Unraveling the enigma of ‘Psychological Pillow’: A unique catatonic phenomenon

Dear Editor,

Psychological pillow, a rare catatonic sign. Pathophysiology includes dysregulation of motor circuit loops, namely Cortico-subcortico-cortical loop (movement initiation/inhibition), cortico-thalamo-cerebello-subcortical loop (modulate movement dynamics/timing), cortico-cortical (regulate the speed and organization of motor activity). Specifically, which circuit dysregulates is a matter of ongoing debate^55,56. The right inferior parietal cortex is proposed to be the structure involved in these functions, and dysfunction possibly results in posturing.[1,2]

A 22-year-old male, Hindu by religion, educated up to the 5^th grade, and from a low socioeconomic background, was brought to the psychiatric outpatient clinic. He had a history of repeatedly fleeing from home for 3 years, harboring suspicions about family members, frequent self-muttering and disrobing of clothes, along with unprovoked physical or verbal aggression. Additionally, the patient experienced gradually progressive stiffness in all four limbs, mutism, episodic agitation, and bizarre posturing that persisted for 22 weeks. Notably, the patient would often assume a unique posture resembling “Psychological pillow,” where their head and trunk were lifted above the pillow for several minutes to half an hour, even when lying supine on the bed [Figure 1]. There was no indication of substance abuse, drug use, or medication causing these symptoms. The patient’s family believed that a malevolent spirit had possessed his body, leading them to consult multiple local faith healers. Previously, the patient received medical advice at a district hospital and was prescribed olanzapine 10 mg and lorazepam 2 mg, but did not comply adequately or make successive visits. Relevant investigations including brain Imaging, CSF analysis, and Electroencephalogram (EEG) were unremarkable. Baseline Bush Francis catatonia rating scale score (BFCRS) was 32, and Brief Psychiatric Rating Scale (BPRS) score was 85. With a diagnosis of catatonia associated with schizophrenia, the patient was treated with intravenous lorazepam gradually up-titrated to 4 mg three times daily, along with other measures like proper hydration, input/output measurement, vital monitoring, and postural care. Risperidone (oral dissolving) tablets were also introduced and up-titrated in divided doses. The BFCRS scale score was reduced to 15 after the resolution of catatonic symptoms. Within a week, the patient’s catatonic symptoms showed improvement with a maintenance dose of lorazepam at 8 mg per day and risperidone up-titrated to 8 mg daily dosing. However, there was minimal change (76) in the BPRS score from the baseline in 2 week’s time. For ensuring compliance, the patient was advised to use a long-acting depot injectable (intramuscular Flupentixol 40 mg) monthly upon discharge. During the follow-up visits to the outpatient psychiatry department at 2 weeks, the patient achieved BFCRS scores of 8, and BPRS score came down to 66.

Figure 1.

Psychological Pillow

Clinical presentation of catatonia is extremely diverse, and till now, 40 different catatonic symptoms have been identified.[3] Among all these signs, perhaps the most peculiar and unusual sign is posture, in which affected individuals maintain an unorthodox bodily position for a sustained period against the effect of gravity, with complete akinesia.[4] The patient can remain fixed in that respective position for a variable amount of time (hours, days, sometimes weeks). Characteristics peculiar to psychological pillow firstly include the absence of fatigue or extra effort to maintain this bizarre posture, and secondly, it is usually painless for the patient. A literature search on PubMed and Google Scholar for case reports in the English language depicting catatonia and psychological pillow revealed 16 case reports of catatonia with features of psychological pillow [Table 1]. It was present in patients of all age groups (ranging from 14 years to 87 years) and in patients with mood disorders as well as psychotic disorders. In a few cases, other medical causes like poisoning or systemic lupus erythematosus were found. The treatment basically involved treating the primary cause. Despite its rarity, recognizing this phenomenon can lead to timely and targeted interventions, significantly impacting patient outcomes. However, the enigma surrounding the underlying pathophysiology of “psychological pillow” remain unexplained. Further studies are required to unravel its association with specific neural circuits or structures.

Table 1.

Summary of reviewed Case reports of Catatonia with Psychological Pillow sign

Case report	Age/gender	Primary diagnosis	Psychological pillow sign	Treatment
Lake et al.[5]	54/M	Schizophrenia with Hyperthyroidism	+	Haloperidol cessation, Propylthiouracil and Propranolol
Sher et al.[6]	19/F	Primidone-induced Catatonic Schizophrenia	+	IV Lorazepam, Primidone cessation
Trabattoni et al.[7]	68/M	Nightshade (Atropa Belladonna) Poisoning	+	IV Glucose, Thiamine, Electrolytes
Bahro et al.[8]	61/F	Schizophrenia with status Postfrontal lobotomy	+	Risperidone treatment switched to Clozapine
Trivedi et al.[9]	64/F	Bipolar II disorder	+	ECT
Manjunatha et al.[10]	26/M	Recurrent Opisthotonus in Catatonia	+	IV Lorazepam, ECT
Wachtel et al.[11]	14/M	Autism and Mild Mental Retardation	+	IV Lorazepam, ECT (Bitemporal)
Mehta et al.[12]	26/M	Acute Polymorphic Psychotic disorder	+	IV Lorazepam, ECT
Kumar et al.[13]	29/M	Schizophrenia	+	IV Lorazepam, ECT
Nasti et al.[14]	87/F	Moderate Dementia with Hypernatremia	+	Risperidone cessation, saline/dextrose infusion
Chattopadhyay et al.[15]	14/M	Psychosis	+	IV Lorazepam, ECT, Clozapine
Agadagba and Bates.[16]	16/M	Schizophrenia	+	IV Lorazepam, Clozapine
Jing et al.[17]	23/F	Catatonia associated with Major depressive disorder	+	Escitalopram
Mehta et al.[18]	28/F	Schizophrenia	+	ECT (Bitemporal), Risperidone
Gupta N et al.[19]	20/F	Systemic Lupus Erythematosus	+	IV Lorazepam, Quetiapine
Järventausta et al.[20]	40/M	Undifferentiated Schizophrenia	+	ECT (Twice daily), Clozapine

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