My Silence Says It All: A Case Report and Literature Review of Catatonia in First Episode Psychosis

Abstract

Background: Catatonia is a severe psychomotor syndrome associated with various psychiatric disorders and medical conditions. While it is associated with multiple conditions, it is studied most in psychiatric patients. In Schizophrenia, for eg, rates have been found in the range of 1% to 50%. It can present as a symptom cluster of psychomotor and behavioral symptoms such as automatism, negativism, mutism, waxy flexibility, echolalia amongst others. Motor symptoms including catatonia can be seen in psychosis, but little literature exists specifically on first episode psychosis (FEP) presenting with the specific motor cluster of catatonia. Materials and Methods: In our poster, we will present a case of catatonia in FEP and will also review existing literature which alludes to the topic. Case Report: Mr. X is a 24-year-old male without prior medical or psychiatric history who presented to the emergency room in a catatonic state, with immobility, mutism, staring, catalepsy, rigidity, withdrawal and negativism. He was admitted for medical management and subsequently required transfer to inpatient psychiatry. On the psychiatric unit, even after resolution of catatonia, patient continued to elicit delusional thoughts, internal preoccupation and paranoid ideation. As of date of submission, he is still on the inpatient unit. Discussion: Studies have alluded to motor symptoms being present in first episode psychosis, although significant epidemiological information was unable to be found in the literature. Cuesta et al studied 100 antipsychotic-naive FEP patients undertaking extensive motor evaluation including symptoms of catatonia but also parkinsonism, dyskinesia, akathisia and neurological soft signs. Patients were followed up over the course of months and years to track how motor symptoms correlated with disease outcomes. It was observed that early catatonic signs and dyskinesia at drug-naive state were significantly associated with poor long-term psychosocial functioning. Having more data about motor signs, specifically catatonia in psychosis has implications for treatment. Benzodiazepine and Electroconvulsive Therapy (ECT) are first line treatments, however antipsychotic medication remains an area to be studied regarding risk versus benefits for alleviating psychotic symptoms, while possibly increasing the risk for Neuroleptic Malignant Syndrome (NMS). The data is also unclear on first or second generation antipsychotics, with conflicting reports showing efficacy and detrimental side effects for both classes. Conclusion: Further research into the etiology of catatonia is warranted as well as its relationship with other motor symptoms and action of neurotransmitters (GABA, Serotonin, Dopamine). This will have treatment implications as current first line treatment includes benzodiazepines and ECT; Treatment with antipsychotics remains controversial, with evidence supporting and negating its efficacy and possibility for inducing Neuroleptic Malignant Syndrome (NMS).