Catatonia Case Report From Belgium: Atypical Symptom

 Out on PubMed is this case report from clinicians in Belgium:[Repetitive inappropriate sexual behaviour as a symptom of agitated depression: catatonic stereotypy?].Boonen I, de Velde NV, Tandt H, De Smul C, Lemmens G.

Tijdschr Psychiatr. 2021;63(4):301-304.PMID: 33913147 Dutch

Some of the text, translated by Google:

Patient A, a 55-year-old woman with bipolar disorder, was hospitalized with a depression with psychotic features and catatonia. They had a first depressive episode (with psychotic characteristics) at the age of 53. This was followed by a hypomanic episode and a second depressive episode with psychotic and catatonic characteristics that are successful was treated with ECT. Patient was taking at the start of admission the following medication: lithium carbonate 750 mg daily, trazodone 200 mg daily and estradiol valerate 2 mg daily. In addition, the patient also took 8 mg lorazepam daily because of suspected catatonia. The current depressive episode was characterized by pronounced loss of interest, insomnia, concentration problems and subjective memory problems. Next visual hallucinations were mood congruent delusions, such as misgivings, the belief dementia to have and to die. The psychomotor skills were clearly disturbed the patient was unable to remain seated in her chair during the recording call. In addition, there was of stereotypical lip movements, pacing and repetitive rubbing movements on the genitals similar to actions performed at masturbation. This maladaptive and repetitive touching of the genitals occurred several times a day the common areas of the psychiatric ward of the hospital. The patient failed to stop these repetitive rubbing movements despite verbal admonition from the nursing staff. Nor did these movements provide relief the (sexual) arousal she constantly reported. There was no other maladaptive behavior or other form from disinhibition to others

...The dose of lorazepam was titrated to 16 mg per day with insufficient response (total score BFCRS: 11). A transition was made to ECT with bitemporal electrodeposition 3 times a week. After 5 sessions of ECT was there is a significant improvement in both the catatonia features if it is repetitive sexually maladjusted behaviour. Clinical remission was achieved after 9 sessions ECT. During admission, lorazepam could be gradually tapered off. A return of depressive symptoms forced the continuation of the ECT with an additional 11 sessions. Maintenance treatment after ECT existed from continuing lithium carbonate, 1200 mg daily with a lithium level of 0.6 mmol /l.

...Conclusion:

We described the presence of repetitive maladaptive sexual behavior in a patient with depression with psychotic features. We set catatonia as probability diagnosis given the combination of following characteristics: excitement / agitation, stereotype and rigidity. The repetitive maladaptive sexual behavior in that case we can consider it as a stereotype within the catatonia, which is simultaneous with other catatonia characteristics and the underlying depressive state picture improved under ECT. The literature has previously hypothesized that tics and self-injurious behavior within the autism spectrum disorder can be a stereotype fitting within catatonia and improving under ECT. The lack of clarity about the definition and diagnostics of catatonia raises a counter-argument to this one hypothesis as there may be discussion about the diagnosis of catatonia in our patient. It's repetitive inappropriate sexual behavior can in that case be explained as an expression of psychomotor agitation and so be a symptom of agitated depression. Possibly the psychomotor symptoms are in catatonia and agitated depression are on the same spectrum of impaired motor skills and speech. More research is needed to create unanimity on the definition of catatonia. In addition, there is also more need to investigate the occurrence of repetitive inappropriate sexual behavior within the context of (agitated) depression and catatonia so that can be tested whether this behavior becomes a stereotype within catatonia.

This is an interesting case report of agitated psychomotor behavior including repetitive inappropriate genital touching in the context of severe bipolar disorder. Several courses of ECT were successful for mood episode resolution, and maintenance ECT was subsequently helpful. Catatonia and psychomotor symptom  specialists will be interested in the phenotypic borders of the catatonia diagnosis, as discussed by these authors. Google translation of the whole case and reading should take ~15 minutes.