Refractory Catatonia: Case Report From England
Out on PubMed, from clinicians in England, is this case report:
Refractory catatonia in old age: a case report.
J Med Case Rep. 2021 Aug 14;15(1):406. doi: 10.1186/s13256-021-03000-3.PMID: 34389061
The abstract is copied below:
Background: Catatonia is a clinical syndrome characterized by psychomotor disruption, which often goes undiagnosed. Most reports have focused on interventions and outcomes for catatonia in younger people and those with schizophrenia. The clinical characteristics and course of catatonia in old age are poorly understood. We present a report of an older person whose catatonia was refractory to extensive treatment, and we identify important implications for the management of catatonia in old age.
Case presentation: We describe a 73-year-old white man with longstanding autistic spectrum disorder who presented with symptoms of depression. Following a period of diagnostic uncertainty and failure to improve with antidepressant medication, a lorazepam challenge yielded an abrupt improvement in presentation. The patient was treated extensively with lorazepam, zolpidem, and electroconvulsive therapy during his 16-month hospital admission, but his catatonia ultimately proved refractory to treatment.
Conclusions: Catatonia should be considered promptly as a differential diagnosis in older people presenting with atypical features of functional mental illness. Although partial improvement of catatonic features was achieved using benzodiazepines and electroconvulsive therapy, these were not sustained in our patient. We identified comorbid autistic spectrum disorder, prolonged duration of catatonia, and sensitivity to benzodiazepines as important factors in prognostication in old age.
Keywords: Autistic spectrum disorder; Benzodiazepines; Case report; Catatonia; Electroconvulsive therapy; Old age.
The pdf is here.
And from the text:
Catatonia is a frequently reversible condition with prompt diagnosis and treatment. Our patient was sadly refractory to treatment with benzodiazepines and ECT, and we propose several important factors in this case that may have led to the poor outcome. These include his older age, delayed recognition of catatonia, comorbid autistic spectrum disorder, and sensitivity to benzodiazepine treatment. An obvious limitation to this case report is that we were unable to identify positive prognostic factors owing to the poor outcome for our patient.
(The ECT Courses are the gray bars on the top)
Catatonia is a frequently reversible condition with prompt diagnosis and treatment. Our patient was sadly refractory to treatment with benzodiazepines and ECT, and we propose several important factors in this case that may have led to the poor outcome. These include his older age, delayed recognition of catatonia, comorbid autistic spectrum disorder, and sensitivity to benzodiazepine treatment. An obvious limitation to this case report is that we were unable to identify positive prognostic factors owing to the poor outcome for our patient.
This is well written, sophisticated case report. The clinical signs and symptoms, and treatment trials are carefully reported. The incidental discovery of the benefit of lorazepam when given for sedation prior to a brain CT scan is interesting.The authors struggle to find explanations for the refractoriness of their patient's illness; only the delay in starting ECT (12 weeks) seems plausibly contributory.
ECT is good, nay excellent, for treating catatonia, with high remission rates, but it is not perfect, and some patients will not recover fully.
All catatonia experts/students and geriatric psychiatrists will want to read this case in full (~10 minutes).
The below comment is from Dr. Max Fink, who has a somewhat different take on the care described in this case report:
ReplyDeleteToday’s case is a sad example of medical inexperience. Effective treatments for catatonia were recognized by 1930 with high dose Amytal and in 1934 with the induction of grand mal seizures. Catatonia was buried in schizophrenia in 1890s, then resurrected by the 1990s. Effective treatment protocols were published by 1996: the catatonia rating scale to identify catatonia, a lorazepam remission test to verify catatonia, and relief with high dose lorazepam (8-30mg/day) [successful in 70% cases], and bitemporal placement ECT at a minimum of 3x weekly (daily if febrile or physically incapacitated) with almost universal success. The prescription of neuroleptics, atypical or typical, is interdicted.
The patient was poorly served by failure to follow well documented practices..
Bush et al. Acta Psychiatrica Scandinavica 1996; 93 (2): 129-36, 137-143.
Max