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A case series of catatonia: Lessons to learn

Article · June 2015

DOI: 10.4038/sljpsyc.v6i1.8059

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 A case series of catatonia: Lessons to learn

Brief report

A case series of catatonia: Lessons to learn

LLA Isuru, KALA Kuruppuarachchi

Summary aware of medical causes of catatonia. The patients

Catatonia is a neuropsychiatric syndrome which is with B12 and folic acid deficiency and
associated with a diverse range of psychiatric and hyponatreamia made a dramatic recovery after
medical disorders. Current nosological approach correction of the underlying cause, and the patient
supports the view that catatonia is a separate clinical with SLE and viral encephalitis also showed a good
entity. We present a case series of patients with clear clinical response following appropriate treatment.
catatonic symptoms associated with or as a result of Early identification of underlying cause and
vitamin B12 and folic acid deficiency, hyponatreamia, initiation of treatment facilitates a better outcome
Systemic Lupus Erythromatosis (SLE) and viral in patients with catatonia.
encephalitis, highlighting the importance of being SL J Psychiatry 2015; 6(1): 29-31

Introduction she became mute and showed posturing. There was no

past history of significant medical or psychiatric
Catatonia can be described as a neuropsychiatric conditions. Mental state examination revealed evidence
syndrome, and its common clinical features are mutism, of self-neglect and waxy flexibility in addition to mutism.
stupor, refusal to eat or drink, posturing and excitement Other than mild pallor she was physically normal. Her
or hypokinesia (1). Catatonia was described and haemoglobin level was 9.6g/dl with increased mean
introduced by Kahl Kahlbaum in 1874. Subsequently corpuscular volume (MCV). Her blood picture was very
Emil Kreapalin included catatonia as a subcategory of compatible with folate and vitamin B12 deficiency. All
dementia praecox and later considered it as a psy- the other investigations including liver function tests,
chiatric condition often associated with schizophrenia renal function tests, serum electrolytes, C-reactive
(2). For more than a century catatonia was regarded as protein, thyroid function tests and computed
a subtype of schizophrenia. The DSM-5 does not tomography (CI) of the brain were normal. She did not
recognise catatonia as an independent disorder, but respond to an array of treatment modalities such as an
identifies it as a specifier of other mental disorders or adequate course of risperidone, lorazepam, electro-
includes it under the ‘unspecified’ category for example, convulsive therapy and chemical abreaction. However,
schizophrenia co-morbid with catatonia (3). The she showed a marked clinical and functional
underlying aetiological factors for the syndrome are improvement within 2 weeks after treatment with
many and are commonly associated with mood disorders hydroxycobalamine 1 mg intra muscularly on alter-
(4). Catatonia is also associated with many medical and native days for 10 days and folic acid 5 mg daily. Her
neurological conditions (1,5,7). Prospective studies haemoglobin level improved (12.5 mg/dl) and blood
have demonstrated that catatonia in psychiatry is due picture became normal in subsequent tests. However,
to medical conditions in 20%-25% of presentations (6). we could not measure red cell folate and serum B12
Neuro-psychiatric conditions such as delirious mania, levels due to practical difficulties. She has remained
neuroleptic malignant syndrome, autistic spectrum well for nearly four years up to now, without any
disorders, anti-NMDA receptor encephalitis are also psychotropic medication.
associated with catatonia (7).
Case 2
Identification of the underlying organic cause, if any,
should be a priority in the management of catatonia. A married male in his fifties had been commenced on
Prompt treatment in the early phases of catatonia is fluoxetine for a depressive disorder. Two weeks later he
crucial to obtain a lasting abatement of symptoms. We presented with mutism and posturing. He was afebrile
present an assortment of cases to highlight the organic and the physical examination was normal apart from
causation of catatonia and their management, and the increased muscle tone with passive movements. His
importance of early recognition of such cases. serum sodium level was 112 meq/l and potassium level
was 4.1 meq/l, repeated serum sodium level remained
Case 1 low at 117meq/l. The rest of the investigations including
liver function tests, serum creatinine, full blood count,
A 46-year old housewife presented with suspiciousness, chest x-ray, thyroid function tests were within normal
irritability followed by gradual withdrawal from limits. The reason for hyponatraemia was thought to be
household activities for 6 months duration. Eventually due to fluoxetine and it was discontinued. Catatonic

Sri Lanka Journal of Psychiatry Vol 6(1) June 2015

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 Isuru and Kuruppuarachchi

symptoms rapidly resolved after correction of hyponatraemia has been reported (11). Our second
hyponatraemia. Subsequently he was commenced on patient’s catatonic symptoms are likely to have been due
mirtazapine and the sodium levels remained normal. to hyponatraemia which improved rapidly with the
correction of sodium levels. The importance of performing
serum electrolytes in such patients is highlighted here.
Case 3 Viral encephalitis and meningitis are relatively common
A seventeen year old school girl had been referred from conditions in countries like Sri Lanka. The presentation
a medical ward due to sudden onset mutism. She had may vary from mild symptoms such as headaches to
fever for three days and then rapidly developed catatonic severe presentation such as delirium and seizures. It has
symptoms such as posturing and negativism. She been shown that neuropsychiatric manifestations are
developed a seizure on the day of admission to the common during the acute phase of viral encephalitis,
psychiatry unit. She was febrile but the rest of the which needs to be considered in the differential diagnosis
physical examination was normal except for catatonic of patients who present with behavioural changes in
symptoms. Electroencephalography (EEG) showed slow emergency settings (12). Viral aetiology of psychosis
waves suggestive of encephalopathy and findings of has been hypothesised for many years. Our third patient
the computerized tomography (CT) of the brain were also developed catatonic symptoms following viral
compatible with this. Cerebrospinal fluid analysis was encephalitis and catatonic symptoms resolved following
indicative of viral encephalitis. anti-viral treatment. This case illustrates the importance
of considering the possibility of central nervous system
She was commenced on intravenous acyclovir and infections in the assessment of catatonia.
antiepileptic medication (sodium valproate). She made a
slow but complete recovery. Patients with systemic lupus erythematosus (SLE) may
commonly present with psychiatric and neurological
symptoms. Although rarely seen, patients with SLE
Case 4 presenting with catatonia have been previously reported
(13). Our fourth patient presented with catatonic
A sixteen year old school girl was referred with behavioral
symptoms following cerebral lupus, and the catatonic
changes suggestive of schizophrenia. She was smiling
symptoms improved with steroids. This case again
to self and had been withdrawn from social activities
illustrates the importance of excluding autoimmune
over the previous three months. She also exhibited
disorders such as SLE and the need to perform relevant
negativism and waxy flexibility. Her physical examination
investigations in the assessment of catatonia, particularly
was normal except for a facial rash and catatonic features.
in young female patients.
She had been treated with risperidone at the local hospital
with poor response.
In conclusion, although many catatonic presentations
are due to conditions such as mood disorders, it is
Investigations revealed a high ESR of 118 mm/1st hour
mandatory to look for organic causes, as early detection
which remained high on subsequent measurements at
and treatment of them will certainly improve the
120 mm/ 1st hour. Double stranded DNA was positive,
prognosis. It is noteworthy that our case series also
and CT of the brain and EEG both supported the
supports the concept that catatonia is a neuropsychiatric
diagnosis of cerebral lupus. Her catatonic symptoms
syndrome as Kahlbhaum originally described.
improved after adding prednisolone to the treatment
regime.
Conflict of interest
None declared
Discussion
Catatonia is a syndrome which cuts across several
psychiatric diagnoses. Several medical, neurological and
metabolic disorders are also associated with or LLA Isuru, University Psychiatry Unit, Colombo North
aetiologically related to the clinical syndrome of catatonia Teaching Hospital, Ragama, Sri Lanka
(1,5,7). Pernicious anaemia is known to be associated KALA Kuruppuarachchi, University of Kelaniya, Faculty
with psychiatric conditions such as mood disorder, of Medicine, Ragama, Sri Lanka
psychosis and dementia (8). An incidental finding of
Corresponding author: KALA Kuruppuarachchi
pernicious anaemia in a patient with catatonia has been
reported (9). Vitamin B12 deficiency as a causative factor E-mail: [email protected]
of catatonic symptoms has also been described in a case
study where complete remission of symptoms was
achieved following B12 replacement (10). Our first case
supports the view that there is an association between References
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 A case series of catatonia: Lessons to learn

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