responded rapidly and significantly |
| Nersesjan et al19 | A prospective, consecutive, observational study | 61 patients aged ≥18 years, consecutively admitted with COVID-19 to a tertiary referral centre in Copenhagen | No test used; the diagnosis was based on the clinical pictures. Other scales were used to test the level of consciousness: Glasgow Coma Scale and Full-Outline UnResponsiveness (FOUR) scale |
1b | Out of the 61 patients included, a total of 19 patients had signs of encephalopathy. Eight patients were apathetic and profoundly hypokinetic, with almost no voluntary movements and without verbal output. Patients were able to indicate yes and no by nodding with their heads when spoken to. On neurological examination, all patients had some frontal release signs (e.g. palmomental reflexes). They were diagnosed with akinetic mutism |
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| Zandifar and Badrfam20 | A case report | A 61-year-old male | Clinical examination | 4 | Nil previous physical health history; a history of schizophrenia for many years | Worsening of schizophrenia and sudden onset of seizure. PCR test for COVID-19 was positive. Patient developed catatonic symptoms and was treated with lorazepam 2 mg three times a day. Within 24 h, his catatonic symptoms resolved. After 36 h, his lethargy decreased, and he started consuming water and food |
| Deocleciano de Araujo et al21 | A case report | A 50-year-old male | Clinical examination | 4 | Nil previous medical history; history of mild intellectual disability | Symptoms started a week before admission; severe body stiffness, negativism, urinating and defecating in clothes, and refusal to feed and weight loss, which required ICU admission and ECT. A COVID-19 test was positive. Oral lorazepam 2 mg three times daily was given. Despite benzodiazepines, stiffness and diaphoresis remained extreme, and he remained in critical condition. On day 19, he was transferred from intensive care to the psychiatric unit. ECT with bilateral stimulus 30% was started. After ten ECT sessions, the catatonic syndrome improved substantially. However, he unable to recall the time during admission and the weeks prior |
| Gouse et al22 | A case report | An elderly male | BFCRS | 4 | History of chronic obstructive pulmonary disease, interstitial lung disease, type 2 diabetes, hypertension, atrial fibrillation and essential tremor; history of schizophrenia | Patient presented to the emergency department with worsening COVID-19 symptoms. On hospital day 3, he exhibited catatonia. Lorazepam 1 mg was initiated intravenously. On reassessment 30 min post dose, his BFCRS improved from 18 to 9. Because of concern for catatonia, his aripiprazole was held and intravenous lorazepam 1 mg three times daily was initiated. On day 4, his BFCRS score was 13. Intravenous lorazepam was decreased to 0.5 mg three times daily, by his primary team, because of concern for his progressive respiratory failure; patient had a do-not-intubate status. On day 5, his BFCRS was 19. An ECT consult was placed but declined, because of concern for his medical stability. The patient died on day 7. |
| Amouri et al23 | A case report | A 70-year-old female | BFCRS | 4 | Medical history of diabetes mellitus type 2, end-stage renal disease on haemodialysis, hypertension, coronary artery disease, hypothyroidism and a history of transient ischemic attack; nil previous psychiatric history | Patient presented to the hospital with a few days history of physical and psychiatric symptoms and recent positive test result for COVID-19. On day 12, the patient had a BFCRS of 11/21, indicating the presence of catatonia and delirium. She received eight total doses of lorazepam 0.5 mg between day 12 and 15. On day 15, she showed improved alertness and orientation. Mild symptoms of catatonia remained stable. Lorazepam was subsequently discontinued on day 16, without the return of catatonic signs |
| Pilotto et al24 | A case report | A 60-year-old male | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric history | Patient presented to the emergency department with a severe alteration of consciousness. On admission, the patient showed a severe akinetic syndrome associated to mutism. He was diagnosed with COVID-19-induced encephalitis. Three days after admission, intravenous steroid treatment was started (methylprednisolone 1 g/day for 5 days), with a good response |
| Caan et al4 | A case report | A 43-year-old male | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric history | Developed catatonic features 2 weeks post positive test of COVID-19; classic symptoms of catatonia. He responded immediately to lorazepam |
| Huarcaya-Victoria et al25 | A case report | A 23-year-old female | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric history | Patient was admitted with COVID-19 symptoms, agitation and delusion, and the following catatonic symptoms: stereotyped movements, catalepsy, verbigeration. Patient was given intravenous midazolam to treat the agitation, with little effect. Treated successfully with 40 mg ziprasidone followed by olanzapine, with a good response |
| Raidurg et al26 | A case report | A 28-year-old female | BFCRS | 4 | Nil previous physical health history; nil previous psychiatric history | History of 3 weeks psychotic behaviour. After admission to a private psychiatry hospital, she stopped talking completely. Her BFCRS score was 16. A lorazepam challenge test was done, to which her catatonic features responded well. Patient was discharged on day 8 with 90% remission, on tablet lorazepam 1 mg twice daily, and on tablet olanzapine 5 mg |
| Palomar-Ciria et al27 | A case report | A 65-year-old male | Clinical examination | 4 | Hypertension and sleep apnoea syndrome treated with CPAP; schizophrenia for more than 20 years | Patient presented with bizarre behaviour for 20 days, with positive results for both IgG and IgM, but PCR was then negative. He was diagnosed with delirium owing to COVID-19 with a relapse in his schizophrenic illness, and discharged from the hospital. He was taken to the emergency room after a few days, with suicidal behaviour. During the second hospital admission, the predominant symptoms were disorganised behaviour, reiterative or blocked speech, bradyphrenia, disorientation, apraxia, echolalia and bradykinesia without rigidity. He was diagnosed with catatonia and treated with ECT |
| Austgen et al28 | A case report | A 52-year-old female | BFCRS | 4 | History of well-controlled type 2 diabetes, mild hypertension and post-viral reactive airway disease periodically requiring oral steroids; nil previous psychiatric history | A month after testing positive for COVID-19 by PCR, she was admitted to hospital because of depression and paranoia. She developed the following symptoms of catatonia: immobility, negativistic and mutism, with a BFCRS score of 18. She was treated with ECT and concurrent use of lorazepam 8 mg daily, and she improved |
| Kaur et al29 | A case report | A 59-year-old male | BFCRS | 4 | Past medical history included well-controlled hypertension and hyperlipidaemia; a history of bipolar spectrum illness | Patient presented with severe depression; PCR COVID-19 testing was negative on admission. He received Moderna two-dose COVID-19 vaccination series approximately 4 months before admission. Within 7 days of admission there was an abrupt onset of catatonia. Repeat PCR testing was performed and was positive for COVID-19. Oral lorazepam was started and titrated. He was unable to tolerate lorazepam beyond 6 mg daily and titration was stopped. He received six brief-pulse ECT bitemporal treatments, with excellent response |
| Flannery et al30 | A case report | A female in her 20s | Clinical examination | 4 | Nil previous physical health history; nil previous psychiatric history | Constellation of symptoms (spontaneous defecation, catatonia, sudden encephalopathy without metabolic or infectious findings) coupled with preliminary CSF results and history of deterioration after SARS-CoV-2 vaccination led to a strong clinical suspicion of an autoimmune-mediated encephalitis driven by the vaccine. Catatonia appeared after more than 2 weeks, and was treated with rituximab, antipsychotics and steroids |
| McHattie et al31 | A case report | 53-year-old female | Clinical examination | 4 | Ductal carcinoma of breast in remission and psoriasis; history of depression | Two-week history of confusion and catatonia. Her swab for SARS-CoV-2 RNA was negative and was treated with acyclovir for suspected viral encephalitis. She tested positive for COVID-19 on day 14. Treatment included hydroxychloroquine, intravenous immunoglobins, tocilizumab, antibiotics, amphotericin and levetiracetam. After 1 month, she made remarkable progress |
| Sakhardan et al32 | Case series | A 21-year-old male | BFCRS | 4 | Underlying genetic condition, early-onset Parkinson's disease; nil previous psychiatric history | A month's history of mutism, withdrawal, staring, posturing, urinary incontinence, autonomic instability, immobility, rigidity, negativism, waxy flexibility and postural instability, with symptomatic worsening over the preceding 4 days. The patient was initiated on oral lorazepam but switched to intravenous lorazepam (6 mg daily) in three divided doses, because of inadequate response (BFCRS score 17). Bitemporal ECT, administered thrice weekly, were commenced following non-response to lorazepam (BFCRS score 9). Improvement after the tenth ECT session was observed. Given persistent rigidity and gait instability, a neurology opinion was obtained and a diagnosis of atypical Parkinson's disease was considered. |
| A 26-year-old male | BFCRS | 4 | Nil previous physical health history; history of schizophrenia | One month's history of stupor, mutism, staring, posturing and grimacing suggestive of catatonia. There was no prior history of catatonia. Catatonic signs improved with the lorazepam challenge (2 mg intravenous), in-patient care was planned for the management of residual catatonia and psychotic illness. Oral lorazepam (6 mg daily in divided doses) resulted in the resolution of catatonia over 2 days (BFCRS score 0) | ||
| A 38-year-old female | BFCRS | Nil previous physical health history; nil previous psychiatric history | Patient presented with 4-day history of psychotic symptoms plus mutism, posturing, staring, withdrawal, immobility and automatic obedience, in the absence of any prior history of catatonia or psychiatric illness. COVID-19 exposure was present (immediate family member). The patient was diagnosed with acute transient psychotic disorder with catatonia (baseline BFCRS score of 8). RT-PCR test was positive. No respiratory or systemic abnormalities were noted. She was admitted to the PCU and commenced on oral olanzapine 10 mg daily, and lorazepam 4 mg daily (divided doses). Catatonia resolved over a week (BFCRS score 0) | |||
| A 24-year-old male | BFCRS | Nil prior physical health history; history of schizoaffective disorder | Patient presented with 2 weeks of immobility, mutism, staring, posturing, grimacing, mannerism, negativism, withdrawal, impulsivity and ambitendency. Intravenous lorazepam (8 mg in divided doses) was associated with improvement in food intake. Subsequently, it was replaced with oral lorazepam (8 mg daily) and oral aripiprazole titrated to 20 mg. As inadequate response to lorazepam was noted, bifrontal ECT were commenced. Following the first ECT, he was identified as COVID-19 positive and. given the persisting residual mutism, staring, grimacing and impulsivity, ECTs were commenced. A course of five bifrontal ECT sessions contributed to improvement in catatonia and mood symptoms. He was discharged on lorazepam 2 mg. On follow-up after 2 weeks, he was readmitted for worsening catatonia with immobility, mutism, staring, grimacing and ambitendency (BFCRS score of 7). Oral lorazepam up to 6 mg and nine bifrontal ECT sessions were administered, which improved both catatonic (BFCRS score 0) and psychiatric symptoms |
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| A 35-year-old female | BFCRS | History of hypothyroidism; history of schizoaffective disorder | No history of catatonia was noted in the past, but she had received ECT for psychiatric relapses. Patient presented with a 1-month duration of depressive symptoms and 4 days of stupor, negativism, mutism, posturing, staring, gegenhalten and withdrawal (BFCRS score 18). In the emergency ward, catatonia responded to intravenous lorazepam (6 mg daily); however, negativism and withdrawal persisted, for which in-patient care was planned. The RT-PCR test was positive, requiring admission to PCU. A concurrent course of 7 bitemporal ECT sessions (twice weekly, with first three ECT sessions in the PCU with precautions) contributed to gradual improvement in catatonic (BFCRS score 0) and depressive symptoms. Parenteral lorazepam was switched to oral lorazepam 6 mg daily and gradually tapered and stopped over 2 weeks |
BFCRS, Bush–Francis Catatonia Rating Scale; IgM, immunoglobulin M; RT-PCR, reverse transcription polymerase chain reaction; IgG, immunoglobulin G; PCR, polymerase chain reaction; ICU, intensive care unit; MRI, magnetic resonance imaging; CSF, cerebrospinal fluid; ECT, electroconvulsive therapy; CPK, creatine phosphokinase ; CPAP, continuous positive airway pressure; PCU, progressive care unit.