Organic Catatonia Research Articles

Use of ECT in patients with organic catatonia

BackgroundElectroconvulsive therapy (ECT) is considered to be a treatment of choice in patients with catatonia, who do not respond to lorazepam, irrespective of the underlying aetiology. Although, significant data is available for successful use of ECT in patients with catatonia secondary to affective and psychotic disorders, little information is available for use of ECT in organic catatonia. AimTo assess demographic and clinical profile of patients with organic catatonia receiving ECT. MethodologyUsing a retrospective study design, ECT register of the department was reviewed for the period of 2019–2023 to identify the patients with organic catatonia, who received ECT. The treatment records of these patients were reviewed to extract the demographic and clinical profile. ResultsDuring the study period, out of the 926 patients who received ECT, 12 (1.3 %) patients diagnosed with organic catatonia received ECT. The mean age of study sample was 41.67 (SD- 20.68) years and mean number of ECTs given in a course of ECT were 8 (SD- 4.3). In majority of the patients, ECT was considered after the failure of lorazepam challenge test. Majority (75 %) of the patients showed good response to ECT and only 16.67 % of the patients experienced complications during the course of ECT. ConclusionECT is an effective and well-tolerated treatment for organic catatonia.

ALTERED BIOCHEMICAL PARAMETERS IN CATATONIA: A SHORT TERM EVALUATION

BACKGROUND Catatonia, a bizarre psychomotor syndrome, which was earlier considered as a manifestation of schizophrenia, is now often seen in patients with mania, depression and many other medical condtions. It has been a matter of debate for several decades, whether catatonia is a separate disease entity or a manifestation of different psychiatric or medical disorder. AIMS AND OBJECTIVES In our study, we tried to evaluate and compare the altered biochemical parameters in different conditions of catatonia. This hospital based cross-sectional observational study was conduc METHODS ted in a tertiary care hospital in Guwahati, Assam for a period of 1year from May2021 to April2022 after obtaining clearance from Institutional Ethical Committee(H) of the institution. Total 50 cases of catatonia fullling the selection criteria were included in the study. Bush Francis Catatonia Rating Scale (BFCRS) was used to quantify different conditions of catatonia. The biochemical parameters that were altered RESULTS in majority of the catatonia patients were CPK (increased in 98%patients), haemoglobin(low in 64%patients) and serum iron(low in 54%patients). Statistically signicant difference with the highest mean CPK (514.86) was found in schizophrenia while the lowest mean CPK value(254.54) was found in organic catatonia patients. CONCLUSION Although, there is no specic test for catatonia, laboratory studies provide insight into the pathogenesis of catatonia and has diagnostic and therapeutic implications.

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Background:Catatonia is a motor syndrome associated with various psychiatric and medical disorders. Studies show that 20-39% of patients with catatonia have an underlying organic aetiology which is often under diagnosed in non-psychiatric settings. Although no specific guidelines are available, lorazepam and electroconvulsive therapy (ECT) have been the mainstay in the management of organic catatonia. We aim to report the clinical correlates and outcome in patients presenting with catatonia secondary to physical illness.Methodology:This was a retrospective file review study of 7 patients with a diagnosis of organic catatonia between January 2016 and September 2021. We extracted sociodemographic details, clinical features, and details of medical co-morbidities, biochemical investigations, electroencephalogram and neuroimaging findings, and treatment response.Results:Seven patients (4 female and 3 male) with a mean age of 30.14 (SD 8.38) years presented with organic catatonia. The median duration of symptoms was 10 (IQR 44) days. Mutism (n=7) and staring (n=7) were the most common catatonic symptoms. Five out of 7 patients responded to lorazepam with a mean dose of 8 (SD 3.26) mg, and the remaining 2 received ECT and had poor outcome.Conclusion:Organic catatonia is often under diagnosed and poses varied treatment challenges due to co-morbid physical illness. Treatment with lorazepam appears to be promising as first line option. Safety of ECT in organic catatonia needs further evaluation.Key messages:1. Organic catatonia poses varied diagnostic and therapeutic challenges in comparison to its psychiatric counterpart.2. Lorazepam is promising in the management of organic catatonia, while the safety of electroconvulsive therapy needs further evaluation.

Young Psychiatrist Award

Background:The treatment in organic catatonia includes benzodiazepines, ECT and treatment of underlying condition. In a pilot study1, Lorazepam produced sedation, hypotension and respiratory depression. Tofisopam, (FDA approved for IBS2) was safe and effective which can be a treatment alternative. This study was designed to study the efficacy and adverse effects of Tofisopam in organic catatonia.Materials and Methods:This study included 60 patients irrespective of age and gender with diagnosis of Organic Catatonia (F061, ICD-10). Patients with Delirium, Psychiatric illness and SUD were excluded. Busch Francis Catatonia Rating Scale (BFCRS) was used to assess the features of catatonia at baseline and at 48 to 72 hours. Tofisopam 50-100mg/day was administered. Changes in BP, RR, spO2 and GCS was noted. Paired T test, Chi square test, Pearson’s correlation and SPSS 17 was used.Results and Discussion:The mean age was 54.27 ± 16.5 years with 46 males and 14 females. The mean baseline score in BFCRS was 11.73+-1.31. Out of 60 patients, 44 (71%) had response. Response was defined as reduction of catatonic signs to 1 or none on 14 item BFCRS3. Response occurred in CKD, Parkinsonism, Hypertensive encephalopathy, post-CABG and post-GI surgery patients. No response occurred in Septicemia, CKD with Multi-organ Failure. The domains with significant response were Stupor, Mutism, Staring, Posturing, Rigidity, Negativism and Withdrawal without significant side-effects. Tofisopam (mixed dopamine agonist- antagonist)4 modulates the hypo-dopaminergic state in catatonia. Its non-sedative, non-hypotensive5 property can explain the added advantage over lorazepam.Conclusion:Tofisopam can be a safe and effective alternative treatment in Organic Catatonia.

Use of Electroconvulsive Therapy in Adolescents: A Retrospective Study

Background:This study aimed to evaluate the clinical profile of adolescents aged up to 19 years who had received electroconvulsive therapy (ECT).Methods:A retrospective chart review was carried out to identify adolescents aged up to 19 years who had received ECT during the period 2012–2018. Details regarding their sociodemographic and clinical variables and ECT data were extracted from the records.Results:During the study period, a total of 51 adolescents received ECT, and complete records of 50 patients were available for analysis. 4.04% (51 out of 1260) of the patients who received ECT were aged up to 19 years. There was a decreasing trend of use of ECT over the years. The most common diagnosis was schizophrenia (42%), and this was followed by bipolar disorder (22%) and unipolar depression (20%). The mean number of ECTs administered per patient was 8.84 (SD: 5.34; range: 1–21). On the various rating scales, the percentage improvement in patients with psychotic disorders was 77.4%. For patients with depression, the percentage improvement was 77.2%, and that for mania was 80.3%. The percentage improvement in organic catatonia was 64.6%. The number of patients achieving ≥50% response ranged from 87.5% to 100%, and when the response was defined as ≥75% improvement, the proportion of patients varied from 50% to 76.9%. The majority of patients with depression (72.7%) and mania (77.8%) achieved remission. Immediate complications associated with the use of ECT included acute blood pressure changes (18%).Conclusion: ECT is effective and safe in adolescents with severe mental disorders. The clinician should not hesitate and delay the use of ECT in adolescents who require it.

2.6 CATATONIA AND AUTOIMMUNE CONDITIONS IN CHILDREN AND ADOLESCENTS: A DIAGNOSTIC AND THERAPEUTIC CHALLENGE

Pediatric catatonia is a rare and life-threatening syndrome. Approximately 20 percent of juvenile catatonia is associated with such organic causes as genetic, neurometabolic, and autoimmune disorders. Specific treatments are available for some of these conditions and can drastically improve catatonic symptoms if high-dose benzodiazepines or ECT are insufficient. Systemic autoimmune disorders (lupus, Hashimoto encephalopathy, anti-N-methyl-d-aspartate [anti-NMDA], and anti-gamma-aminobutyric acid [anti-GABA] autoimmune encephalitis) are likely to include catatonia associated with other severe mental illness symptoms (psychosis, mania). Some autoimmune disorders may occur in the context of genetic disorders. Autoantibody-negative but probable autoimmune encephalitis may also be associated with these symptoms. Catatonia may be a marker of a more severe and resistant form of autoimmune encephalitis. To facilitate decision making, we formulated a causality assessment score (CAUS) using a stepwise approach and an immunosuppressive therapeutic challenge. Our objectives were to validate the CAUS and define its threshold, retrospectively, for an accurate distinction between organic catatonia and nonorganic catatonia and specifically between autoimmune catatonia and nonorganic catatonia.

A causality algorithm to guide diagnosis and treatment of catatonia due to autoimmune conditions in children and adolescents

ObjectivesPediatric catatonia is a rare and life-threatening syndrome. Around 20% of juvenile catatonia is associated with organic condition (Consoli et al., 2012). Autoimmune conditions represent a diagnostic and therapeutic challenge since specific antibodies can be missed. To facilitate decision making, we recently formulated a causality assessment score (CAUS) using a stepwise approach and an immunosuppressive therapeutic challenge (Ferrafiat et al., 2016). Our objectives were to validate retrospectively CAUS and to define its threshold for an accurate distinction between organic catatonia and non-organic catatonia, and specifically between autoimmune catatonia and non-organic catatonia. MethodTo obtain a sufficient number of cases with organic catatonia, we pooled two samples (N=104) – one from a child psychiatry center, the other from neuro-pediatrics center – expert in catatonia and autoimmune conditions. Organic conditions were diagnosed using a multidisciplinary approach and numerous paraclinical investigations. Given the binary classification needs, we used receiver operating characteristic (ROC) analysis (Peacock and Peacock, 2010) to calculate the best classification threshold. ResultsThe cohort included 67 cases of non-organic catatonia and 37 cases of organic catatonia. ROC analysis showed that the CAUS performance in discriminating both organic catatonia vs. non-organic catatonia, and autoimmune catatonia vs. non-organic catatonia was excellent (Area Under the Curve=0.99). In both analyses, for a CAUS threshold≥5, accuracy equaled to 0.96. ConclusionRegarding juvenile catatonia, the use of the CAUS score algorithm combining a therapeutic challenge and a threshold≥5 may help to diagnose and treat autoimmune conditions even without formal identification of auto-antibodies.

Practical Approach to Management of Catatonia

In this article, we discuss important issues in the management of catatonic symptoms in busy clinical settings. Catatonic symptoms are common among inpatients, not only in psychiatry but also in acute medicine and neurology. Prompt recognition of these symptoms is easy if clinicians maintain a high index of suspicion. Early diagnosis and treatment can reduce the significant morbidity and mortality associated with these cases. Speedy investigation to rule out organic catatonia and identify dangerous complications forms an important part of management. Early treatment with benzodiazepines can aid diagnosis and shorten the duration of catatonia, thereby improving outcomes. Electroconvulsive therapy has an important role where benzodiazepines have been ineffective, but antipsychotics can be potentially harmful. There are a number of other treatment options that are less robustly evidence-based, but supportive management is essential in all cases.

EPA-1754 – Transcranial direct current stimulation (TDCS) in a patient with corpus callosum aplasia and organic catatonia – a case report

Transcranial direct current stimulation (tDCS) is currently discussed as a therapeutic intervention in various psychiatric disorders. Based on the report about the effectiveness of tDCS in a patient with catatonic schizophrenia, we applied bilateral prefrontal tDCS in a patient with corpus callosum aplasia (CCA) and severe catatonia instead of maintenance electroconvulsive therapy (ECT). To investigate whether tDCS can replace ECT in a largely treatment-resistant patient. The 41 year-old male patient showed severe catatonic symptoms since adolescence and was treated by weekly ECT for almost 6 years. Due to cardiac complications and increasing cognitive deficits caused by long-term ECT and weekly anesthesia, tDCS was suggested. The anode was positioned over the left dorsolateral prefrontal cortex (DLPFC), the cathode over the right DLPFC. 2mA tDCS was delivered for 2x 20 minutes (90 minutes break in between), three times a week for the first two weeks, thereafter once to twice weekly. Concomitant medication (clozapine 600 mg/d, aripiprazole 10 mg/d, pirenzepine 50 mg/d, lorazepam 3 mg/d) was continued. So far, more than 20 double sessions of tDCS were applied. ECT was needed once after a period of hospitalisation for 10 days due to pneumonia. Since then the patient has solely received tDCS for more than 13 weeks. Catatonic symptoms resolved further under tDCS compared to ECT (Bush-Francis Catatonia Rating Scale: 27/69 points during ECT, 5/69 during tDCS). tDCS in combination with neuroleptic treatment could be an alternative to ECT in organic catatonia. Further studies are needed to support our hypothesis.

Catatonia Due to a General Medical Condition (Organic Catatonia)

While much has been written about catatonia, there are only a few scholarly reviews focused on catatonia due to a general medical condition, also referred to as organic catatonia. There has been a long list of causative conditions that account for the development of organic catatonia which are informative but not clinically helpful. We performed a literature search using the term ‘catatonia’ covering the last ten years. We found 31 titles of catatonia due to drugs and 76 titles of catatonia due to a general medical condition. Of these, 9 were catatonia due to NMDA antibody associated encephalitis. In order to update this body of knowledge, we have revisited the differential diagnosis of catatonia and attempted to delineate catatonia due to a general medical condition from phenomenologically similar but etiologically disparate conditions. We also focused on catatonia due to systemic lupus erythematosis. We also present a case of catatonia due to hydrocephalus to illustrate treatment issues. In spite of the pharmacologic treatment for catatonia, this patient has not improved. We hope that this review and discussion will aid in the identification and treatment of catatonia due to a general medical condition. Medical causes must be addressed to ensure the best outcome.

Electroconvulsive Therapy for the Treatment of Organic Catatonia Due to Viral Encephalitis

Catatonia is a common presentation to psychiatric services in developing countries. Medical causes of catatonia are common and are difficult to treat. A 20-year-old woman presented with an acute illness consisting of fever, delirium, perceptual abnormalities, and catatonic state. After trials with antiviral medications, benzodiazepines, and atypical antipsychotic medications, she was treated with 6 sessions of electroconvulsive therapy with complete recovery and no complications. Catatonia arising in the background of organic pathology can be treated on similar lines as in other psychiatric disorders. Electroconvulsive therapy can be a safe option that needs consideration in such cases after ruling out the contraindications.

Catatonia: A Brief Update

Catatonia has undergone many changes since it was first described by Kahlbaum in 1874 (“madness of rigidity”). Nowadays, we can distinguish many different ethiologies for this syndrome: Organic catatonia (the most common); affective (the next one); schizophrenic; and drug-induced. In recent reviews, there was no psychiatric disorder in 76% of cases of catatonia. The unitary pathophysiological conception of catatonia (“catatonic syndrome”) is supported by current research, including neurological causes, endocrine-metabolic, immunological, therapeutic and abuse drugs, psychiatric diseases, and others. Differential diagnosis is based on a complete somatic and psychopathological evaluation, and we must also play a biochemical and neuroimaging complementary tests´ battery. When an organic disorder is considered to be the ethiology, therapy should be targeted against this medical condition. If this is not feasible and/or catatonia persist or interferes with medical treatment, the elective therapeutic management should be benzodiazepines and Electroconvulsive Therapy (ECT). Memantine, aripiprazol, and other drugs have been also used with weak results. Keywords: Catatonia. Organic-Psychiatry. Benzodiazepines. Electroconvulsive-Therapy (ECT), Endocrine-Metabolic, Neurological, Immune system, Therapeutic, Pathophysiology, Dopamine

The horse with stripes: a case of anti-NMDA receptor encephalitis.

The horse with stripes: a case of anti-NMDA receptor encephalitis.

The Horse With Stripes

The Horse With Stripes

Drug-induced catatonia

Catatonia is a heterogeneous syndrome that varies in etiology, presentation, course and sequelae. Initially conceptualized as a subtype of schizophrenia, catatonia is now recognized to occur not only with other psychiatric conditions but also with medical conditions and drug-induced and toxic states. While drug-induced catatonia is now a recognized entity, most studies club it with catatonia due to general medical conditions or organic catatonia, thus precluding any meaningful interpretation of such cases. The literature on drug-induced catatonia mostly draws from scattered case reports. This article attempts to review the available literature in this realm and integrate the information in an attempt to explore the epidemiology, etiology, mechanism and treatment of drug-induced catatonia.

Risperidone and Refusal to Eat After Traumatic Brain Injury

Back to table of contents Previous article Next article LetterFull AccessRisperidone and Refusal to Eat After Traumatic Brain InjuryYoshito Mizoguchi, M.D., Akira Monji, M.D., Hiroyuki Isayama, M.D., and Nobutada Tashiro, M.D., Yoshito MizoguchiSearch for more papers by this author, M.D., Akira MonjiSearch for more papers by this author, M.D., Hiroyuki IsayamaSearch for more papers by this author, M.D., and Nobutada TashiroSearch for more papers by this author, M.D., Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JapanPublished Online:1 Feb 2002AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: The major clusters of psychiatric symptoms related to traumatic brain injury (TBI) are those of behavioral sequelae and of cognitive impairment. Clinically, these psychiatric symptoms are a very difficult barrier to overcome in rehabilitation programs.We report a case of a brain-injured patient with refusal to eat who responded to risperidone after failing to respond to other treatments.Case Report>A 66-year-old man without any past psychiatric history suffered traumatic brain injury following a traffic accident and was thereafter admitted to a hospital. A left orbitofrontal lobe contusion and a traumatic subarachnoid hemorrhage were documented by a CT scan. Neurosurgical intervention was not indicated in this case.After the head injury, the patient developed psychiatric symptoms. His behavioral symptoms included increased aggression, agitation with yelling, and depression. Cognitive problems involved decreased attention and problems with memory. Residual deficits also included moderate right hemiparesis. The neurobehavioral deficits continued to be a very difficult barrier to rehabilitative progress. Medication trials with conventional antipsychotics (haloperidol, chlorpromazine) at therapeutic dosages were not effective.In addition, about a month after the traffic accident, he started to refuse eating and would not cooperate with any medical treatment. He actively resisted requests to participate in rehabilitation. He refused to allow either food or medicine to be placed in his mouth. He lost weight, and undernourishment made his rehabilitative progress even more difficult. Medication trials with sulpiride 150 mg/day, amantadine 300 mg/day, fluvoxamine 150 mg/day, and some benzodiazepines did not improve the situation.He was referred to our hospital 2 months after the traffic accident. At that time, risperidone was initiated at a dose of 2 mg/day, and 3 weeks later it was increased to 3 mg/day. About a week after the initiation of risperidone, he began to calm down and showed a greatly reduced level of aggression. He also accepted food without resistance. He agreed to participate in physical therapy 2 weeks after starting the risperidone treatment. Cognitive function also improved. He was discharged home 2 months after starting risperidone treatment and has subsequently been maintained on 3 mg/day of risperidone while pursuing outpatient rehabilitation programs.CommentThe patient's refusal to eat and active resistance to instructions were considered to be catatonic signs.1 Catatonia is a clinical syndrome that has multiple causes.2 There is a case report of organic catatonia following frontal lobe injury;3 the patient's catatonic signs included stereotypic movements, iterations, and verbigerations, and she responded well to clozapine. Gamma-aminobutyric acid (GABA) receptors have been suggested to play a crucial role in catatonia,1 but the precise mechanisms by which psychotropic drugs relieve catatonic symptoms have not yet been elucidated.4 There is one case report of catatonic stupor and mutism that were successfully treated with risperidone;5 a CT scan in that case revealed bilateral orbitofrontal atrophy. Whatever the central mechanism, risperidone appears to be an effective treatment for patients who refuse to eat.Further studies are needed to confirm the effectiveness of risperidone for the treatment of refusal to eat after TBI.References1 Rosebush PI, Hildebrand AM, Furlong BG: Catatonic syndrome in a general psychiatric inpatient population: frequency, clinical presentation and response to lorazepam. J Clin Psychiatry 1990; 51:357-362Medline, Google Scholar2 Gomez EA, Comstock BS, Rosario A: Organic versus functional etiology in catatonia: case report. J Clin Psychiatry 1982; 43:200-201Medline, Google Scholar3 Rommel O, Tegenthoff M, Widdig W, et al: Organic catatonia following frontal lobe injury: response to clozapine. J Neuropsychiatry Clin Neurosci 1998; 10:237-238Link, Google Scholar4 Kopala LC, Caudle C: Acute and long-term effects of risperidone in a case of first-episode catatonic schizophrenia. J Psychopharmacol 1998; 12:314-317Crossref, Medline, Google Scholar5 Cook EH, Olson K, Pliskin N: Response of organic catatonia to risperidone. Arch Gen Psychiatry 1996; 53:82-83Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByJournal of Critical Care, Vol. 30, No. 4The Use of Atypical Antipsychotics After Traumatic Brain InjuryJournal of Head Trauma Rehabilitation, Vol. 23, No. 2 Volume 14Issue 1 February 2002Pages 87-a-88 Metrics History Published online 1 February 2002 Published in print 1 February 2002

Does risperidone have a place in the treatment of nonschizophrenic patients?

There is a now a substantial body of evidence that suggests the new antipsychotic agent, risperidone, may be safe and effective for treating psychotic, affective or behavioural symptoms associated with various disorders other than schizophrenia, schizophreniform disorder or schizo-affective disorder. These conditions include bipolar disorder, obsessive-compulsive disorder, Tourette's syndrome, dementia, Lewy body disease, mental retardation, Parkinson's disease, idiopathic segmental dystonia and organic catatonia. Although much of the data is anecdotal or in the form of open studies, there is now emerging a small number of well controlled investigations supporting efficacy for mania, dementia, behavioural disturbance in mental retardation and conduct disorder. Conventional antipsychotics have long been used, either in a primary capacity or as an adjunct to treat these disorders; however, they have limited benefit, pose significant risks of extrapyramidal side-effects, and may cause the potentially life-threatening neuroleptic malignant syndrome. In contrast, risperidone at the recommended low doses may be efficacious and pose reduced risk of motor side-effects. This article reviews the evidence that risperidone may be an effective new treatment for disorders other than schizophrenia.

Catatonic signs in neuroleptic malignant syndrome

The study assessed catatonic signs in neuroleptic malignant syndrome (NMS). Records of inpatients meeting both stringent research criteria and DSM-IV criteria (n = 11) or only DSM-IV criteria (n = 5) for NMS were identified. The records were systematically rated on a 23-item rating scale for the presence of catatonic signs. Scores for NMS severity were related to the number of catatonic signs. Fifteen patients met both research criteria for catatonia and DSM-IV motor criteria for organic catatonia. The severity scores of NMS correlated with the number of catatonic signs (Spearman p = +.71, P < .005). We conclude that multiple catatonic signs are present in NMS and the severity of NMS predicts the number of catatonic signs.