Catatonia Due to General Medical Conditions in Psychiatric Patients: Implications for Clinical Practice

Abstract

Catatonic syndrome is frequently observed over the course of severe mental disorders and general medical conditions, but when catatonia occurs in psychiatric patients with co-morbid medical or neurologic conditions, diagnosis and management may be challenging. Several medical conditions may cause catatonia in psychiatric patients, but some, such as brain injury, infections, hyponatremia and critical illness, may be most relevant in this population. Alongside appropriate etiologic treatment, benzodiazepines and electroconvulsive therapy in refractory cases are effective and safe, and may resolve catatonic syndrome rapidly. When newly-onset psychotic symptoms in catatonic patients with established psychotic disorders occur, delirium should be suspected and appropriately managed. An extensive clinical and laboratory diagnostic workup to determine the underlying etiology of catatonic syndrome should be carried out. In cases of acute multi-morbidity, the exact cause of catatonic syndrome in psychiatric patients may be unclear. It is recommended to avoid antipsychotic drugs in acutely catatonic patients, because they may exacerbate the catatonic symptoms. The akinetic type of catatonia should be differentiated from hypoactive delirium, as treatments for these syndromes differ substantially. When a psychiatric patient presents with symptomatology of both catatonia and delirium, treatment is particularly challenging.

Rebound Catatonia Associated With Injectable Paliperidone

“…A comprehensive workup for catatonia may involve various tests, including complete blood count, comprehensive metabolic panel, thyroid panel, urinalysis, urine toxicology, ESR, serum creatinine phosphokinase, serum iron, antinuclear antibody (ANA) panel, CT, MRI, EEG, lumbar puncture, CSF analysis, and other clinically relevant studies. It is crucial to consider a broad differential and conduct a thorough assessment when evaluating patients presenting with catatonia in the emergency department [ 18 , 20 ].…”

“…Both typical and atypical antipsychotics can contribute to maintaining or worsening catatonia and increase the risk of developing NMS, with a higher risk associated with neuroleptics that have strong D2 antagonism [ 17 , 19 ]. Therefore, in cases of neuroleptic-induced catatonia, it is generally recommended to discontinue the antipsychotic and administer benzodiazepines or electroconvulsive therapy (ECT) [ 14 , 19 , 20 ]. Other treatments include zolpidem, a positive allosteric modulator of the GABA-A receptor, glutamate antagonists, anti-epileptic drugs such as valproic acid and carbamazepine, and repetitive transcranial magnetic stimulation (rTMS) [ 18 , 20 ].…”

“…Therefore, in cases of neuroleptic-induced catatonia, it is generally recommended to discontinue the antipsychotic and administer benzodiazepines or electroconvulsive therapy (ECT) [ 14 , 19 , 20 ]. Other treatments include zolpidem, a positive allosteric modulator of the GABA-A receptor, glutamate antagonists, anti-epileptic drugs such as valproic acid and carbamazepine, and repetitive transcranial magnetic stimulation (rTMS) [ 18 , 20 ].…”

“…Atypical antipsychotics may have a role in cases with residual psychotic symptoms such as delusions and hallucinations, especially in schizophrenia, or as a prophylactic treatment in psychosis and mood disorders [ 16 , 18 , 20 ]. Atypical antipsychotics with low D2 blockade, such as quetiapine, olanzapine, or aripiprazole with D2 partial agonism, should be preferred in these populations [ 18 , 20 ].…”

“…Despite improved recognition and treatment, malignant catatonia has a mortality rate of approximately 9-10% [ 18 ]. Medical complications associated with catatonia include dehydration, acute renal failure, urinary retention, aspiration pneumonia, deep venous thrombosis, pulmonary embolism, rhabdomyolysis, hypoglycemia, cachexia, EKG changes, respiratory arrest, myocardial infarction, cardiac arrest, and death [ 19 , 20 ].…”