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Catatonia Treatment & Management

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Catatonia Treatment & Management

Author: James Robert Brasic, MD, MPH; Chief Editor: Selim R Benbadis, MD more... Updated: Feb 15, 2012

Approach Considerations
Prompt treatment in the early phases of catatonic states is crucial to obtaining a lasting abatement of symptoms. Treatable conditions must be identified immediately. Specifically, neuroleptic malignant syndrome, encephalitis, nonconvulsive status epilepticus, and acute psychosis must be diagnosed and treated. Neuroleptic malignant syndrome, encephalitis, and nonconvulsive status epilepticus constitute neurologic emergencies that merit admission to a neurologic or medical intensive care unit. Acute psychosis merits admission for intensive psychiatric inpatient evaluation and treatment. Because of the possible development of neuroleptic malignant syndrome, the use of traditional neuroleptics is avoided. Successful treatment of catatonia has been reported with several medications, including carbamazepine,[69] clonazepam,[69] olanzapine,[70] and dantrolene.[71] Cyclooxygenase (COX) inhibitors have been reported to protect against the development of perphenazine-induced catatonia in rats.[72] Because catatonia was reported in a 47-year-old woman treated with levofloxacin, prudent clinicians exercise caution when treating patients with fluoroquinolones.[49] If a patient fully recovers from catatonia, the gradual reduction and discontinuation of medications, 1 by 1, is reasonable. A return of symptoms and signs of catatonia may necessitate maintenance of pharmacologic interventions.

Inpatient care
Due to the risk of serious complications of catatonia, admission to an intensive care unit is the treatment of choice for a patient with catatonia. While placement in an intensive care unit may precipitate the development of catatonia,[51] an intensive care unit is the appropriate location to monitor a patient with catatonia until the symptoms have improved to allow transfer to a less restrictive setting. The onset of catatonia merits hospitalization to accomplish the workup and provide intervention for assaultiveness; refusal to eat requires parenteral nutrition. Vitamin K deficiency may result from inadequate nutrition.[73] Vitamin K
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Catatonia Treatment & Management

deficiency must be identified and treated in people with catatonia.[73] Autonomic instability requires intravenous fluids and monitoring of vital signs. Because catatonia is often periodic in occurrence, a patient who has recovered from an episode of catatonia is at risk of developing further episodes of catatonia. A recurrence of catatonia is an indication for hospitalization to perform a diagnostic workup and initiate therapeutic interventions.

Outpatient care
Regular outpatient follow-up visits are advisable to check for the recurrence of catatonia. In some patients, catatonia remits only in response to electroconvulsive treatment (ECT). Some patients may require weekly ECT on an outpatient basis.

Transfer
The need to administer parenteral nutrition and fluids and to monitor vital signs may require transfer of a patient from a psychiatric unit to a neurologic or medical unit. If the patient poses a risk of injury to himself or herself or to staff members, then the use of a 1-on-1 psychiatric attendant at all times is indicated.

Diet
Refusal to eat requires parenteral nutrition.

Activity
Supervised activity is indicated. Prompt intervention may be needed to prevent collapse from exhaustion.

Electroconvulsive Treatment
When nonconvulsive status epilepticus, diffuse encephalopathy, and other neurologic disorders are ruled out, ECT is indicated for patients who do not respond to pharmacotherapy in 5 days or who manifest malignant catatonia. ECT is effective for many patients with catatonia,[74, 75, 71] including those with catatonia secondary to mood disorders or to autistic disorder[76] or another pervasive developmental disorder.[20, 21] ECT is beneficial for adolescents with catatonic schizophrenia.[77, 71] Slooter and colleagues reported the improvement of an adolescent with malignant catatonia, apparently due to viral encephalitis, following treatment with ECT.[78] Right, unilateral, ultra-brief ECT has been reported to be an effective treatment for catatonia in adolescents and adults.[79]

Consultations
Medical consultation is recommended to rule out treatable medical disorders. The following consultations may be required: Consultation with a neurologist is recommended to rule out treatable neurologic conditions; specifically, neuroleptic malignant syndrome, encephalitis, and focal status epilepticus must be ruled out Ophthalmologic consultation is recommended to rule out Kayser-Fleischer rings, pigmented rings at the edge of the cornea that are characteristic of Wilson disease Hematologic consultation is appropriate to prevent thromboembolic disease if people with catatonia demonstrate evidence of early coagulation activation[3] Consultation with a psychiatrist is indicated to rule out acute psychosis Consultation with a movement disorders specialist may help to clarify the diagnosis and treatment (for information about locating movement disorder experts, please contact The Movement Disorder Society )

Contributor Information and Disclosures

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Catatonia Treatment & Management

Author James Robert Brasic, MD, MPH Assistant Professor, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine James Robert Brasic, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, and Movement Disorders Society Disclosure: Taylor and Francis Royalty Independent contractor; Wolters Kluver/Lippincott Williams & Wilkins Royalty Independent contractor; National Alliance for Research on Schizophrenia and Depression Grant/research funds Other; National Institutes of Health Grant/research funds Other Chief Editor Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting Additional Contributors Nestor Galvez-Jimenez, MD, MSc, MHA Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Acknowledgments The research for this article was supported by the Essel Foundation; the National Alliance for Research on Schizophrenia and Depression (NARSAD); the Tourette Syndrome Association, Inc; the National Institutes of Health; and the Department of Psychiatry of Bellevue Hospital Center and the New York University School of Medicine, New York, New York. The cooperation of the Health and Hospitals Corporation of the City of New York is gratefully acknowledged.

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