A case report: Catatonic symptoms secondary to systemic lupus erythematosus with multiple infections: neuropsychiatric or "mimickers?"

RATIONALE: Systemic lupus erythematosus (SLE) is frequently accompanied by neuropsychiatric (NP) manifestations. However, typical symptoms of catatonia are uncommon. Neuropsychiatric SLE or its "mimickers" may cause NP symptoms, making differential diagnosis a significant challenge in clinical practice. PATIENT CONCERNS: A 68-year-old female with SLE was hospitalized for edema, lung infection, and recurrent fungal mouth ulcers after multiple courses of cortisol and immunosuppressive therapy. Five days after admission, stupor, immobility, mutism, and rigidity were observed. DIAGNOSIS: "Mimickers": catatonic disorder due to a general medical condition. INTERVENTION: Initially, relevant laboratory tests, imaging studies, and the disease activity index score were performed. A survey of the causes of the disease was conducted among the patient's relatives. Subsequently, we discontinued moxifloxacin, corticosteroids, fluconazole, and other medications and inserted a gastric tube for nutritional support. During this process, traditional Chinese medicine and acupuncture have been utilized. OUTCOMES: After 3 days, the patient recovered and only complained of fatigue. CONCLUSION: When SLE presents with NP symptoms, it is essential to make a correct diagnosis in order to guide appropriate treatment by actively searching for inducers and clinical, laboratory, and neuroradiological characteristics that can aid in the differential diagnosis. When treatment options are limited, it can be beneficial to try a variety of combination strategies, such as traditional Chinese medicine and acupuncture.

Presença de risco de transtorno do estresse pós-traumático em policiais militares feridos por arma de fogo / Presence of risk of posttraumatic stress disorder in military police officers wounded by firearms / Presencia de riesgo de trastorno de estrés postraumático en policías militares heridos por armamiento de fuego

Este estudo teve como objetivo identificar o risco de desenvolvimento de transtorno de estresse pós-traumático (TEPT), bem como sua associação com pensamentos ou tentativas suicidas e a saúde mental de policiais militares feridos por arma de fogo, na Região Metropolitana de Belém (RMB), nos anos de 2017 a 2019. A pesquisa contou com a participação de 30 entrevistados, que responderam o Inventário Demográfico e a Lista de verificação de TEPT para o DSM-5 (PCL-5). Para análise dos dados, utilizou-se a técnica estatística Análise Exploratória de Dados e a técnica multivariada Análise de Correspondência. Os resultados revelaram a existência de risco de desenvolvimento do transtorno de forma parcial ou total em uma expressiva parcela da população entrevistada, tendo homens como maioria dos sintomáticos, com média de 38 anos, exercendo atividades operacionais e vitimados em via pública quando estavam de folga do serviço. O ferimento deixou a maioria com sequelas, com destaque para dores crônicas, limitações de locomoção e/ou mobilidade e perda parcial de um membro. E, ainda, policiais sintomáticos apresentaram comportamentos suicidas, relatando já terem pensado ou tentado tirar a própria vida. Desta forma, conclui-se que policiais militares são expostos constantemente a traumas inerentes a sua profissão. Quando há ameaça de vida, como nos casos de ferimentos por arma de fogo, são suscetíveis a sequelas físicas decorrente do ferimento, somadas a sequelas mentais tardias, como o surgimento de sintomatologias de TEPT e ideação suicida.(AU)

This study aimed to identify the risk of developing post-traumatic stress disorder (PTSD) and its associations around suicidal thoughts or attempts and mental health in military police officers injured by firearms, in the Metropolitan Region of Belem (RMB), from 2017 to 2019. The research had the participation of 30 respondents who answered the Demographic Inventory and the PTSD checklist for DSM-5 (PCL-5). For data analysis, we used the statistical technique Exploratory Data Analysis and the multivariate technique Correspondence Analysis. The results revealed the existence of risk of developing partial or total disorder in a significant portion of the interviewed population, with men as most of the symptomatic individuals, with mean age of 38 years, developing operational activities and victimized on public roads when they were off duty. The injuries left most of them with sequelae, especially chronic pain, limited locomotion and/or mobility, and partial loss of a limb. In addition, symptomatic officers showed suicidal behavior, such as reporting they had thought about or tried to take their own lives. Thus, we conclude that military policemen are constantly exposed to traumas inherent to their profession. When their lives are threatened, as in the case of firearm wounds, they are susceptible to physical sequelae resulting from the injury, in addition to late mental sequelae, such as the appearance of PTSD symptoms and suicidal ideation.(AU)

Este estudio tuvo como objetivo identificar el riesgo de desarrollo de trastorno de estrés postraumático (TEPT) y sus asociaciones con pensamientos o tentativas suicidas y la salud mental en policías militares heridos por armamiento de fuego, en la Región Metropolitana de Belém (Brasil), en el período entre 2017 y 2019. En el estudio participaron 30 entrevistados que respondieron el Inventario Demográfico y la Lista de verificación de TEPT para el DSM-5 (PCL-5). Para el análisis de datos se utilizaron la técnica estadística Análisis Exploratoria de Datos y la técnica multivariada Análisis de Correspondencia. Los resultados revelaron que existen riesgos de desarrollo de trastorno de estrés postraumático de forma parcial o total en una expresiva parcela de la población de policías entrevistados, cuya mayoría de sintomáticos eran hombres, de 38 años en media, que ejercen actividades operacionales y fueron victimados en vía pública cuándo estaban de día libre del servicio. La lesión dejó la mayoría con secuelas, especialmente con dolores crónicos, limitaciones de locomoción y/o movilidad y la pierda parcial de un miembro. Aún los policías sintomáticos presentaran comportamiento suicida, tales como relataran qué ya pensaron o tentaron quitar la propia vida. Se concluye que los policías militaran se exponen constantemente a los traumas inherentes a su profesión. Cuando existe amenaza de vida, como en los casos de heridas por armamiento de fuego, son expuestos a secuelas físicas transcurridas de la herida, sumado a secuelas mentales tardías, como el surgimiento de sintomatologías de TEPT y la ideación suicida.(AU)

Prevenção do suicídio: esquecimento do ser e era da técnica / Suicide prevention: forgetfulness of being and technical era / Prevención del suicidio: olvido del ser y la era de la técnica

Martin Heidegger, em sua ontologia, destaca uma característica específica da atualidade que atravessa o comportamento humano, na filosofia, na ciência ou no senso comum: o esquecimento do ser. O filósofo diferencia a época atual das demais épocas históricas. O horizonte histórico contemporâneo se desvela por meio do desafio e da exploração, da tentativa de controle e domínio dos acontecimentos, ao modo da disponibilidade e em função da produtividade. O filósofo esclarece que todo esse desenraizamento do homem atual está atrelado ao esquecimento daquilo que é o mais essencial, qual seja, a existência. A questão que norteia este estudo é apurar, por meio das referências de Heidegger e dos estudos sobre suicídio, o quanto a interpretação da morte voluntária nos dias atuais está atravessada por tal esquecimento. Pretendemos investigar o quanto as ações de prevenção desenvolvidas pela suicidologia se encontram atravessadas por tal esquecimento do ser do homem e, dessa forma, acabam por estabelecer relações entre ser e ente em uma consequente redução ao ente como invariante e atemporal. O caminho para investigar a questão iniciará por abordar, em maiores detalhes, a analítica existencial, a questão da técnica e o movimento de esquecimento do ser apontados por Heidegger a fim de problematizar as perspectivas científicas atuais sobre o suicídio em sua prevenção para, então, estabelecer uma compreensão fenomenológica e existencial sobre o referido fenômeno.(AU)

Martin Heidegger, in his ontology, highlights a specific characteristic of the present moment that crosses human behavior, in philosophy, science, or common sense: the forgetfulness of being. The philosopher differentiates the current age from other historical ages. The contemporary historical horizon is unveiled by the challenge and the exploration, from the attempt to control and dominate events, to the mode of standing reserve and in terms of productivity. The philosopher clarifies that all this uprooting of the current man is linked to the forgetfulness of what is the most essential, namely, the existence itself. The question that guides this study is to investigate, via Heidegger's references and studies on suicide, to what extent the interpretation of voluntary death today is crossed by such forgetfulness. We intend to investigate to what extent the prevention actions developed by suicidology are crossed by such forgetfulness of the human's being and, in this way, they end up establishing relationships between being and entity in a consequent reduction to entity as an invariant and timeless. The path to investigate the issue will start by addressing, in greater detail, the existential analytics, the question concerning technique and the movement of forgetting the being pointed out by Heidegger to problematize the current scientific perspectives on suicide and its prevention to, then, propose a phenomenological and existential understanding about the referred phenomenon.(AU)

Martin Heidegger en su ontología destaca una característica específica del presente que atraviesa el comportamiento humano, ya sea en la filosofía, la ciencia o el sentido común: el olvido del ser. El filósofo diferencia la época actual de otras épocas históricas. El horizonte histórico contemporáneo se devela el desafío y la exploración, el intento de controlar y dominar los eventos, en la modalidad de disponibilidad y en términos de productividad. Y así aclara que todo este desarraigo del hombre actual está involucrado en el olvido de lo más esencial, que es la existencia misma. A partir de las referencias a Heidegger y de los estudios sobre el suicidio, este estudio busca saber hasta qué punto la interpretación de la muerte voluntaria hoy está atravesada por este olvido. Pretendemos investigar en qué medida las acciones de prevención desarrolladas por la suicidología se encuentran atravesadas por el olvido del ser del hombre y, de esta manera, terminan por establecer relaciones entre el ser y el ente, en una consecuente reducción al ente como invariante y atemporal. Para investigar el tema se abordará inicialmente, con mayor detalle, la analítica existencial, la cuestión de la técnica y el movimiento del olvido del ser señalado por Heidegger para problematizar las perspectivas científicas actuales sobre el suicidio y su prevención y, luego, proponer una comprensión fenomenológica y existencial sobre el referido fenómeno.(AU)

Crossing State Lines: Ethical and Clinical Considerations in Treating a Child With Catatonia.

Catatonia is a complex constellation of symptoms presenting with abnormalities in movement and behavior and arises from multiple medical, neurologic, and psychiatric conditions. In recent years, there has been a call to move catatonia from a classifier to a diagnosis of its own in the DSM-5.1,2 Catatonia is often underdiagnosed in the hospital and carries with it substantial morbidity and mortality.3 Malignant catatonia, characterized by autonomic instability, hyperactivity, mutism, and stuporous exhaustion, is a medical emergency requiring intensive care.4 Early diagnosis and treatment are imperative, as untreated malignant catatonia may be fatal in up to 10% to 20% of cases, sometimes only days from onset.5 The combination of lorazepam and electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia in both adults and children, although the body of literature pertaining to children remains limited.6,7 In addition, there are multiple case reports of improvement in catatonia with ECT regardless of etiology.8 However, laws in some US states prohibit ECT's use despite evidence of its effectiveness and safety in children and adolescents.9 Here, we describe a case presentation that was both prolonged and complicated by state laws pertaining to the use of ECT in children and adolescents.

The polysemous concepts of psychomotricity and catatonia: A European multi-consensus perspective.

Current classification systems use the terms "catatonia" and "psychomotor phenomena" as mere a-theoretical descriptors, forgetting about their theoretical embedment. This was the source of misunderstandings among clinicians and researchers of the European collaboration on movement and sensorimotor/psychomotor functioning in schizophrenia and other psychoses or ECSP. Here, we review the different perspectives, their historical roots and highlight discrepancies. In 1844, Wilhelm Griesinger coined the term "psychic-motor" to name the physiological process accounting for volition. While deriving from this idea, the term "psychomotor" actually refers to systems that receive miscellaneous intrapsychic inputs, convert them into coherent behavioral outputs send to the motor systems. More recently, the sensorimotor approach has drawn on neuroscience to redefine the motor signs and symptoms observed in psychoses. In 1874, Karl Kahlbaum conceived catatonia as a brain disease emphasizing its somatic - particularly motor - features. In conceptualizing dementia praecox Emil Kraepelin rephrased catatonic phenomena in purely mental terms, putting aside motor signs which could not be explained in this way. Conversely, the Wernicke-Kleist-Leonhard school pursued Kahlbaum's neuropsychiatric approach and described many new psychomotor signs, e.g. parakinesias, Gegenhalten. They distinguished 8 psychomotor phenotypes of which only 7 are catatonias. These barely overlap with consensus classifications, raising the risk of misunderstanding. Although coming from different traditions, the authors agreed that their differences could be a source of mutual enrichment, but that an important effort of conceptual clarification remained to be made. This narrative review is a first step in this direction.

Storms and silence: a case report of catatonia and paroxysmal sympathetic hyperactivity following cerebral hypoxia.

BACKGROUND: Delayed Post Hypoxic Leukoencephalopathy (DPHL) is a syndrome that occurs after hypoxia, and can present with a variety of neuropsychiatric symptoms, including catatonia and paroxysmal sympathetic hyperactivity (PSH). The gold standard for the treatment of catatonia is electroconvulsive therapy (ECT). However, ECT can exacerbate the paroxysms of sympathetic hyperactivity and complicate recovery from DPHL. The treatment of PSH is not well established. CASE PRESENTATION: We present a case of a patient with multiple opiate overdoses who presented with altered mental status. He was diagnosed with catatonia and subsequently treated with ECT. His clinical condition worsened, and a revised diagnosis of PSH was established. The patient's condition improved with medical management. CONCLUSION: This case highlights the need to distinguish between these two related symptom clusters, as the incidence of DPHL and opioid overdose related neuropsychiatric problems increase. This distinction can greatly influence the course of treatment, and the need to consider alternative treatments.

Multimodal Magnetic Resonance Imaging Data Fusion Reveals Distinct Patterns of Abnormal Brain Structure and Function in Catatonia.

Catatonia is a nosologically unspecific syndrome, which subsumes a plethora of mostly complex affective, motor, and behavioral phenomena. Although catatonia frequently occurs in schizophrenia spectrum disorders (SSD), specific patterns of abnormal brain structure and function underlying catatonia are unclear at present. Here, we used a multivariate data fusion technique for multimodal magnetic resonance imaging (MRI) data to investigate patterns of aberrant intrinsic neural activity (INA) and gray matter volume (GMV) in SSD patients with and without catatonia. Resting-state functional MRI and structural MRI data were collected from 87 right-handed SSD patients. Catatonic symptoms were examined on the Northoff Catatonia Rating Scale (NCRS). A multivariate analysis approach was used to examine co-altered patterns of INA and GMV. Following a categorical approach, we found predominantly frontothalamic and corticostriatal abnormalities in SSD patients with catatonia (NCRS total score ≥ 3; n = 24) when compared to SSD patients without catatonia (NCRS total score = 0; n = 22) matched for age, gender, education, and medication. Corticostriatal network was associated with NCRS affective scores. Following a dimensional approach, 33 SSD patients with catatonia according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were identified. NCRS behavioral scores were associated with a joint structural and functional system that predominantly included cerebellar and prefrontal/cortical motor regions. NCRS affective scores were associated with frontoparietal INA. This study provides novel neuromechanistic insights into catatonia in SSD suggesting co-altered structure/function-interactions in neural systems subserving coordinated visuospatial functions and motor behavior.

Characterisation and outcome of neuropsychiatric symptoms in patients with anti-NMDAR encephalitis.

BACKGROUND: Encephalitis due to anti-N-methyl-D-aspartate receptor antibodies (ANMDARE) is the most frequent immune-mediated encephalitis. It is distinguished by the subacute onset of neuropsychiatric symptoms. OBJECTIVE: To evaluate the characteristic neuropsychiatric symptoms and their outcome in patients diagnosed with ANMDARE. METHODS: This was a prospective, longitudinal study in patients with a diagnostic suspicion of ANMDARE that presented to the National Institute of Neurology from March 2018 to February 2019. A comparative analysis of two groups (positive N-methyl-D-aspartate receptor [NMDAR] vs. negative NMDAR antibodies in cerebrospinal fluid [CSF]) was done on admission and at discharge. Neuropsychiatric systematic assessments included the Neuropsychiatric Inventory Questionnaire, the Bush Francis Catatonia Rating Scale, the Confusion Assessment Method Severity, the Montreal Cognitive Assessment, and the Overt Agitation Severity Scale. RESULTS: 24 individuals were analysed: 14 had positive NMDAR antibodies, and 10 had negative NMDAR antibodies in CSF. On admission, agitation/aggression, euphoria/exaltation, and disinhibition were more common in patients with positive antibodies. Excited catatonia and delirium were diagnosed more frequently in patients with positive antibodies. At discharge, there was an important decrease in neuropsychiatric symptoms, but substantial cognitive impairment remained. The mean hospitalisation length was 41.71 (SD 39.33) days for patients with definitive ANMDARE (p 0.259). CONCLUSIONS: Neuropsychiatric symptoms profile in ANMDARE was associated with the early onset of euphoria/exaltation and disinhibition, accompanied by marked psychomotor agitation. When ANMDARE was suspected, the presence of excited-type catatonia and delirium showed a tendency to predict definitive ANMDARE. At discharged, most patients recovered from catatonia, delirium, and psychosis, but marked cognitive symptoms, anxiety, and depression persisted at discharge.

Cingulate-basal ganglia-thalamo-cortical aspects of catatonia and implications for treatment.

The catatonic syndrome is an example of a multifactorial neurobehavioral disorder that causes much morbidity and mortality but also has the potential to unlock the mystery of how motivation and movement interact to produce behavior. In this chapter, an attempt is made to understand better the catatonic syndrome through the lens of neurobiology and neuropathophysiology updated by recent studies in molecular biology, genomics, inflammasomics, neuroimaging, neural network theory, and neuropsychopathology. This will result in a neurostructural model for the catatonic syndrome that centers on paralimbic regions including the anterior and midcingulate cortices, as they interface with striatal and thalamic nodes in the salience decision-making network. Examination of neurologic disorders like the abulic syndrome, which includes in its extreme catatonic form, akinetic mutism, will identify the cingulate cortex and paralimbic neighbors as regions of interest. This exploration has the potential to unlock mysteries of the brain cascade from motivation to movement and to clarify catatonia therapeutics. Such a synthesis may also help us discern meaning inherent in this complex neurobehavioral syndrome.

Association between catatonia and levels of hair and serum trace elements and minerals in autism spectrum disorder.

The objective of the study was to investigate the association between catatonia in autism spectrum disorder (ASD) and the levels of hair and serum trace elements and minerals in children with ASD. The levels of hair and serum trace elements and minerals of boys suffering from ASD with (n = 30) and without (n = 30) catatonia, as well as 30 age- and sex-matched neurotypical controls were assessed using ICP-MS. Hair calcium (Ca) and selenium (Se) levels were lower in ASD patients as compared to the controls. Hair mercury (Hg) levels in ASD patients were more than 3-fold and 2-fold higher as compared to the controls and children with catatonia in ASD. Hair iodine (I) and manganese (Mn) were the lowest and the highest in ASD + Catatonia, respectively. Serum aluminium (Al) and cadmium (Cd) levels in healthy controls were significantly higher in comparison to the patients of both groups. Serum chromium (Cr), copper (Cu) levels were significantly increased in patients with ASD and catatonia, whereas vanadium (V) levels were elevated in patients both with and without catatonia. Multiple regression analysis demonstrated that hair Hg and serum Al and Cd levels were negatively associated with catatonia in ASD in crude and adjusted models. Although the etiology of catatonia in ASD is unclear, the obtained data demonstrate that catatonic symptoms in ASD may be at least partially mediated by altered trace element levels. Further studies are required to elucidate the role of trace elements in the potential signaling mechanisms of catatonia.

Excited catatonia in a patient with fatal pulmonary embolism and a successful treatment strategy.

BACKGROUND: Patients with psychiatric disorders in critical condition are difficult to treat. In this study, we report on a patient with underlying schizoaffective disorder who developed catatonia, cardiac arrest, and pulmonary embolism, as well as a successful treatment strategy. CASE PRESENTATION: The inpatient is a 41-year-old morbidly obese male with schizoaffective disorder whose clozapine dosage was titrated from 100 mg to 175 mg due to auditory hallucination and agitation. The patient abruptly developed acute cardiopulmonary symptoms associated with an elevated troponin-I level. He was transferred to a cardiac intensive care unit, where he remained for 3 days. He was also found to have excited catatonic symptoms, and the lorazepam-diazepam protocol was initiated to quickly relieve the catatonia. Once the coronary angiogram was read as normal, the patient was transferred back to the psychiatric ward. However, the patient then suffered from in-hospital cardiac arrest. He was resuscitated and again transferred to the medical intensive care unit. Computed tomography confirmed the diagnosis of a pulmonary embolism. The patient was treated with Rivaroxaban 30 mg/d for the first 21 days, followed by 20 mg daily for 3 months. To control his severe and refractory psychotic symptoms, the patient was re-prescribed clozapine. During the 15-month follow-up period, the patient demonstrated a fair response and tolerability to clozapine 150 mg without symptoms relapse and no thromboembolic event. CONCLUSION: This report can serve to remind psychiatrists and physicians to be aware of fatal conditions in patients with psychiatric diseases and physical illnesses.

Persistent catatonia following epileptic seizures: a case report and systematic literature search.

BACKGROUND: Catatonia is frequently associated with mood and psychotic disorders as well as with general medical conditions, especially with seizures. In the case of the latter, catatonia mostly resolves when the seizures respond to the anticonvulsive treatment. We report, to our knowledge, the first case of a patient without affective or psychotic disorder, who developed catatonia in the postictum and whose catatonia did not resolve with anticonvulsive treatment, but did so with lorazepam. CASE PRESENTATION: We describe a 36-year-old man, with no psychiatric history, except for a possible disorder in the use of cannabis, who developed catatonia after epileptic seizures. The catatonia did not respond to the anticonvulsant therapy, but did so to lorazepam 17 mg/d. Lorazepam could be tapered slowly and stopped without reemergence of catatonic signs. CONCLUSION: Catatonia should be part of the differential diagnosis in patients with bradyphrenia and/or remarkable postictal behavior. This report shows that lorazepam should be taken into consideration (before moving to ECT), in cases of unresolved catatonia, even if the seizures are reduced with anticonvulsants.

Aberrant Hyperconnectivity in the Motor System at Rest Is Linked to Motor Abnormalities in Schizophrenia Spectrum Disorders.

Motor abnormalities are frequently observed in schizophrenia and structural alterations of the motor system have been reported. The association of aberrant motor network function, however, has not been tested. We hypothesized that abnormal functional connectivity would be related to the degree of motor abnormalities in schizophrenia. In 90 subjects (46 patients) we obtained resting stated functional magnetic resonance imaging (fMRI) for 8 minutes 40 seconds at 3T. Participants further completed a motor battery on the scanning day. Regions of interest (ROI) were cortical motor areas, basal ganglia, thalamus and motor cerebellum. We computed ROI-to-ROI functional connectivity. Principal component analyses of motor behavioral data produced 4 factors (primary motor, catatonia and dyskinesia, coordination, and spontaneous motor activity). Motor factors were correlated with connectivity values. Schizophrenia was characterized by hyperconnectivity in 3 main areas: motor cortices to thalamus, motor cortices to cerebellum, and prefrontal cortex to the subthalamic nucleus. In patients, thalamocortical hyperconnectivity was linked to catatonia and dyskinesia, whereas aberrant connectivity between rostral anterior cingulate and caudate was linked to the primary motor factor. Likewise, connectivity between motor cortex and cerebellum correlated with spontaneous motor activity. Therefore, altered functional connectivity suggests a specific intrinsic and tonic neural abnormality in the motor system in schizophrenia. Furthermore, altered neural activity at rest was linked to motor abnormalities on the behavioral level. Thus, aberrant resting state connectivity may indicate a system out of balance, which produces characteristic behavioral alterations.

A General Pediatrics and Integrative Medicine Approach to Pervasive Refusal Syndrome: A Case Report.

INTRODUCTION: Pervasive refusal syndrome (PRS) describes children with social withdrawal who become unable to walk, eat, or care for themselves. This case report examines whether an integrative medicine approach is useful for treating PRS. CASE PRESENTATION: A seven-year-old girl with symptoms most consistent with PRS and depression was admitted to a pediatric ward in Germany that integrates conventional pediatric and psychosomatic care with anthroposophic medicine. She was integrated into the structured activities of the ward and received massages, movement therapy, and color light therapy. Her parents were fully integrated into her care. After four weeks, she talked again, showed increased appetite, and supported herself when moved passively. She made a full recovery within four weeks after hospital discharge. DISCUSSION: Integration of parents and an integrative medicine approach providing a variety of comforting sensory experiences was helpful for this patient with PRS.

Catatonia secondary to synthetic cannabinoid use in two patients with no previous psychosis.

BACKGROUND AND OBJECTIVES: Synthetic cannabinoids (SC) have become widely abused as recreational drugs, and are now known to carry risk of severe mental and physical health effects. Catatonia, spanning the gamut from motor retardation to agitation, can constitute a psychiatric emergency for which benzodiazepines are the mainstay of treatment. The purpose of this paper is to report on an unusual occurrence of catatonia in the context of synthetic cannabinoid use, and a discussion of treatment options that have been helpful as adjuncts to benzodiazepines. METHODS: We present two cases of catatonia occurring in context of SC use. The first patient was using SC quasi-daily for 18 months. The second patient used a large quantity over a two-week period. Both patients were admitted to our emergency center with catatonia and no overt psychosis or mood symptoms. RESULTS: The absence of pre-existing mood or psychotic disorder and the severity of catatonic symptoms separates these cases from other cases reported in the literature. Additionally, pharmacological management targeting gamma-aminobutyric acid (GABA) and serotonin neurotransmitter systems were used, specifically aripiprazole and valproic acid, supplementing benzodiazepine administration; these were needed for optimal symptom control. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The above-reported cases are highly significant because of the severity of catatonic symptoms requiring inpatient hospitalization, the potential for rapid and severe decompensation with catatonia, and the atypical/unexpected development of catatonia with SC use.

Prevalence and symptomatology of catatonia in elderly patients referred to a consultation-liaison psychiatry service.

OBJECTIVES: To determine the prevalence and clinical correlations of catatonia in patients aged over 65 years who are referred to a consultation-liaison service within a regional area of Australia. Additionally, to examine if the use of standardised screening tools is likely to change the rate of diagnosis of catatonia within the consultation-liaison service. METHODS: One hundred and eight referrals from general hospital wards were assessed using the Bush-Francis Catatonia Screening Instrument (BFCSI) and associated examination; each consented patient was screened for catatonic symptoms. If two or more signs were present on the BFCSI, then severity was rated using the Bush-Francis Catatonia Rating Scale. These clinical characteristics were compared with their socio-demographic and medical data. RESULTS: Prevalence of catatonia was 5.5%. The most common symptoms appeared to be rigidity, posturing and immobility (67% of cases), and were elicited through routine psychiatric examination. CONCLUSIONS: Routine psychiatric history and examination are likely sufficient to elicit catatonic signs in a consultation-liaison setting. Standardised screening examination may be more suited for conducting research or for use when examining for catatonia in psychiatric inpatient settings.

Catatonia.

Catatonia is associated with psychomotor symptoms and severe disturbances of executive functioning. While the prognosis is good in most cases, malignant catatonia still continues to occur. The first-line choice for drug therapy is lorazepam, which usually results in a good response. In catatonic stupor, i.e. immobility and stupor, the first-line therapy is electrotherapy, preferably at an earliest possible stage. In mania, catatonia may become manifest also as psychomotor excitement. Electrotherapy can be used primarily in malignant catatonia, with dantrolene and bromocriptin also finding use in a critical situation.