Open access Case report Gen Psych: first published as 10.1136/gpsych-2021-100494 on 3 September 2021. Downloaded from Does recurrent catatonia manifest in a similar fashion in all the episodes of mood disorder? A case series with literature review Santanu Nath ,1 Rosali Bhoi,2 Biswaranjan Mishra,2 Susanta Padhy2 To cite: Nath S, Bhoi R, ABSTRACT conditions, catatonia occurs more frequently Mishra B, et al. Does Catatonia, originally conceptualised by Kahlbaum in 1868, with mood disorders than with non-affective recurrent catatonia manifest is a neuropsychiatric condition that has been found to psychosis such as schizophrenia.2 There are in a similar fashion in all the occur concomitantly with several organic and psychiatric episodes of mood disorder? examples in the literature that point to the conditions. Starting from the era of Kraepelin and Bleuler, A case series with literature recurrent nature of catatonia that occurs in this condition was faultily linked with schizophrenia review. General Psychiatry the setting of the relapsing-remitting course alone; however, over time, greater associations have 2021;34:e100494. doi:10.1136/ of mood disorders: the catatonia understood gpsych-2021-100494 been found between catatonia and mood disorders. as a phenotypical manifestation within the Despite the availability of several reports supporting 1 Received 29 January 2021 this finding, there is a relative paucity of studies that particular mood episode. When a patient Accepted 16 August 2021 specifically focus on catatonia to be the first symptom presents with recurrent catatonia, clinicians manifestation heralding a subsequent mood episode. In should attempt to identify the underlying addition, there is scant literature to determine whether conditions that otherwise remain masked there are specific presentations of catatonia that show under the catatonic presentation. A detailed greater associations with mood disorders and whether assessment after catatonia management is these signs and symptoms recur in a stereotypical fashion always needed to diagnose the underlying in the subsequent mood episodes in the lifetime of an psychiatric disorder, which will entail a holistic individual. We hereby report two cases with a diagnosis of management. There is a paucity of literature mood disorders (bipolar disorder and recurrent depressive disorder) who had catatonia as the initial symptom not that suggests catatonia to be the first pheno- http://gpsych.bmj.com/ only at presentation but also at subsequent episodes. typical manifestation of a mood episode. We The report emphasises that recurrent catatonia can be hereby report a series of two cases in which the initial clinical manifestation of an underlying mood catatonia was the first symptom manifesta- episode, which appears otherwise masked behind the tion of all the mood episodes in both along catatonic presentation. These catatonic symptoms can with its persistence in a similar fashion in all be interestingly similar in all the subsequent episodes. the episodes. We will also briefly review the A detailed clinical evaluation is thus warranted after existing literature about recurrent catatonia catatonia has been duly treated to provide a holistic and its association with episodes of mood on September 24, 2021 by guest. Protected copyright. management. disorders. INTRODUCTION Catatonia is a neuropsychiatric condition char- CASE HISTORY © Author(s) (or their employer(s)) 2021. Re- use acterised by alterations in motor behaviour, Case 1 permitted under CC BY-NC. No thought, affect and vigilance. Originally A 25- year- old Hindu unmarried man with commercial re- use. See rights conceptualised by Kahlbaum in 1868, cata- unremarkable family and personal history but and permissions. Published by tonia was initially incorporated in dementia with past two episodes of suggestive catatonia BMJ. 1 praecox in 1893 by Kraepelin and later in presented with a 3- day history of remaining Psychiatry, All India Institute 1 of Medical Sciences, Deoghar, schizophrenia by Bleuler. Over the years, mute, maintaining a posture for long and Jharkhand, India catatonia has been found to be associated refusing to interact with others along with 2Psychiatry, All India Institute of with not only schizophrenia but also mood refusal to eat and drink. His initial mental Medical Sciences, Bhubaneswar, disorders and a multitude of organic brain status examination (MSE) revealed catatonia Odisha, India conditions such as epilepsy, neurodegener- (mutism, negativism and posturing) (Bush- Correspondence to ative disorders, tumours, haemorrhage and Francis Catatonia Rating Scale (BFCRS) 3 Dr Santanu Nath; neuro- infections. Recent advances have led score=16), and it precluded further exam- beta. santanu@ gmail. com to the understanding that among psychiatric ination of his affect, thought and perception. Nath S, et al. General Psychiatry 2021;34:e100494. doi:10.1136/gpsych-2021-100494 1 General Psychiatry Gen Psych: first published as 10.1136/gpsych-2021-100494 on 3 September 2021. Downloaded from He was admitted, and on investigations, his haemato- Rating Scale (HDRS) score=24),6 he was started on logical and biochemical parameters (complete haemo- olanzapine- fluoxetine (5 mg+20 mg) combination (OFC), gram; renal, hepatic and thyroid function tests; serum and he was given a further course of six ECTs. There was electrolytes; creatinine phosphokinase) and MRI of his significant improvement in his depressive symptoms brain were within the normal range. He was initially (HDRS score=13).6 During this time, we tried to assess managed with the injection of lorazepam 4 to 8 mg/day, the causes for the previous three catatonic episodes using which led to remission of catatonia in 3 days (BFCRS information shared by his wife, and it revealed that all score=0).3 On remission of catatonia, he started to show such episodes in the last 4 years were apparently provoked goal- directed hyperactivity and talkativeness with thought with stressful life events (property dispute with relatives, content revealing grandiosity, which gradually increased financial loss, etc) after which he had similar catatonic for the next few days. During this time, his MSE revealed features (mutism, negativism, posturing, withdrawal) increased speech output with prolixity, increased psycho- that resolved with treatments and would be followed by motor activity, delusion of grandiosity and no percep- low mood, lethargy, increased concern for family issues, tual abnormalities (Young Mania Rating Scale (YMRS) feeling worthless, anorexia and hypersomnolence. His score=26).4 Further clarification of the past two catatonia provisional diagnosis was hence changed to recurrent episodes revealed that in each episode, he would first depressive disorder with current episode of severe depres- present with the similar type of symptoms such as mutism, sion with catatonia. He was discharged on OFC, and on a posturing and negativism (and stupor as an additional follow- up after 2 weeks, and a month later he was found symptom in the first episode), which would be the initial to be well. We however got a call from his wife 4 months presentation and have an abrupt onset with a dramatic later that there was another similar episode for which he response to treatments prescribed by a psychiatrist that was taken to a tertiary care psychiatric hospital and was would ultimately manifest in a similar mental state similar managed in similar lines. We however planned to follow to the index episode (ie, mania). However, in none of him prospectively having a suspicion whether he may these episodes, he continued with the psychiatrist’s land up in a bipolar disorder diagnosis in future. advice. Considering the past episodes and the current index presentation, he received a provisional diagnosis of bipolar affective disorder, current episode mania with DISCUSSION psychosis according to ICD-10,5 and he was started on Catatonia has long been thought to be associated more tablet sodium valproate 1 g/day, quetiapine 100 mg/day with schizophrenia, starting from the era of Kraepelin and and lorazepam 2 mg/day, with which he showed signifi- Bleuler. However, Kahlbaum, who initially gave the descrip- cant improvement in the next 3 weeks (YMRS score=11).4 tions of catatonia along with its types (table 1) in 1868, He was discharged on this regimen and on a subsequent conceptualised it to be associated mostly with mood disor- 1 follow- up after a month, he was found to maintain well. ders. Over the years, its association with mood disorders http://gpsych.bmj.com/ has been strengthened. Catatonic signs have consistently Case 2 been reported with mood disorders in 13% to 31% cases.7 A 42- year- old Hindu married man with no significant Various systematic studies reported that, among hospital- family and personal history but with a history of catatonia ised manic patients, more than 25% meet the criteria for thrice in the last 4 years presented with a 5-day history catatonia, whereas among patients with catatonia, more 8 of remaining mute, not taking food and water, not inter- than half meet the criteria for a manic- depressive illness. 9 acting with family members and moving away from any The seminal paper of Barnes et al also favoured this asso- interventions. On admission, his vital parameters were ciation. Thirty- six per cent of 25 patients with catatonia on September 24, 2021 by guest. Protected copyright. within the normal range, and his initial MSE revealed whom they described over a span of 12 years