In my early emergency department (ED) days, I of course had a patient with catatonia. I didn’t tell anyone how this was such a bizarre experience but usually felt like the lone ranger and thought no one is going to understand. Till this day, I still don’t know anyone else who had to deal with this complication, but it’s one of the reasons why I have a category for peculiar cases. I’ve been in many alarming situations and simply don’t want other people to experience the same apprehensions… Prior to the pandemic, mental health affected everything but it was mainly ignored, except in the ED! Therefore, when I read this article, it was refreshing to see others speak up about rare medical cases in healthcare.

–Osmosis

What is Catatonia?

Catatonia is a complex neuropsychiatric syndrome characterized by abnormal motor behavior, thought disturbances, and emotional dysregulation. It can occur in various psychiatric, neurological, or medical conditions, most commonly in mood disorders (especially bipolar disorder) and schizophrenia.

Catatonia presents in different forms, including retarded-stuporous (marked by immobility, mutism, staring, and posturing) and excited-delirious (involving agitation, impulsivity, and echolalia/echopraxia). Symptoms can fluctuate and may include negativism, waxy flexibility, or autonomic instability.

Diagnosis is clinical, as there are no definitive laboratory or imaging tests. Catatonia is treatable, with benzodiazepines (like lorazepam) and electroconvulsive therapy (ECT) being the most effective interventions. If left untreated, it can lead to severe complications, including medical deterioration and death.

–NIH

There’s also several rating tools

Assessing catatonia severity and screens for catatonia in psychiatric and neurologic conditions:

Bush-Francis Catatonia Rating Scale -MD + Calc

The Case Report

“John,” a 26-year-old African man, was referred to our facility after a 2-month stay at another district hospital. He had been brought to the initial hospital by the police after being found wandering the streets, unable to communicate or identify himself. His psychiatric history was initially unknown. For the first 6 weeks, no psychiatric intervention was provided (as the patient was being treated as a social case) until a fall resulting in a fractured capitulum raised suspicion of an underlying psychiatric condition. Risperidone 2 mg and fluoxetine 20 mg were started, but no benzodiazepines or psychiatric rating scales were utilized.

Key Takeaways

• Catatonia requires prompt diagnosis and treatment, often challenging in resource-limited settings, to prevent significant morbidity.
• Lorazepam is the first-line treatment for catatonia, with risperidone as an alternative when ECT is unavailable.
• Junior doctors in South Africa often manage complex conditions like catatonia with limited supervision and resources.
• The case highlights the importance of adaptability and resourcefulness in managing psychiatric emergencies in under-resourced settings.

–Psychiatric Times

Personal Thoughts

The article was really validating, because it talks about an underline condition… if you have a family/psych history of mental illness, especially with schizophrenia this a MAJOR factor with catatonia. There’s little research or an understanding what or how it happens with very few resources. Insurance usually doesn’t cover ECT!

The ED Presentation 

The patient was a young, black male “BR” and was a freshman at a local major university who went to a party, and afterwards became mute, catatonic, and his eyes were fixated to the corner of the isolation room (like the cat in the picture). BR has no medical or psych hx, no abnormal labs or testing, and Rx screen was only positive for THC, parents believe paraphernalia was involved and worried about his overall prognosis. The patient was ordered to be in 4-point restraints (fall and agitation risks), foley catheter, and received a one time dose of lorazepam. BR was eventually was able to move his arms, blink eyes more often, but remain mute and incontinent, only providing comfort measures. Neuro cleared him for psych. Pt. was hospitalized pending psych inpatient, diagnosed with psychosis, continues to be nonverbal, unknown prognosis…

Key Points 

• The other article mentioned how John was transferred to their facility after 2 months at another hospital and eventually was able to communicate a month in half later.. thus, it took him about 3-4 months to be verbal or show no further signs of catatonia. The treatment they used was (under the supervision of a visiting psychiatrist), with risperidone 2 mg QHS, biperiden (e.g. levodopa) 2 mg twice a day, and lorazepam was initiated.
• The facility in the article was based in rural South Africa, but in America -I can’t imagine the bill to be inpatient that long. John was found wandering outside and wasn’t able to speak or be identified initially. His father reports mental illness in the family and someone putting curse on him, but regardless at least John was in a position to received proper care for a couple of months.
• Rule out other causes? but it seems the patients are relatively healthy… The article mentioned John having an infection and elevated inflammation markers, which many people have without psych symptoms and it’s still not clear how the catatonia occurs and the plan of care. It’s interesting that they were using a Parkinson’s medication, but that drug and lorazepam is usually not given outpatient or covered on these terms. At the very least, neurology should be consulted, if your facility has one available.

In Conclusion

Continue to educate patients, especially younger populations to AVOID marijuana and also shrooms. Avoid drugs if you have a history of psych in the family. They can cause a psychotic break, which a person may or may not have long-term effects. THC and substances are STILL scheduled substances, therefore you’re not able to do random control studies or fully evaluate toxicities, risks, or the therapeutic effects. It seems there are many undiagnosed, vulnerable populations, and they already have limited resources. I just hope to add some value to these rare cases to offer more insight and support in mental health.