Psychiatric Times.
No. 9
Update on Catatonia
By Andrew Francis, PhD, MD
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August 1, 2006
Dr Francis reports that he has no conflicts of interest concerning the subject matter of this article.
Although amobarbital(Drug information on amobarbital) has not been directly compared with benzodiazepines for initial treatment of catatonia, arguments favoring benzodiazepines include familiarity in contemporary psychiatric practice, a favorable therapeutic index, and the availability of flumazenil(Drug information on flumazenil), a specific antagonist for benzodiazepines. (Of note, the salutary effect of lorazepam(Drug information on lorazepam) was reversed by flumazenil in a case of catatonic stupor and mutism.34)
Recent prospective open trials show that marked improvement or complete resolution of catatonia will occur in 60% to 80% of cases within hours or a few days with lorazepam and related benzodiazepines. Initial dosages of 2 to 6 mg of lorazepam per day are recommended by any route of administration, but some patients may require titration to higher doses ranging from 12 to 16 mg daily. Prolonged trials of benzodiazepines are not advised for severe catatonia, since complications such as dehydration, decubitus ulcers, and embolic events have been reported in this situation.
Benzodiazepines appear effective for catatonia attributed to psychiatric illness, neuroleptic toxicity, and a variety of other conditions. Age, sex, and severity of catatonia do not appear to predict treatment response,20,35 but comorbid schizophrenia may predict a less robust effect.35,36 Since these comorbid disorders cannot be reliably assessed in mute catatonic patients, specific treatment may be delayed until resolution of the catatonic state. Chronic catatonia associated with schizophrenia may be poorly responsive to lorazepam added to antipsychotics.37
Convulsive therapy has both a historical tradition and modern support as a treatment for catatonia. In the 1930s, the use of both chemically induced and electroconvulsive seizures was described. Since then, clinical experience and case series have shown that ECT produces remission of catatonia even when other treatments such as amobarbital or lorazepam have failed.38 An additional advantage of ECT is its effectiveness for both the catatonic syndrome and the frequently associated affective or psychotic disorders. Clinical reports suggest that ECT and lorazepam are synergistic in the treatment of catatonia.14
The available literature on antipsychotics in the treatment of catatonia is inconsistent and suggests caution. Several clinical reports show that the older highpotency agents, such as haloperidol(Drug information on haloperidol) or second-generation antipsychotics, failed to improve catatonia, induced or worsened catatonia, or led to progression from catatonia to NMS.26,33,39-43 In contrast, other case reports suggest risperidone(Drug information on risperidone) or other second-generation antipsychotics may be beneficial.44 One report reanalyzed data from clinical trials of schizophrenia, using 3 items from the Positive and Negative Symptom Scale as a retrospective proxy for catatonia, and suggested modest treatment benefit of olanzapine(Drug information on olanzapine) after 6 weeks.45
Only 1 randomized double-blind study involving antipsychotics in catatonia has been published.22 In this study, 14 of 68 nonaffective catatonic patients in whom a trial of lorazepam failed were randomized to receive risperidone plus sham ECT (n = 6) or bilateral ECT plus placebo (n = 8). Scores on the BFCRS declined more than 90% with ECT and approximately 50% with risperidone after 3 weeks.
The inconclusive literature on antipsychotics has led to an expert consensus favoring initial treatment with lorazepam and consideration of ECT for refractory or severely compromised cases if lorazepam fails after a period of days. Unfortunately, ECT may not be available, leading the clinician to consider use of second-generation antipsychotics. In this situation, Rosebush and Mazurek33 envision a cautious trial of these agents with continued benzodiazepines and careful monitoring for worsening catatonia or signs of NMS.
Use of antipsychotic agents in the treatment of malignant catatonia (an uncommon severe variant characterized by extreme agitation, fever, and other autonomic disturbances) is also not recommended because of the risk of exacerbation. In this setting, prompt use of ECT has been advocated.46
Summary
Catatonia is a distinct neuropsychiatric syndrome that is becoming more recognized clinically and in ongoing research. It occurs with psychiatric, metabolic, or neurologic conditions. It may occur in many forms, including NMS. Treatment with benzodiazepines or ECT usually leads to a dramatic and rapid response, although systematic randomized trials are lacking. An important unresolved question is the role of antipsychotic agents in treatment and their potential adverse effects.
Dr Francis is professor of psychiatry in the department of psychiatry and behavioral science at the health sciences center of the State University of New York at Stony Brook.
Dr Francis reports that he has no conflicts of interest concerning the subject matter of this article.
Drugs mentioned in this article
Amobarbital (Amytal)
Apomorphine (Apokyn)
Flumazenil (Romazicon)
Haloperidol (Haldol)
Lorazepam (Ativan)
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Zolpidem (Ambien)
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