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Chronic Excited Catatonia: a Case Report Journal of Case Reports: Clinical & Medical Open Access Case Report Chronic Excited Catatonia: A Case Report Shawn Yehudian1 and Dolores Malaspina2* 1Creedmoor Psychiatric Center, USA 2Department of Psychiatry, New York University School of Medicine, USA A R T I C L E I N F O A B S T R A C T Article history: Received: 26 February 2018 The fifth edition of the DSM considers catatonia a separate disorder for the Accepted: 21 June 2018 Published: 26 June 2018 first time. The diagnosis requires the presence of at least three of its twelve Keywords: characteristic features. Catatonia may occur in the context of numerous Chronic excited; GABA-A; medical conditions and psychiatric disorders, including affective disorders and NMDA schizophrenia. It is listed as “unspecified” when the nature of the underlying Copyright: © 2018 Malaspina D et al., condition has not been elucidated. Recognition of catatonia can be a J Case Rep Clin Med This is an open access article distributed complicated process, as there is a range of symptoms that can occur in myriad under the Creative Commons Attribution License, which permits unrestricted use, combinations. Catatonia is usually not optimally treated with antipsychotics, distribution, and reproduction in any medium, provided the original work is which may present a problem in patients who carry a diagnosis of properly cited. schizophrenia and catatonia. This report describes a case of chronic Citation this article: Yehudian S, hyperkinetic (excited) catatonia, a form of catatonia that is not as well-known Malaspina D. Chronic Excited Catatonia: A Case Report. J Case Rep Clin Med. 2018; as other forms. The prominent negativistic features interfered with treatment, 2(1):118. (including the refusal of oral medications), and the hyperkinetic activity threatened the patient’s health and the milieu of the inpatient unit. Ultimately, high-dose intramuscular lorazepam injections achieved only a partial remission. This report may stimulate increased rates of recognition of hyperkinetic catatonia. Introduction Catatonia is described as a psychomotor disturbance that can include an array of symptoms. The exact pathophysiology is unknown and may be heterogeneous. According to the DSM-5, catatonia may be associated with another mental disorder. The diagnosis is present in cases of psychiatric, neurodevelopmental and other medical conditions. The overall prevalence of catatonia is unknown, but over 15% of psychiatric inpatients may meet criteria for the condition [1]. DSM-5 lists 12 features, of which at least three are required for diagnosis: 1) Stupor (absence of psychomotor activity); 2) catalepsy (passive induction of a posture that is then held against gravity); 3) waxy flexibility (slight, even Correspondence: resistance to positioning by the examiner); 4) mutism (which can be selective); Dolores Malaspina, 5) negativism (no response or resistance to external stimuli); 6) posturing Department of Psychiatry, New York University School of (spontaneous and active maintenance of a posture against gravity); 7) Medicine, 1 Park Avenue, 8th mannerisms (caricatures of normal actions); 8) stereotypy (repetitive non-goal- Floor, Rm 222, Icahn Mt. Sinai School of Medicine, New York, NY: directed movements); 9) agitation (not influenced by external stimuli); 10) Tel: 718 877-5708; Email: [email protected] Chronic Excited Catatonia: A Case Report. J Case Rep Clin Med. 2018; 2(1):118. Journal of Case Reports: Clinical & Medical grimacing; 11) echolalia; 12) echopraxia. The most which can precipitate muscle spasms [8]. Laboratory common signs of catatonia are immobility, mutism, and studies including complete blood count, blood urea refusal to eat [2]. There is no specific feature of nitrogen, creatinine, serum glucose level, thyroid function catatonia that is required for its diagnosis. tests, rapid plasma reagent, vitamins B12 & folate, liver Accompanying features include abnormal motor function tests, creatine phosphokinase, functioning, inability to suppress complex motor activities HIV test, serum iron, urine toxicology, urinalysis, (such as stereotypy), and even life-threatening physical electroencephalogram, anti-NMDA receptor antibody, symptoms such as autonomic instability [3]. and brain MRI may assist in ruling out organic causes. Four main types of catatonia have been described, Of importance, catatonia is best treated with including classic withdrawn, periodic, malignant and benzodiazepines and with ECT for medication-refractory hyperkinetic (excited). The classic withdrawn type may cases. Other treatments that are likely less effective and include stupor, mutism, negativism, and posturing with of which there is a small number of studies include the minimal movement despite being awake and watchful. GABA-A agonist zolpidem, Repetitive Transcranial Malignant catatonia includes fever and autonomic Magnetic Stimulation (rTMS), NMDA antagonists instability and is a risk factor for neuroleptic malignant amantadine and memantine, and topiramate, which syndrome. Periodic catatonia, considered to be a works on GABA receptors [9]. The response from genetic form of catatonia associated with schizophrenia memantine suggests that glutamate hyperactivity might [4], is typified by recurrent brief episodes (days) of be related to catatonic symptoms. NMDA hyperactivity hyperkinetic catatonia, separated by asymptomatic may cause dysregulation of GABA-A function. NMDA intervals. Hyperkinetic (excited) catatonia does not antagonists indirect-ly restore GABA-A function in the encompass the quintessential stupor that is seen in the frontal lobes. GABA-A agonists such as zolpidem may classic withdrawn type. Instead, it entails excessive correct dysregulation of GABA ergic tone in the motor activity with no end goal. Other variable features orbitofrontal cortex [10]. can include disorientation or disorganized speech, According to a recent review article, the treatment of violent, aggressive acts and physical injuries without catatonia may involve a stepwise treatment algorithm, awareness [5]. A recent article highlighted that starting with intravenous lorazepam, followed by ECT, catatonia is under-diagnosed in general hospitals, and amantadine, an anti-epileptic and ending with an cites agitation and grimacing (among others) as criteria atypical antipsychotic in combination with lorazepam [6]. that are often overlooked in patients with catatonia [6], Often, an unsuccessful lorazepam treatment leads to a and therefore are less likely to be diagnosed. treat-ment plan of ECT, especially in hyperkinetic Catatonia may be associated with malignant catatonia; however, it is difficult to administer, especially hyperthermia, Parkinson’s disease, and metabolic- in the context of refusal by the patient or proxy. The induced stupor. Additionally, the NMDA receptor third step in the algorithm is amantadine, a glutamate antibody may be implicated as a precipitant of antagonist. Carbamazepine or valproic acid is the next catatonia [7]. The differential diagnosis for catatonia step, followed by aripiprazole (with its partial D2 can include about 100 different medical conditions, such agonism) or clozapine, atypical antipsychotics that may as metabolic disorders, infections (HIV), autoimmune have a lower chance of exacerbating catatonia, versus disorders (systemic lupus erythematosus), paraneoplastic typical high potency ones. These atypicals are especially encephalitis, head trauma and stroke. Notably, an recommended in patients with catatonia and a primary overlapping set of features with catatonia is the “Stiff- psychotic illness. If this is not sufficient, adding Person Syndrome,” a rare neurological disorder lorazepam to the antipsychotic may be therapeutic. associated with autoimmune disorders which includes Notably, there is evidence that catatonia due to a sensitivity to noise, touch, and emotional distress, and primary psychotic illness such as schizophrenia may be Chronic Excited Catatonia: A Case Report. J Case Rep Clin Med. 2018; 2(1):118. Journal of Case Reports: Clinical & Medical less responsive to just benzodiazepines [11], and noted to be posturing at the hospital, a symptom of therefore the addition of an atypical antipsychotic to a catatonia, and was described as being delusional, benzodiazepine may be warranted early on in irritable, and with impoverished thought content. She treatment if benzodiazepines are not successful. As was eventually discharged on risperidone after a two- described above, ECT may be complicated to week hospitalization. She was in and out of hospitals administer. Amantadine may increase the likelihood of several times as a result of bizarre behavior, with psychosis and therefore should be used with caution in hospitalizations leading to minimal lasting improvements. schizophrenic patients. 4.2. Social history: The family described the patient as Case Presentation a shy child growing up, with healthy development and Ms. X, in her 30s, a woman of Jewish descent, never upbringing. There was no significant substance use married, who is a fraternal twin and whose twin is history except for a remote self-reported history of healthy. She was enrolled in a technical graduate school alcohol use years prior to her psychiatric symptoms. She before the onset of schizophrenia and was living with had no legal history, no family history of psychiatric her parents prior to hospitalization. Leading up to this illness and no exposure to trauma. She graduated high admission, the patient evidenced marked isolation
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