Page 100 - JCBP-2-4

Journal of Clinical and
Basic Psychosomatics Recurrent catatonia in a complex patient

approximately 2.7 – 17% of acute psychiatric patients the patient initially presented with a syncopal-type event
demonstrate catatonia, a setting-dependent statistic. 8 and had been psychiatrically stable and functioning in
the community without medication for years before this
2. Case presentation presentation. Further investigation revealed a positive

A 57-year-old Caucasian male with a history of bipolar antinuclear antibody (ANA) titer of 1:160, which warranted
I disorder (BD1) and polycythemia was evaluated by a rheumatology consultation. No additional systemic
our psychiatric team for depressive symptoms and issues were identified, and the patient’s hemoglobin level
suicidal thoughts after being admitted to hospital due to and hematocrit remained stable. The patient showed signs
loss of consciousness. Initial neurological assessments, of gradual improvement and was discharged with plans for
including magnetic resonance imaging of the brain follow-up care. A timeline of the patient’s overall clinical
and electrocardiogram for syncope and stroke, were course is shown in Figure 1.
normal. Laboratory results showed elevated hemoglobin 3. Discussion
(18.9 g/dL) and hematocrit (57%), with decreased
erythropoietin levels (2.5 mIU/mL). He tested negative Catatonia can arise from various medical conditions,
for a JAK2 V617F mutation. Arterial blood gas analysis and benzodiazepines are used as the primary treatment
showed a partial pressure of carbon dioxide (pCO ) of 35.0, approach for this syndrome. The polycythemia described
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a partial pressure of oxygen (pO ) of 79.7, and pH of 7.432. in this case may be related to obstructive sleep apnea and a
2
Following therapeutic phlebotomy, he was transferred positive ANA titer, but its implications for the development
to the psychiatric unit and started on lurasidone 40 mg of catatonia in this patient remain unclear. This patient did
daily for bipolar depression. The patient had stopped not display delirium, which often coexists with catatonia,
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receiving psychiatric treatment for 30 years and had and his laboratory results were otherwise negative for
recently experienced social and economic stressors, metabolic derangements.
including a career change and moving in with family. Alternative treatments for catatonia include memantine,
Notably, the patient had never undergone any preventative anti-epileptic drugs, and amantadine. Memantine and
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psychotherapy or counseling. amantadine are used primarily in schizophrenia spectrum
During his psychiatric stay, he was diagnosed with disorders, while anti-epileptics such as carbamazepine
catatonia, with a Bush–Francis Catatonia Rating Scale and valproic acid may be beneficial in mood disorder
score of 18. His symptoms included immobility, mutism, cases. It has been reported that patients with catatonia
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echolalia, as well as abnormal willpower and behavior. He and underlying mood disorders positively responded to
exhibited a positive response to the lorazepam challenge carbamazepine in a daily dose of 100 – 1,000 mg, without
test. A daily 6 mg lorazepam led to the significant resolution taking benzodiazepines concurrently. Valproic acid, in
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of the catatonic symptoms, and lorazepam was tapered a daily dose of 600 – 4,000 mg, has also been used as an
before discharge after 2.5 weeks of hospitalization. effective monotherapy in patients with excited catatonia
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complicated by schizophrenia spectrum illnesses.
Two days later, the patient returned with worsening
bipolar depression. We increased lurasidone to 60 mg, Daily topiramate at a dose of 200 mg, together with
but catatonia reappeared 1 week thereafter. Lorazepam benzodiazepine as an adjunct, has also been used to treat
10,11
was reintroduced into the treatment regimen, but due catatonia in four patients, as described in one case series.
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to bradycardia, he could not tolerate doses of lorazepam The application of levetiracetam and zonisamide for
above 1 mg. No rigidity, fever, or leukocytosis was observed the treatment of catatonia has also been conducted and
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in the patient, and normal levels of ferritin and creatinine described in the literature.
phosphokinase were recorded. Due to logistic and ECT is a viable option for refractory or severe cases
administrative obstacles, electroconvulsive therapy (ECT) involving malignant features, malnourishment, and severe
was not performed due to inability; otherwise, he may have depression, but it was not accessible in this instance. We
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been a candidate. Divalproex sodium and memantine were believe that our patient would have been a potentially
initiated as alternative treatments. suitable candidate for ECT if it was available in our facility.
The second hospital admission lasted 3 weeks, during Regarding further pharmacological treatments,
which the patient’s condition stabilized following the antipsychotics are generally avoided in patients with
administration of tolerable doses of lorazepam. During catatonia due to the heightened risk of neuroleptic
the second hospital stay, other potential medical causes malignant syndrome or worsening catatonia. Despite this,
were explored given the recurrence of catatonic signs after if needed, a second-generation antipsychotic should be
a prolonged hospital stay and stabilization. In addition, used. Clozapine is the recommended antipsychotic to be

Volume 2 Issue 4 (2024) 2 doi: 10.36922/jcbp.4140