ECT for Catatonia in an Adolescent-Case Report

 Electroconvulsive therapy in an adolescent patient with catatonia: a case report.

Clermont A, Loubriel D, Li E, Mitera D, Samuels S.Neurocase. 2020 Dec 9:1-4. doi: 10.1080/13554794.2020.1859545. Online ahead of print.PMID: 33297838

The abstract is copied below:

Catatonia is characterized by motor and behavioral symptoms and can arise in a wide variety of medical and psychiatric conditions. We describe the case of a 16-year-old female with a history of anxiety and depression who presented with prominent symptoms of negativism, initially diagnosed as conversion disorder. She failed to respond to increasing doses of benzodiazepines; after over six weeks of hospitalization, she received electroconvulsive therapy (ECT), resulting in significant remission of symptoms. This case demonstrates the importance of prompt diagnosis and treatment of catatonia in adolescent patients, as well as the safety and efficacy of ECT in this population. Abbreviations: AACAP: American Academy of Child and Adolescent Psychiatry; BPAD: Bipolar affective disorder; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-5: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; ECT: Electroconvulsive therapy; NMDA: N-methyl-D-aspartate.

Keywords: Catatonia; adolescent psychiatry; benzodiazepines; bipolar disorder; conversion disorder; electroconvulsive therapy.

Excerpts from the text are copied below:

The patient’s behavior began to change three months prior
to presenting to our facility, when she became progressively
weaker and less active, lying in bed and not opening her eyes.
Two months prior to presentation, she was admitted to an
outside psychiatric hospital for three weeks. She was initially
diagnosed with a suspected mood disorder and started on
risperidone for three days, which was discontinued due to
a dystonic reaction (torticollis). Her oral intake decreased during
the initial portion of her admission, leading to changes in
vital signs; therefore she was transferred to the pediatric medicine
service. While briefly on the pediatric ward, consultation-liaison
child and adolescent psychiatrists suspected that she
might be catatonic and performed a lorazepam challenge test,
which was positive, confirming the catatonia diagnosis.
Once the patient was stabilized, she was transferred back to
the inpatient psychiatric unit, where she continued to be treated
for presumed catatonia with oral lorazepam. Shortly thereafter,
the inpatient team noted that the patient only displayed
significant catatonic symptoms while in the presence of her
parents, but otherwise was functioning relatively well. Given
these findings, it was presumed that her presentation was more
consistent with conversion disorder. She was discharged in
early December on a lorazepam taper, and at that time she
was able to eat, walk, and talk. However, two nights later, the
patient’s mother found her on the floor of their home and
brought her to another outside hospital, where the emergency
department again provided a diagnosis of conversion disorder.
She was subsequently transferred to our facility at her mother’s
request for neurological workup.

...The patient received 8 bilateral ECT treatments using a MECTA spECTrum 5000Q.
Each treatment was tolerated well without complication.
Patient was initially titrated at a frequency of 20 Hz, pulse
width of 0.5 msec, and duration of 2 sec to determine seizure
threshold. The following settings were utilized and continued
throughout her treatment course at 150% above seizure
threshold as follows:
Pulse width: 0.5 msec
Frequency: 20 Hz
Duration: 5 sec
Current: 800 mA
Charge: 80 mC
The patient received midazolam 4 mg IV for postictal agitation
and ketorolac 15 mg IV for headache.
After her second treatment, the patient awoke, showered,
began eating on her own, and stated she was feeling better.
Her parents assessed her to be “70% improved” toward her
baseline, but she remained noticeably slowed in speech and
movement. After her fourth ECT treatment, the patient stated
she was reluctant to undergo further sessions, denying any
continuing symptoms and citing concerns about memory
loss. However, after several days of refusing treatment, she
became increasingly paranoid and isolative, exhibiting signs
of perseveration, confabulation, labile affect, and delusional
thinking. Due to these emerging psychotic symptoms, at the
recommendation of her care team and with the ongoing consent
of her parents, ECT was resumed after a six-day gap. 

The patient was transferred from the pediatric medical ward
to the inpatient psychiatric unit for continued stabilization. She
remained hospitalized for another 43 days for ongoing treatment,
diagnostic clarification, and medication titration. She
received an additional five sessions of bilateral ECT during this
time, by the end of which she had a Bush-Francis score of 0. She
developed symptoms of elevated mood, grandiosity, and
hypersexuality during her inpatient psychiatric stay; this presentation,
taken in conjunction with her previous symptoms
prior to ECT, led to an ultimate diagnosis of bipolar I affective
disorder (BPAD) with psychotic features and catatonia. After
multiple failed medication trials at therapeutic doses, including
chlorpromazine, aripiprazole, and lithium, she was discharged
on olanzapine 10 mg at bedtime, a lorazepam taper, and
maintenance ECT.

...Of note, our patient also received a first-generation antipsychotic
(chlorpromazine), although antipsychotics are typically
not recommended in catatonia due to the risk of worsening
catatonic symptoms or precipitating neuroleptic malignant
syndrome (Benarous et al., 2018; Dhossche & Withane, 2019).
This demonstrates the importance of correctly diagnosing catatonia,
a condition that can be difficult to recognize, particularly
for non-psychiatrist physicians (Anand et al., 2019;
Dhossche & Withane, 2019). Although conversion disorder
and catatonia can present similarly, they are not the same
condition and are treated differently (Ryznar & Wilcox, 2019).
We believe that initial confusion over this patient’s diagnosis
was one of the factors that complicated and delayed her
treatment.

This is a well-presented case report of a very typical clinical situation with an adolescent patient displaying catatonic symptoms. Unfortunately, as described, the diagnosis is often delayed and definitive treatment deferred. ECT's rapid, dramatic effects are again noted.

ECT for adolescents remains uncommon enough that reporting cases such as this in the literature serves an important function. These authors are to be applauded for the excellent care provided and their willingness to publish this report.

(Please see blog post of October 29th, 2020, for a similar case.)

received a total of eight sessions and continued to regain

function.