Successful Recovery of a Catatonic Patient with Severe Pneumonia and Respiratory Failure: Modified Electroconvulsive Therapy Following Tracheotomy

Backgroud: Catatonia encompasses a group of severe psychomotor syndromes affecting patients' motor, speech, and complex behaviors. Common features include rigidity, reduced mobility, speech, sputum production, defecation, and eating. Risks associated with catatonia, such as increased muscle tension and reduced swallowing and coughing reflexes, along with risks from therapeutic approaches like prolonged bed rest and sedative drugs, can elevate the risk of aspiration pneumonia, severe pneumonia, and acute respiratory failure. These complications significantly impede catatonia treatment, leading to poor prognosis and jeopardizing patient safety. Case Description: In this report, we present a case of catatonia complicated by severe pneumonia and respiratory failure, successfully managed with modified electroconvulsive therapy alongside tracheotomy. We hope this case provides valuable insights for psychiatrists encountering similar scenarios, facilitating the development of rational therapeutic strategies for prompt improvement of patient condition. (AU)

Brain Motor Region Diffusion Tensor Imaging in Patients with Catatonic Schizophrenia: A Case-Control Study.

BACKGROUND: Only a small proportion of schizophrenia patients present with catatonic symptoms. Imaging studies suggest that brain motor circuits are involved in the underlying pathology of catatonia. However, data about diffusivity dysregulation of these circuits in catatonic schizophrenia are scarce. OBJECTIVES: To assess the involvement of brain motor circuits in schizophrenia patients with catatonia. METHODS: Diffusion tensor imaging (DTI) was used to measure white matter signals in selected brain regions linked to motor circuits. Relevant DTI data of seven catatonic schizophrenia patients were compared to those of seven non-catatonic schizophrenia patients, matched for sex, age, and education level. RESULTS: Significantly elevated fractional anisotropy values were found in the splenium of the corpus callosum, the right peduncle of the cerebellum, and the right internal capsule of the schizophrenia patients with catatonia compared to those without catatonia. This finding showed altered diffusivity in selected motor-related brain areas. CONCLUSIONS: Catatonic schizophrenia is associated with dysregulation of the connectivity in specific motoric brain regions and corresponding circuits. Future DTI studies are needed to address the neural correlates of motor abnormalities in schizophrenia-related catatonia during the acute and remitted state of the illness to identify the specific pathophysiology of this disorder.

Tratamiento del Síndrome Neuropsiquiátrico Diferido por intoxicación con monóxido de carbono con risperidona y oxígeno hiperbárico / Treatment of Delayed Post-Hypoxic Leukoencephalopathy as a complication of carbon monoxide poisoning with risperidone and hyperbaric oxygen therapy

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Catatonia with schizophrenia: From ECT to rTMS.

BACKGROUND: Electroconvulsive therapy is indicated in cases of catatonic schizophrenia following a failure of the challenge test with lorazepam or Zolpidem®. Some patients need maintenance treatment with ECT. Repetitive Transcranial Magnetic Stimulation (rTMS) and anodal Transcranial direct-current stimulation (tDCS) might be effective against catatonia. OBJECTIVE: Consider an alternative to ECT for a refractory patient. REVIEW: Twenty-one articles were identified mainly based on case reports series were found using search on Medline, Google Scholar, PsychInfo, CAIRNS. Key words were:"catatonia", and "rTMS", and more generally with"ECT","tDCS","Zolpidem®". At the end there were only six case reports with rTMS and three with tDCS. We discussed the alternative to ECT and follow up rTMS strategies illustrated by these case reports. FINDINGS: Patients mean age was 35; numbers of previous ECT vary from zero to 556; the most common motor threshold (MT) is 80%, with two patients with 110%, the most common treatment placement is L DLPFC. In one of them, ECT was the only acute-state or maintenance treatment effective in this patient, who underwent 556 ECT sessions over 20 years. High-frequency rTMS was considered as a possible alternative, given the potential adverse effects of chronic maintenance ECT in a patient with comorbid epilepsy. rTMS treatment was 3-4×/week and over time extended to once every two weeks. A persistent objective improvement in catatonia was observed on the Bush-Francis Catatonia Rating Scale. CONCLUSION: rTMS is helpful for acute and maintenance treatment for catatonic schizophrenia who both failed multiple pharmacologic interventions and had safety concerns with continuing maintenance ECT. Clinicians should consider rTMS as a potential treatment option for refractory catatonia.

Schizophrenia with prominent catatonic features: A selective review.

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Is motor imagery different in catatonic schizophrenia?

Catatonic schizophrenia, a rare subtype in this disease group, is characterized by motor disturbances. The current study investigated the reactivity of electroencephalographic mu rhythm in a motion imagery task in two single cases of first-episode catatonic schizophrenia, assuming they would show less mu rhythm reduction compared to paranoid schizophrenic patients and healthy controls.

[German version of the Northoff catatonia rating scale (NCRS-dv) : A validated instrument for measuring catatonic symptoms]. / Deutsche Version der Northoff Catatonia Rating Scale (NCRS-dv) : Ein validiertes Messinstrument zur Erfassung katatoner Symptome.

The clinical picture of catatonia includes impressive motor phenomena, such as rigidity, dyskinesia, festination, negativism, posturing, catalepsy, stereotypies and mannerisms, along with affective (e. g. aggression, anxiety, anhedonism or emotional lability) and behavioral symptoms (e.g. mutism, autism, excitement, echolalia or echopraxia). In English speaking countries seven catatonia rating scales have been introduced, which are widely used in clinical and scientific practice. In contrast, only one validated catatonia rating scale is available in Germany so far. In this paper, we introduce the German version of the Northoff catatonia rating scale (NCRS-dv). The original English version of the NCRS consists of 40 items describing motor (13 items), affective (12 items) and behavioral (15 items) catatonic symptoms. The NCRS shows high internal reliability (Crombachs alpha = 0.87), high interrater (r = 0.80-0.96) and high intrarater (r = 0.80-0.95) reliability. Factor analysis of the NCRS revealed four domains: affective, hyperactive or excited, hypoactive or retarded and behavior with individual eigenvalues of 8.98, 3.61, 2.98 and 2.82, respectively, which explained 21.5 %, 9.3 %, 7.6 % and 7.2 % of variance, respectively. In conclusion, the NCRS-dv represents a second validated instrument which can be used by German clinicians and scientists for the assessment of catatonic symptoms.

[Catatonia in childhood and adolescence: obstacles to diagnosis and treatment]. / Katatonie in de kindertijd en adole-s-centie: obstakels bij de diagnose en behandeling.

BACKGROUND: Catatonia in children and adolescents is the same as it is for adults; in other words it is a recognisable psychomotor syndrome that follows a characteristic course and responds favourably to treatment with benzodiazepines and/or ect. Therefore, one would not expect to encumber many obstacles to diagnosis and treatment. In fact, the obstacles are fairly numerous. AIM: To explore the obstacles that can hinder a simple approach to diagnosis and treatment and to provide support for the clinicians involved. METHOD: We studied the literature systematically using Limo and keywords. RESULTS: For several decades, particularly in the literature, catatonia was defined as a subtype of schizophrenia. This exclusive link to schizophrenia led to the under-diagnosis of catatonia in patients with other psychiatric conditions and to delays in the administration of the correct treatment. Not only this historical error but also other important problems are complicating the approach to catatonia even today. Among other factors hindering diagnosis and treatment are the belief that catatonia is a rare illness, often denied by family members and some clinicians, the use of neuroleptics and the stigmatisation of benzodiazepines and/or ect. CONCLUSION: Controversy about catatonia continues. Although diagnosis and treatment are clearly defined, catatonia is still putting professionals to the test. In our essay we offer some practical guidance and advice.

Atypical course in severe catatonic schizophrenia in a cannabis-dependent male adolescent: a case report.

INTRODUCTION: Adolescents with psychoses usually have full recovery from their first psychotic episode, but the first relapse often arises within 2 years of the first episode. Cannabis-related psychoses are difficult to distinguish from schizophrenic psychoses. Here, we describe a particularly severe clinical case, with a first psychotic episode occurring after heavy cannabis smoking, an atypically long symptom-free duration, and a subsequent non-substance-related episode. CASE PRESENTATION: A 17-year-old male adolescent of Middle-East origin presented with delusions and hallucinations after extensive cannabis smoking. His first psychotic episode, with paranoid delusions and hallucinations, progressed into severe catatonic symptoms. His symptoms were treated with electroconvulsive therapy and risperidone and he was transferred to a residential substance abuse treatment center. He remained drug-free and non-psychotic for 3.5 years. Given the temporal association with extensive cannabis use, and his full remission of symptoms lasting several years, a cannabis-induced psychosis-though atypically extended-could be suspected. However, after 3.5 years without psychiatric care, and in a drug-free state, our patient again presented with positive psychotic symptoms, possibly induced by a period of severe psychosocial stress. CONCLUSION: We here discuss whether a primary schizophrenic episode possibly induced by cannabis can increase the risk of subsequent non-drug-related schizophrenic episodes.

PERSISTENT CATATONIA IN A PREGNANT NIGERIAN WOMAN: A CASE REPORT.

BACKGROUND: The syndrome of catatonia appears to exist with many conditions, yet goes undetected by the skillful eyes of clinicians. This case which is rarely reported in literatures shows the effectiveness of antipsychotic augmenting in a persistent catatonic schizophrenia disorder. METHOD: This is a case narration of persistent catatonia in a 24-years old pregnant Nigerian woman with schizophrenia disorder. RESULTS: First line management with benzodiazepines and electroconvulsive therapy (ECT) failed to resolve the syndrome which later responded to Electroconvulsive Therapy with low dose antipsychotic augmentation. CONCLUSIONS: Cautious augmenting of electroconvulsive therapy with neuroleptics may be a quick and relatively safe procedure in the relief of schizophrenia with catatonia in pregnancy.

[Changes to Schizophrenia Spectrum and other psychotic disorders in DSM-5]. / Psychotische Störungen im DSM-5. Die revisionen.

This article provides an overview of the main changes in the chapter "Schizophrenia Spectrum and Other Psychotic Disorders" from DSM-IV-TR to DSM-5, which, once again, does not make allowance for potential characteristics of children and adolescents. Changes in the main text include abandoning the classical subtypes of Schizophrenia as well as of the special significance of Schneider's first-rank symptoms, resulting in the general requirement of two key features (one having to be a positive symptom) in the definition of Schizophrenia and the allowance for bizarre contents in Delusional Disorders. Further introduced are the diagnosis of a delusional obsessive-compulsive/body dysmorphic disorder exclusively as Obsessive-Compulsive Disorder, the specification of affective episodes in Schizoaffective Disorder, and the formulation of a distinct subchapter "Catatonia" for the assessment of catatonic features in the context of several disorders. In Section III (Emerging Measures and Models) there is a recommendation for a dimensional description of psychoses. A likely source of confusion lies in the double introduction of an "Attenuated Psychosis Syndrome." On the one hand, a vague description is provided among "Other Specified Schizophrenia Spectrum and Other Psychotic Disorders" in the main text; on the other hand, there is a precise definition in Section III as a "Condition for Further Study." There is some cause to worry that this vague introduction of the attenuated psychosis syndrome in the main text might indeed open the floodgates to an overdiagnosis of subthreshold psychotic symptoms and their early pharmacological treatment.

[Catatonia and neuroleptic malignant syndrome in view of a psychopathological and pathophysiological overlap: a brief review]. / Katatónia és neuroleptikus malignus szindróma a pszichopatológiai és patofiziológiai átfedések tükrében: rövid összefoglaló tanulmány.

Catatonia was first described in the 19th century as a syndrome with motor, affective and behavioral symptoms. During the 20th century it was rather regarded as a rare motoric manifestation of schizophrenia and that classification has almost resulted in the disappearance of catatonia among patients outside of the schizophrenia spectrum. With the introduction of neuroleptics, the incidence of catatonic schizophrenia also declined which was attributed to effective treatment. Simultaneously, neuroleptic malignant syndrome was described, which shows many similarities with catatonia. Recently, several researchers suggested a common origin of the two disorders. In this paper we review case reports of the last five years, in which both neuroleptic malignant syndrome and catatonia had emerged as a diagnosis. Additionally, based on the relevant literature, we propose a common hypothetical pathomechanism with therapeutic implications for the two syndromes. Besides underlining the difficulties of differential diagnosis, the reviewed cases demonstrate a transition between the two illnesses. The similarities and the possible shifts may suggest a neuropathological and pathophysiological overlap in the background of the two syndromes. Electroconvulsive therapy and benzodiazepines seem to be an effective treatment in both syndromes. These two treatment approaches can be highly valuable in clinical practice, especially if one considers the difficulties of differential diagnosis.

[The use of acatinol in the treatment of stable patients with schizophrenia with predominance of behaviour disorganization and subcatatonic features].

Our study was based on the hypothesis that a non competitive antagonist of NMDA receptors can improve clinical effects of antipsychotic therapy in a subgroup of patients with schizophrenia with clinical signs of glutamatergic hyperfunction such as catatonic symptoms and disorganization. The study design was open and non-comparative. The duration of the study for each patient was 6 months, the target dosage of acatinol was 20 mg. Forty stable patients with schizophrenia with predominance of signs of disorganization and subcatatonic symptoms were included. The following instruments were used: PANSS, NSA, CGI, BACS, UKU. Adding of acatinol to the antipsychotic treatment improved clinical symptoms, cognitive functioning and social functioning and decreased the number of side effects. The drug was well-tolerated.

[The typology of oneiroid-catatonic states in schizophrenia].

OBJECTIVE: To determine the types of oneiroid-catatonic states characteristic of corresponding schizophrenia attacks and their treatment-related changes. MATERIAL AND METHODS: We examined 68 outpatients, 25 men and 43 women, aged from 18 to 54 years, using psychopathological and follow-up methods. Results and conclusion. Two groups of oneiroid states were described. Oneiroid-catatonic states with the predominance of visual (optical) component derangement of consciousness were characteristic of the first group and oneiroid states with the prevalence of sensory component of derangement of consciousness were described in the second group. The second group was divided into two subgroups by the severity of the visual component (minimal and mixed). The types of oneiroid-catatonic states determined the dynamics of the attack in whole and were related to treatment (drug-induced pathomorphosis). These results are significant for differential diagnosis, treatment, and prognosis of the disease.

Neuroleptic malignant syndrome masked by cerebral malaria.

A 38-year-old man with an underlying psychiatric illness presented with altered sensorium and abnormal behaviour. He was febrile at 38°C and weak looking; otherwise no other abnormalities were detected. A blood film conducted for malarial parasite (BFMP) revealed Plasmodium falciparum; hence a diagnosis of cerebral malaria was made. He was treated with antimalarial drugs for 2 days prior to being transferred out to the ward following clinical improvement. He subsequently developed episodes of stupor and refusal of feeding. Following an evaluation by the psychiatrist, a diagnosis of catatonic schizophrenia was made and he was started on oral sulpiride and benhexol. Unfortunately, he developed high-grade fever at 40°C with muscle rigidity and fasciculation. The diagnosis of neuroleptic malignant syndrome (NMS) was clinched and the antipsychotics were discontinued. However he succumbed to NMS several days later due to multiorgan failure.

[Schizophrenia and aggressive behaviour: the impact of catatonic phenomena]. / Schizophrenie und aggressives Verhalten - die Bedeutung katatoner Phänomene.

OBJECTIVE: Patients suffering from schizophrenic psychoses show an increased risk for aggressive and violent behaviour. This raises the question if such acts are associated with specific psychopathological symptoms such as catatonic features. METHODS: Based on clinical case reports, psychopathological symptoms and clinical course in five patients with schizophrenic psychoses and episodes of aggressive behaviour are described. In this connection, the role of catatonic features is analysed. RESULTS: In the reported cases, aggressive behaviour patterns can be described as stable catatonic symptoms. Attempts to provide community-based treatment failed in each of these five patients. CONCLUSIONS: General adult psychiatry should provide effective treatment strategies and adequate care systems for patients with psychosis, catatonic symptoms and aggression.

[Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases].

Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases remain a topical problem in modem psychiatry. The author describes psychopathologcal features of oneiroid depending on the form of the affect and presents new data on its relation to peculiarities of the development of attacks.