Role of lorazepam challenge test in childhood catatonia

Dear Sir,

Catatonia is a condition in which patients are unable to move normally despite having the full physical capacity to do so. Catatonia was originally described in 1874 by Kahlbaum as a separate brain disorder with a cyclic, alternating, and progressive course.[1]

A study of 198 child and adolescent psychiatric outpatients showed a 5% prevalence of catatonia and 17% prevalence in the subgroup with psychotic disorders.[2] Catatonia is poorly recognized in children and adolescents due to overshadowing by medical or neurological or pervasive developmental disorders. There is a wide variety of causes of catatonia reported in the literature. Developmental disorders (autism, childhood disintegrative disorder, mental retardation, Prader–Willi syndrome), psychotic disorders, mood disorders, mental disorder due to general medical condition, substance-induced disorders, Tourette's syndrome, medication-induced movement disorder (neuroleptic malignant syndrome) have been associated with catatonia in children and adolescents.[3]

Taylor and Fink[4] have described a number of cardinal features of this syndrome, including mutism, echolalia, echopraxia, negativism, automatic obedience, waxy flexibility, catalepsy, stereotypes and mannerisms.[4]

We report a case of a 14-year-old boy who presented with cardinal features of catatonia. This case further outlines the need for clinicians to be vigilant for such presentations in children and adolescents

M, a 14-year-old boy, student of seventh standard, presented to pediatrics out-patient of our medical college hospital with abrupt onset and gradually progressive course of decreased interpersonal interaction and decreased -care for 6 months. He also had a complaint of sitting or standing in same postures for several minutes to hours (posturisation) and gradually his body also became rigid (lead pipe-like rigidity). According to his father, he was apparently asymptomatic 6 months ago. His mother expired due to some chronic illness and the patient developed all the symptoms after this tragedy. For the above-mentioned complaints he was taking treatment from some local practitioners and quacks, the details of the treatment were unknown to us. As there was no improvement in patient's condition, he was brought to our hospital. He was admitted to the pediatric ward and evaluated thoroughly. Personal and developmental history was uneventful. There was no history of any seizure, fever, drug use preceding onset of illness. On examination, he had mutism, automatic obedience, waxy flexibility and catalepsy. His general and systemic examination did not reveal any abnormalities. Slit lamp examination did not reveal K-F ring. Hemogram, renal function tests, liver function tests, thyroid profile and magnetic resonance imaging brain did not reveal any abnormalities. As no organic cause was found, lorazepam challenge test was done by giving him 1 mg lorazepam intravenously. There was a dramatic improvement in patient's behavior, stiffness and gait, but after 1–2 h he went into the same status as before. Based on the above findings we made a diagnosis of catatonia and referred him to psychiatry for opinion and advice.

On mental state examination, patient had psychotic features (delusion of reference and delusion of persecution). There was evidence of depressive illness. He was diagnosed to have catatonia and psychosis unspecified and treated with oral risperidone (2.5 mg/day) and oral lorazepam (1 mg/6 hourly). He gradually improved over 6 weeks. Lorazepam was tapered off and stopped. He was discharged on risperidone 2.5 mg/day. At 3 months follow-up, he had no signs of catatonia and psychotic symptoms. He had gone back to school.

According to Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition there is requirement of 3 or more of 12 psychomotor features (stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia) for diagnosis of “catatonia associated with mental disorder.”[5] In our patient posturisation, waxy flexibility, mutism, negativism and catalepsy were observed. After thorough clinical examination and investigations no physical condition was found. Lorazepam challenge test (administration of lorazepam 1–2 mg by mouth, intravenous or intramuscular) is done in catatonia, and there is a rapid resolution of all symptoms temporarily.[3] In our patient, the test was positive. If the improvement is seen after the test increasing doses up to 30 mg in adults and 24 mg in adolescents are recommended. Careful monitoring in a medical setup for excessive sedation, respiratory compromise and other side effects are mandatory.[3] In our patient, there was a dramatic improvement in the patient's condition, which lasted for 2 h. Bilateral electroconvulsive therapy (ECT) is recommended for patients who have no improvement with lorazepam. As our patient had a positive response to lorazepam challenge test and continued to improve on oral lorazepam ECT was not required.

Catatonia is not rare, and cases exist in child and adolescent populations. The clinician should evaluate by taking a detailed history, doing a thorough medical examination and ordering appropriate laboratory and radiological investigations to rule out any underlying medical condition. Prompt treatment is necessary as it could be fatal if left untreated. If catatonia is suspected, lorazepam challenge test should be considered. Lorazepam is the first line of treatment. ECT is done if lorazepam fails to improve the condition.