Clinical Course and Management of Drug-Induced Catatonia and Paranoid Behavior in an Adolescent

Abstract

A 19-year-old Hispanic male with past psychiatric history of illicit drug use was brought by his mother to the emergency room of a tertiary care hospital with altered mental status. According to patient's mother his paranoid symptoms consisted of increased suspiciousness towards his friends and other family members, but were not to the extent for him to seek out any medical help. Clinical course and management of this patient, who later progressed to full blown catatonia, is described in this report. Patient had paradoxical disinhibition when treated with benzodiazepine, limiting treatment options. Patient's mother would not consent for ECT treatment after which Olanzapine was selected to manage his catatonic symptoms. This patient's preexisting paranoid ideations and catatonia were stabilized successfully with a few days of olanzapine with significant decrease in Bush-Francis Catatonia Score. Initial catatonia score of 14 points at baseline decreased to 3 points after 20 days of inpatient management. Historically, when risperidone (strong 5HT2A antagonist) was combined with sertraline (serotonin reuptake inhibitor), it potentiated action of 5HT1A receptors and was implicated in development of catatonia. Olanzapine does not bind to 5HT1A receptors; hence it does not possess this risk. On the contrary, it has strong potency for 5HT2A receptors, inhibition of which increases dopamine concentration in striatum via glutamate-GABA pathway. At his 10 months follow-up, patient reported sustained improvement in his symptoms after 6 months of treatment. Rationale of selecting Olanzapine as medication alternative based on pathophysiological basis of catatonia is described and follow-up information after 10 months is presented in this report. Patient's vital parameters, results of investigation modalities, catatonia rating scores and serial description of the events are documented in the report.Despite limited evidence of the use of second-generation antipsychotics for catatonia, this can be a viable treatment option, especially in adolescent patients who are more prone to paradoxical disinhibition.Conclusion: The LOI-CV and OBQ-CV had promising psychometric properties in a community sample of Turkish children and adolescents.