Resolution of catatonic symptoms: a varied presentation

Abstract

Catatonic syndrome is observable in various psychiatric and physical disorders. In the diagnostic systems for psychiatric disorders, catatonia gets subsumed under various psychiatric disorders, without any specific diagnostic category of its own. However, there are occasions where it may be difficult to categorise catatonia as a part of another disorder. We describe catatonia episodes in a patient with diagnostic uncertainties, and variations regarding symptom resolution with and without medication. There was inadequate response to lorazepam, whereas antipsychotic medications seemed effective for resolution and also as maintenance treatment. Diagnostic issues with catatonia are discussed.

Background

Since catatonic symptoms are observable not only in schizophrenic psychoses, but also in affective, somatic or even psychogenic disorders, many researchers consider catatonia as a nosologically unspecific syndrome.¹ Catatonic manifestations can also be organic, secondary to physical disorders, or can be drug induced.^2,3 These could also be independent entities considering the distinctness in presentation, typical course when appropriately treated, and response to treatment.⁴

During the latter half of the last century, the prevalence of the diagnosis of catatonic schizophrenia has decreased considerably. Reports suggest that changes in the diagnostic criteria and the diagnostic procedure itself are responsible for the under-recognition of catatonia.⁵ Recent studies, however, continue to report that it is fairly common in clinical setting across countries.^4,6,7

Associated symptoms of depression, psychosis and organic symptoms are frequent; catatonic recurrence is common; and resolution of catatonic symptoms usually occur. Most cases respond to benzodiazepines, especially lorazepam. There is a need to study the associated psychopathology, response to interventions, and the course of this syndrome. This is especially important, when clinical presentations of cases do not often fit into the current diagnostic categories and have variable course and prognosis.

We present a case where the catatonic symptoms were observed for variable periods of time; resolutions happened with and without medication on separate occasions. These symptoms did not respond adequately to lorazepam, but responded to antipsychotics. The case report also aims to reflect upon the course of the illness and diagnostic issues.

Case presentation

The presenting complaints in a 45-year-old Asian woman, separated and living alone, were gross self neglect, no speech, and non-response to communication attempts. She was not eating or drinking adequately for a while and was losing weight. She was not speaking and was not allowing anyone to enter her house. She was admitted under the Mental Health Act, considering the risk of self neglect. In the hospital, she confined herself to the bed almost always, covering herself with bed sheets. She did not respond to communication attempts and remained mute. There was no eye contact. When attempts were made to perform a physical examination, she did not carry out even the simple requested movements needed. She was resisting any attempts for movement. Her affect appeared considerably restricted. She often resisted attempts to uncover her face, and did not respond to attempts at interaction.

The patient continued to spend most of her time in her room, mostly lying on the bed or sitting by the window in the same position. After starting treatment, initially lorazepam and subsequently haloperidol, she gradually started interacting in a non-verbal way. She started going out of her room for dining. After around 3 weeks she talked. There was poverty of speech, and the contents of her speech did not make a coherent account initially—for example, she said the “sky was being crushed”, and “there was a man and God”. She also mentioned hearing voices for “30 to 40 years” but would not elaborate on this. Within a couple of days of starting to communicate verbally, she was seen talking normally and enjoying herself. She reported her mood as being “alright”; objectively it was normal. She denied having any auditory or visual hallucinations during this phase or in the past. There was no formal thought disorder. She described being aware of clinicians talking to her during this phase of illness, but she was “not able to talk” and was apologetic about this. She said that her “brain had become swollen” and that was the reason she was unable to talk. There were no depressive or anxious cognitions, nor suggestion of dissociation. Her appetite and sleep were good at this stage.

Past history: At the age of 36 years, the patient underwent many psychiatric assessments for legal reasons, following complaints of property damage. These were followed by psychiatric admissions. Probabilities of various diagnoses such as depression, unspecified psychoses, and schizophrenia were considered. However, at the time of discharge she was diagnosed with no mental illness. She was not on medications and at follow-up no mental health problems were found.

Seven years after the first encounter with mental health services, she was admitted following property damage and mental health concerns from local authorities. Initially, paranoid delusions were noted; later the self neglect and catatonic features like mutism and passive resistance to interaction attempts became prominent. Following admission, she refused medications and was mostly medication-free, while the inpatient status was voluntary. Signs of resolution were noted after about a month, but it was patchy with symptoms continuing intermittently for weeks. Before discharge, she had resolution of symptoms and agreed to take olanzapine 10 mg, which she continued for around 5 months after discharge. Within 4–5 months of discontinuing olanzapine she had relapse of self neglect, withdrawal and catatonic symptoms, necessitating this current admission.

Carers did not give any history of longstanding psychotic illnesses or hallucinatory behaviour in the past. They had described the phases in between the episodes of psychiatric ill health as being normal. There was no history of use of psychoactive substances.

Investigations

There were no concerns regarding the patient’s general physical examination. Full blood counts, fasting blood sugar, liver function tests, thyroid function tests, lipid profile and renal function tests were all within normal limits. Computed tomography scan of the brain was normal.

Treatment

Following admission, the patient refused to take oral medications initially and lorazepam 2 mg twice daily was given intramuscularly for about 6 days. There was no appreciable change in her catatonic symptoms, except that she started attending the dining room for meals. She later received haloperidol 5 mg intramuscularly for around a week. Following this she started taking oral tablets. Haloperidol was replaced by risperidone tablets which were increased to 2 mg twice daily. This was later changed to long acting risperidone injection 37.5 mg intramuscularly once every 2 weeks.

Outcome and follow-up

Upon recovery from the mute, uncommunicative state, the patient had no obvious signs or symptoms of mental illness. She took care of her daily activities, accommodation issues, physical well being, and finances. She interacted appropriately and was sociable. She was adherent to depot injections. In the 8 months following discharge, she had periodic follow-up assessments in which no clinical symptoms or concerns were noted.

Discussion

The presentation of this patient was characterised by mutism, passive negativism, and lack of changing postures for prolonged periods. These are suggestive of catatonic features. Variability in presentation of catatonic symptoms in different countries has been reported. These kind of catatonic symptoms have been reported more frequently in patients from an Asian background.⁶

These catatonic presentations happened periodically; there were two observed episodes lasting variable periods of time. There was complete resolution of catatonic symptoms, including the transient period of incoherent speech. The above presentation appears closer to the concept of periodic catatonia.¹

In the index case, the symptoms either in the past or current admissions do not fully meet criteria for any syndromal psychiatric diagnosis. This poses diagnostic uncertainties based on the current systems of classification. There were no obvious physical reasons for the catatonic symptoms. The catatonic symptoms were prominent disturbances. Other symptoms such as decreased social interaction, self neglect, and paranoia appeared as associated secondary manifestations. The delusions were short lasting and not prominent. There were no core schizophrenic or depressive symptoms. There were long periods up to 7 years when there were no reported concerns even without medications. This presentation supports the assertion that catatonia can be a unique and an independent entity.⁴ It has been reported that symptoms of catatonia appear to be independent of the key symptoms of schizophrenia.⁸ The associated transitory psychotic symptoms—that is, paranoid delusions in the past admission and their response to antipsychotic drugs—suggest that the presentation in this patient was still closer to or part of a psychotic type of illness.

Lorazepam has been found to be effective in catatonia and has been reported to be especially effective in small doses (<5 mg/day).⁹ In this case lorazepam was tried up to 4 mg a day and was not adequately effective.

In the index case, the contribution of antipsychotic medications for catatonic symptom resolution may not be clear. This is because of symptom resolution seen in the medication-free period. However, it may be highlighted that during the medication-free period, the process of resolution was gradual and patchy, while it was relatively quicker following intervention with antipsychotic medications. Upon discontinuation of antipsychotic medication, the catatonic symptoms and other associated functional impairment re-emerged. In the previous and most recent admissions, the catatonia-free state was maintained while she continued antipsychotic medications. The above observations regarding the course of the catatonic symptoms with and without antipsychotic drugs suggest that they were effective in maintaining remission.

Learning points

• Catatonia symptoms may persist for longer periods without medication.

• Catatonia symptoms may respond to antipsychotic medications. Response to lorazepam may not be adequate.

• Antipsychotic medications may help in maintaining the remission. Discontinuation of medications in this case was followed by re-emergence of catatonic symptoms.

• In the index case, catatonia did not seem to be part of any other psychiatric or physical disorders. In between the catatonic phases, the patient was not having any other diagnosable disorder. This highlights that catatonic syndrome could be an independent diagnostic entity.