Why do neurologists miss catatonia in neurology emergency? A case series and brief literature review

Patient: Female, 92-year-old Final Diagnosis: Dementia with Lewy bodies Symptoms: Catatonia Medication:— Clinical Procedure: Biomarker Specialty: Neurology • Psychiatry Objective: Unusual clinical course Background: Catatonia can occur in various neuropsychiatric disorders and is usually treated with benzodiazepines. So far, although 1 case of dementia with Lewy bodies (DLB) with catatonia has been reported, there have been no reports on patients with DLB whose initial symptom was a catatonia. Here, we present a patient who developed benzodiazepine-resistant catatonia and was subsequently diagnosed with DLB based on DLB biomarkers. Case Report: The patient was a 92-year-old woman who had not been diagnosed with dementia before. At the age of 91, she experienced catatonia and was initially treated with lorazepam, which did not improve her condition. Later, she transferred to our hospital and was treated with amantadine. Amantadine improved her catatonic symptoms; however, a decline in her cognitive function was observed. We therefore explored the cause of cognitive impairment through imaging studies. We found that the patient did not have the core clinical features of DLB (ie, visual hallucinations, parkinsonism, cognitive fluctuations, and rapid eye movement sleep behavior disorder) but had 2 indicative biomarkers on 123 I-metaiodobenzylguanidine myocardial scintigraphy and dopamine transporter imaging. Possible DLB was diagnosed according to the diagnostic criteria. Conclusions: Our case study suggests that catatonia can be an initial symptom of DLB. Moreover, considering the plausible pathophysiology of catatonia in DLB, amantadine treatment may be the most rational choice for the condition when benzodiazepine treatment is ineffective.

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Section: Discussionmentioning

confidence: 99%

“…First, recent studies have reported that catatonia can be easily overlooked by neurologists [ 13 ]. Since DLB usually presents with extrapyramidal signs, catatonia may be confused with the latter [ 13 ]. The very few reports regarding catatonia in DLB may be attributed to the underdiagnosis of catatonia in DLB.…”

Section: Discussionmentioning

confidence: 99%

Catatonia as the Initial Manifestation of Dementia with Lewy Bodies

et al. 2021

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“…31 In one retrospective review, neurology residents failed to identify catatonia on emergency room consultation in all of the 12 patients who eventually received a catatonia diagnosis. 170 A three-year retrospective chart review determined that 59% of patients meeting three or more of the DSM-5 criteria for catatonia in a general medical hospital were not diagnosed with catatonia, even in the third of those cases for which psychiatric consult was obtained. 32 The precise reasons for this under-recognition are not known, but may include the historic errors in nosology, 16 low catatonia knowledge, 31,171,172 lack of physical examinations done by psychiatrists, 173,174 or confusion regarding the opposing clinical features and variable presentations of catatonia.…”

Section: Under-recognition Of Catatoniamentioning

confidence: 99%

<p>Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives</p>

Lloyd¹,

Silverman²,

Kugler³

et al. 2020

NDT

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Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

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“…Unfortunately, both syndromes remain underrecognized and underdiagnosed in the acute care setting. 4,5 Table 1 summarizes the current DSM-5 diagnostic criteria for catatonia and delirium. 2 Catatonia was originally described by Kahlbaum in 1874 as a syndrome consisting of catalepsy, waxy flexibility, muscle rigidity, mutism, negativism, and autonomic disturbance.…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Benzodiazepine Withdrawal Catatonia, Delirium, and Seizures in a Patient With Schizoaffective Disorder

Mader

Rathore

England

et al. 2020

Journal of Investigative Medicine High Impact Case Reports

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Benzodiazepine withdrawal symptoms vary from mild anxiety to life-threatening delirium or seizures. In susceptible individuals, such as those with mood disorders, benzodiazepine withdrawal may also precipitate catatonia. A 26-year-old man with schizoaffective disorder (depressed type with catatonia) ran out of lorazepam and presented with catatonia, delirium, and seizures. He was taking olanzapine, venlafaxine, and trazodone for schizoaffective disorder. Lorazepam 2 mg twice daily kept him free of catatonia for 6 months. Besides catatonia and delirium, lorazepam withdrawal also triggered convulsive seizures and nonconvulsive status epilepticus. He was admitted to the intensive care unit where he underwent continuous video-EEG monitoring. Catatonia resolved with lorazepam on day 2. Seizures stopped with levetiracetam, lacosamide, and propofol on day 4. His mental status was normal when he was discharged on day 6. If not immediately recognized and treated, catatonia and delirium can lead to significant morbidity or mortality. Unfortunately, physicians tend to overlook catatonia and delirium, especially if both syndromes are present. At first, we suspected that our patient had ictal catatonia, but video-EEG showed no clear-cut correlation between catatonia, seizures, and epileptiform activity. As with prior observations, the patient’s catatonia was more sensitive to benzodiazepine withdrawal and treatment than his seizures. The efficacy of benzodiazepines in aborting catatonia, seizures, and mixed delirium-catatonia syndromes suggests a key pathogenetic role of abnormal GABA neurotransmission in these brain disorders.

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Why do neurologists miss catatonia in neurology emergency? A case series and brief literature review

Cited by 34 publications

References 31 publications

Catatonia as the Initial Manifestation of Dementia with Lewy Bodies

Catatonia as the Initial Manifestation of Dementia with Lewy Bodies

<p>Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives</p>

Benzodiazepine Withdrawal Catatonia, Delirium, and Seizures in a Patient With Schizoaffective Disorder

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