Clozapine Withdrawal-Induced Malignant Catatonia or Neuroleptic Malignant Syndrome: A Case Report and a Brief Review of the Literature.

ABSTRACT: In our brief literature review, we discuss the changes in the concept of catatonia as well as its various types and symptoms. We also succinctly review the possible symptoms of clozapine withdrawal. In addition, we analyze the main features of the very few published cases of clozapine withdrawal-induced catatonia and the relationship between neuroleptic malignant syndrome and the malignant subtype of catatonia. Furthermore, we present the case of a 29-year-old male patient with schizophrenia in whom a malignant catatonic episode/neuroleptic malignant syndrome (with negativism, stupor, mutism, autonomic signs [eg, fever, hyperhidrosis], and elevated creatine kinase levels) began 5 days after the patient decided arbitrarily to cease his clozapine treatment. His catatonic symptoms quickly (ie, within a few days) resolved after the reinstitution of clozapine. Finally, we attempt to provide a theoretical explanation for the surprising finding in the literature that the withdrawal of clozapine, unlike the withdrawal of any other antipsychotics, may be associated with catatonia (frequently its malignant subtype). The take-home message of our case is that clinicians should bear in mind the risk of catatonia (especially the malignant subtype of it) after the prompt withdrawal of clozapine therapy.

Affective Temperaments, Panic Disorder and Their Bipolar Connections.

Background and Objectives: The role of affective temperament in the genesis and outcome of major mood disorders is well studied, but there are only a few reports on the relationship between panic disorder (PD) and affective temperaments. Accordingly, we aimed to study the distribution of affective temperaments (depressive (DE); cyclothymic (CT); irritable (IRR); hyperthymic (HT) and anxious (ANX)) among outpatients with PD. Materials and Methods: Affective temperaments of 118 PD outpatients (80 females and 38 males) with or without agoraphobia but without any other psychiatric disorder at the time of inclusion were evaluated using the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and compared with the affective temperament scores of control subjects. All patients were followed up for at least 1.5 years in order to detect the onset of any major affective disorders, substance use disorders and suicide attempts. Results: Among females, the dominant ANX and DE temperaments were four and three times as common as in a large normative Hungarian sample (for both cases p < 0.01). Among male PD patients, only the dominant DE temperament was slightly overrepresented in a non-significant manner. Females with PD obtained significantly higher scores on ANX, DE and CT subscales of the TEMPS-A, whereas males with PD showed significantly higher scores on ANX, DE and HT temperament subscales compared with the members of a large normative Hungarian sample and also with a gender- and age-matched control group. During the follow-up, newly developed unipolar major depression and bipolar spectrum (bipolar I or II and cyclothymic) disorders appeared in 64% and 22% of subjects, respectively. Conclusions: Our preliminary findings suggest that a specific, ANX-DE-CT affective temperament profile is characteristic primarily for female patients, and an ANX-DE-HT affective temperament profile is characteristic for male patients with PD, respectively. These findings are in line with expectations because PD is an anxiety disorder par excellence on the one hand, whereas, on the other hand, it is quite frequently comorbid with mood (including bipolar) disorders.

Differences in clinical characteristics between bipolar patients with current psychotic symptoms and those who have never been psychotic.

BACKGROUND: Psychotic symptoms are common in bipolar disorder (BD). Data suggest that BD patients with or without psychotic symptoms may differ from each other with regards to some clinical features of BD (e.g., age at onset, suicidality, psychiatric comorbidity, number of hospitalizations). However, the literature in this area is relatively scarce and not always conclusive. Therefore, the objective of the current study was to investigate whether the presence of psychotic symptoms is associated with clinical characteristics of patients with BD. SUBJECTS AND METHODS: We enrolled 365 hospitalized patients who were diagnosed with BD according to the ICD-10 criteria. After we excluded 196 patients without current psychotic symptoms but psychotic mood episodes in their medical history, our final sample consisted of 169 patients (i.e., 89 BD patients presenting with current psychotic symptoms and 80 BD patients who were hospitalized in the same period, but who did not have psychotic symptoms either currently or during their previous hospitalizations). Clinically available data were collected, systematized and statistically processed according to the aims of the study. RESULTS: Early age of onset, bipolar-I diagnosis, comorbid personality disorder, number of hospitalizations and suicidality were significantly more common in the psychotic group compared to the never-psychotic group. On the contrary, sedative/hypnotics dependence was more frequent in the never-psychotic group. CONCLUSIONS: Our results support the notion that the presence of psychotic symptoms in the context of BD may be associated with various other clinical features of this disease.

[Clinical features of psychotic and non-psychotic bipolar patients]. / Klinikai jellemzok pszichotikus és nem pszichotikus bipoláris betegeknél.

BACKGROUND: Psychotic symptoms are common in the case of manic, depressive and mixed episodes of bipolar disorder; however, the assessment of delusions and hallucinations is frequently improper, thus the patients presenting also psychotic symptoms are treated based on their diagnosis of schizophrenia, schizoaffective disorder or paranoia. Psychotic symptoms in bipolar disorder result less favourable outcomes and course of illness. METHODS: 365 patients (106 males, 259 females) were hospitalized in or institution from January 1st 2015 to September 30th 2016, who were diagnosed with bipolar disorder according to the ICD-10 criteria. The number of patients presenting psychotic symptoms was 89 (24%); 55 of whom (62%) belonged to the bipolar I, and 34 (38%) belonged to the bipolar II group. As a control group of the psychotic bipolar patients, we chose 80 bipolar patients hospitalized in the above mentioned period, who did not present psychotic symptoms either at the current or their previous hospitalizations. RESULTS: We found psychotic mania in the case of 24 patients (27%, 12 males, 12 females); and the delusions were of grandiose, religious and paranoid content. The number of depressive patients presenting psychotic symptoms was 39 (44%, 30 females, 9 males); their delusions were dominantly characterized by feelings of guilt, hypochondria and impoverishment. We treated 26 patients (29%, 18 females, 8 males) with mixed episodes accompanied by psychotic symptoms; they were characterized by depressive delusions. Compared to the non-psychotic bipolar patients, in the case of psychotic bipolar patients manic and depressive episodes, bipolar I diagnosis, early onset of the disease (under the age of 20), previous suicide attempts and comorbid personality disorder were significantly more frequent at the time of hospitalization, whereas mixed affective episodes and bipolar II diagnosis dominated in the non-psychotic group. Similarly, the residual symptoms were more common in the psychotic group (64 patients 72% vs 34 patients 43%) and previous hospitalizations was higher in the psychotic group (males 10.6, females 12.5 vs. males 7.8, females 8.6). With regard to psychotic symptoms, there was no difference between the two groups in terms of positive family history, comorbid anxiety disorder or alcohol dependency. CONCLUSIONS: Early onset of the disease, bipolar I diagnosis and comorbid personality disorder were typical of psychotic bipolar patients; in addition, suicide attempts and residual symptoms were more common compared to the non-psychotic group. LIMITATIONS: The relatively lower number of patients (89 and 80 patients) and the fact that the data were processed retrospectively limit the generalizability of our results.