The Diagnosis and Treatment of Catatonia via Telemedicine: A Case Report and Proposed Diagnostic Criteria

To the Editor,

Catatonia is characterized by a range of motor and behavioral disturbances in pediatric and adult patients (Shorter and Fink, 2018), with prospective studies indicating a prevalence of approximately 10% in adult psychiatric inpatients (Francis et al., 2010). Benzodiazepines are the gold-standard treatment of catatonia, with electroconvulsive therapy for refractory cases (Beach et al., 2017; Sorg et al., 2018). The diagnosis of catatonia is made using a combination of physical exam findings and interview, with numerous rating scales including the Bush-Francis Catatonia Rating Scale (BFCRS) measuring the severity of symptoms (Bush et al., 1996). Since the beginning of the COVID-19 pandemic, much of psychiatric outpatient care has shifted to telemedicine, in which audio or audiovisual technology connects patients and providers who are not co-located (Chen et al., 2020). Virtual visits make obtaining a hands-on physical exam impossible, which may provide a barrier to the recognition of catatonia. Here we present a case of a pediatric patient who was diagnosed with catatonia during a telepsychiatry appointment, and propose diagnostic criteria for virtual assessment of catatonia.

The patient is a pre-teen girl with a history of intellectual delay (full-scale IQ < 50) and prior episodes of catatonia responsive to oral lorazepam. She was prescribed lorazepam 1 mg PO up to three times a day as needed for catatonia, with instructions to present for emergency care at the first signs of an episode. During the COVID-19 pandemic the family was lost to care for six months, and a telemedicine intake appointment with a new psychiatrist was conducted using video technology. At that visit the patient was described as acting “off” for the last 10 days, with decreased speech, apparent confusion, reduced movement, and abnormal flapping of her hands.

On telehealth exam, the patient was staring directly at the camera, with minimal blinking. She offered no spontaneous speech, and when addressed would respond with 1–2 words after a significant delay. She maintained a sitting position throughout the encounter, without abnormal movements or posturing. There was no echopraxia, excitement, or combativeness. She was not oriented to date or month. The patient’s guardian was instructed to administer 2 mg PO lorazepam shortly into the encounter, and approximately 45 minutes later the patient had increased spontaneous speech with less delay in response and increased blinking. A diagnosis of catatonia was made, and the patient received daily telemedicine check-ins for one week while continued on lorazepam 2 mg three times daily. Catatonic symptoms resolved by day six, and the lorazepam dose was then tapered and discontinued by day 24.

Catatonia presents with motor and behavioral disturbances which can vary widely, from presentations categorized by stupor as in this case to excited states. Although numerous rating scales for catatonia exist, they measure a relatively conserved set of findings (Sienaert et al., 2011). Table 1 lists the criteria for catatonia diagnosis from the DSM-5, as well as the criteria in the BFCRS (Bush et al., 1996), and indicates features that can be observed by telemedicine and those which cannot be. For instance, measurement of features including rigidity, waxy flexibility, passive obedience (mitgehen), muscle resistance (gegenhalten), grasp reflex, and autonomic instability all require a hands-on assessment. In contrast, principally behavioral symptoms including stupor; speech latency; hypophonia and mutism; decreased eye blink and staring; and posturing may all be readily observed on video. Indeed, it is precisely these features that have allowed for educational videos of catatonia to be developed (“Videos about Catatonia,” n.d.). Assessment using audio-only technology is, in contrast, much more limited (Table 1).

Table 1:

diagnostic features of catatonia from the Bush-Francis Catatonia Rating Scale, and whether they can be elicited on audio-only exam or on audiovisual exam. Diagnostic factors that are also in the DSM-5 criteria for catatonia are bolded.

Feature	Detected by audio only exam	Detected by audiovisual exam
Immobility/stupor		X
Mutism	X	X
Staring		X
Posturing/catalepsy		X
Grimacing		X
Echopraxia/echolalia	X	X
Stereotypy		X
Mannerisms		X
Stereotyped & meaningless repetition of words & phrases (verbigeration)	X	X
Rigidity
Negativism		X
Waxy flexibility
Withdrawal		X
Excitement		X
Impulsivity		X
Automatic obedience
Passive obedience (mitgehen)
Muscle resistance (gegenhalten)
Motorically stuck (ambitendancy)		X
Grasp reflex
Perseveration	X	X
Combativeness		X
Autonomic abnormality

In one review, mutism, withdrawal, posturing, negativism and stupor were found to be the most frequent catatonia signs among acutely ill psychiatric inpatients as well as among chronically ill patients in a state hospital setting (Bush et al., 1996). In another study of chronically hospitalized patients, automatic obedience, posturing, and catalepsy were found in over 70% of cases while mutism and rigidity were found in over 60% of those diagnosed with catatonia (Fink and Taylor, 2006). Thus, many of the most frequent signs and symptoms of catatonia overlap with those appreciable using telemedicine assessment, making the approach acceptable on occasion if not optimal. Paramount to this assessment is the presence of another person, often expected to be a family member but who could also be a medical or mental health professional, who can operate the video apparatus and provide collateral information about behaviors. It is conceivable that this person might also be able to perform some of the motor exam for catatonia and report findings to the viewing clinician, but the accuracy of such assessments are unknown.

In this case, the principally stuporous presentation was readily apparent on video technology. A lorazepam challenge (Suchandra et al., 2020) was in this case performed using PO lorazepam, and provided further evidence for the diagnosis. Continued evaluation via telemedicine by the patient’s psychiatrist permitted a safe outpatient taper of lorazepam once symptoms had improved.

In conclusion, catatonia can be diagnosed via video telemedicine as long as there is an individual who can assist the patient in setting up the video equipment. Without hands-on assessment, examination is limited to observation of speech, posture, and behavior, but these criteria are sufficient to make a diagnosis in many cases. In contrast, audio-only technology presents significant barriers to catatonia diagnosis, and cannot be encouraged.