Journal Article Annotations
2020, 4th Quarter

Catatonia

Annotations by Maalobeeka Gangopadhyay, MD
December, 2020

Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting.
Psychiatric autoimmune conditions in children and adolescents: Is catatonia a severity marker? Prog Neuropsychopharmacol Biol Psychiatry.

- Catatonia in obsessive-compulsive disorder: A systematic review of case studies.
- Non-N-methyl-D-aspartate Autoimmune Encephalopathy and Catatonia Treated With Electroconvulsive Therapy: A Pediatric Case Series and Treatment Guidelines.

PUBLICATION #1 — Catatonia

Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting.

Suchandra HH, Reddi VSK, Aandi Subramaniyam B, Muliyala KP.

Abstract: Aust N Z J Psychiatry. 2020 Oct 30;4867420968915. doi: 10.1177/0004867420968915. Online ahead of print.

Objective:
Catatonia can be life-threatening unless timely identified and treated. Lorazepam’s ubiquitous response has led to its universal acceptance as being the first-line management of catatonia and alludes to catatonia’s neurobiological underpinnings. Lorazepam challenge test (LCT) is widely used to either confirm a catatonia diagnosis or determine lorazepam sensitivity. It has a proposed schedule for administering lorazepam. However, efficacy of recommended LCT doses lack systematic evidence, resulting in variable LCT doses used in clinical and research settings contributing to findings that are challenging to generalize or assist with developing standardized lorazepam treatment protocols for catatonia. Given the same, this study aimed to objectively compare the response between two groups receiving different LCT doses and factors influencing the same.

Methods:
The 6-month study in a psychiatric emergency setting at a tertiary neuropsychiatric center in India evaluated 57 catatonia patients, before and after administration of single 2 mg (n = 37; LCT-2) or 4 mg (n = 20; LCT-4) lorazepam dose, applying Bush Francis Catatonia Rating Scale (BFCRS), Mini International Neuropsychiatric Interview (MINI 5.0) and obtaining sociodemographic, clinical data.

Results:
No between-group differences (LCT-2 vs LCT-4) for sociodemographic, clinical profiles or BFCRS severity score changes to lorazepam on Mann-Whitney U test were noted. Applying Wilcoxon signed rank test comparing individual sign severity demonstrated response variability, with significant response noted to both doses (stupor, mutism, staring, posturing, withdrawal, ambitendency, automatic obedience) and others selectively to 2 mg (echolalia, rigidity, negativism, mitgehen). Notably, sign resolution (present/absent) only to 2 mg was significant for stupor, mutism, staring, posturing, echolalia, rigidity, negativism and mitgehen.

Conclusion:
This study suggests 2 mg lorazepam may be an optimal LCT dose, given significant response to most catatonic signs thereby ensuring accurate detection and preventing misinterpretation of response. It offers future studies direction for standardizing lorazepam dosing schedules for catatonia management and exploring neurobiological underpinnings for individual catatonic signs that may be potentially different, given these findings.

Keywords:
Bush Francis Catatonia Rating Scale; Catatonia; catatonic signs; lorazepam challenge test; neurobiology.

Annotation

The Finding:
57 patients with catatonia were divided between a single 4mg pr 2mg lorazepam dose administered intravenously. Patients’ Bush Francis Catatonia Rating Scale score was calculated pre and post administration. No significant difference in effectiveness was noted between the two groups irrespective of catatonia severity scores. Effectiveness was defined as a 50% reduction in severity of score: 67.6% responded in 2mg arm and 45% showed a response in 4mg arm. The investigators found certain symptoms seemed to respond better at the 2mg dose than the 4mg dose.

Strengths and limitations:
Each patient was examined in detail by an outpatient team as well as the emergency and acute care service psychiatrist; standardized instruments were used to document catatonia symptoms and severity. The investigator was blinded. One limitation of the study was that it was one point in time, and patients were not followed to see if they needed subsequent dose administrations or how long their catatonia persisted. That catatonia was diagnosed by the outpatient team and then referred might lead to some selection bias, particularly as patients presenting directly to the acute service with catatonia were not included.

Relevance:
When a patient presents with catatonia, starting with a 2mg iv administration of lorazepam can be just as effective as a 4mg administration; the latter dose may be reserved for patients with history of catatonia or younger age.

Type of study: (EBM guide):
Prospective cohort study

PUBLICATION #2 — Catatonia

Psychiatric autoimmune conditions in children and adolescents: Is catatonia a severity marker? Prog Neuropsychopharmacol Biol Psychiatry.

Ferrafiat V, Riquin E, Freri E, Granata T, Nardocci N, Medjkane F, Corfiotti C, Tozzo A, Pellerin H, Benarous X, Haroche J, Amoura Z, Duverger P, Jardri R, Gerardin P, Cohen D, Consoli A, Raffin M.

Abstract: Prog Neuropsychopharmacol Biol Psychiatry. 2021 Jan 10;104:110028. doi: 10.1016/j.pnpbp.2020.110028. Epub 2020 Jul 1.

Objectives:
Patients with autoimmune encephalitis (AE) are likely to exhibit an acute onset of severe psychiatric features, including psychosis and/or catatonia. Based on the high prevalence of catatonia in AE and our clinical experience, we hypothesized that catatonia might be a marker of severity requiring more aggressive treatment approaches.

Methods:
To reach a sufficient number of cases with brain-autoimmune conditions, we pooled two samples (N = 58): the first from the French National Network of Rare Psychiatric diseases and the second from the largest Italian neuro-pediatrics center for encephalopathies. Autoimmune conditions were diagnosed using a multidisciplinary approach and numerous paraclinical investigations. We retrospectively compared patients with and without catatonia for psychiatric and non-psychiatric clinical features, biological and imaging assessments, type of immunotherapy used and outcomes.

Results:
The sample included 25 patients (43%) with catatonia and 33 (57%) without catatonia. Forty-two patients (72.4%) had a definite AE (including 27 anti-NMDA receptor encephalitis) and 16 (27.6%) suspected autoimmune encephalitis. Patients with catatonia showed significantly more psychotic features [18 (72%) vs 9 (27.3%), p < 0.001)] and more movement disorders [25 (100%) vs 20 (60.6%), p < 0.001] than patients without catatonia. First line (corticoids, immunoglobulin and plasma exchanges) and second line (e.g., rituximab) therapies were more effective in patients with catatonia, with 24 (96%) vs 22 (66.7%) (p = 0.006) and 17 (68%) vs 9 (27.3%) (p = 0.002), respectively. However, those with catatonia received more combinations of first and second line treatments and had more relapses during outcomes.

Conclusion:
Despite its exploratory design, the study supports the idea that autoimmune catatonia may be a marker of severity and morbidity in terms of initial presentation and relapses, requiring the need for early and aggressive treatment.

Keywords:
Autoimmune condition; Autoimmune encephalitis; Catatonia; Immunosuppressive treatment.

Annotation

The Finding:
58 pediatric patients across 5 centers with definite or suspected autoimmune encephalitis were pooled and compared based upon whether they had catatonia or not. Patients with catatonia also had more psychotic features and movement disorders; they were more likely to receive a combination of first and second line treatments for autoimmune disorders and had more relapsing symptoms. Non-catatonic patients had significantly more anxiety.

Strengths and limitations:
This study illustrates the variety of autoimmune conditions associated with psychiatric symptoms and demonstrates a paradigm of first and second line immunomodulatory treatments and response patterns. The study only has a small sample size. Because patients with catatonia had more severe neuropsychiatric presentations, they likely accessed immunomodulatory treatments more quickly. Because of the multiple centers involved and differing access to medications and procedures, treatment plans were heterogeneous. In addition there can be sampling bias as these were university teaching hospitals where more severe neuropsychiatric conditions present, and each site had different inclusion criteria for the study.

Relevance:
Clinicians should consider autoimmune disorders in pediatric patients presenting with severe psychiatric symptoms and catatonia. Aggressive treatment for the underlying condition with first and second line treatment can lead to improvement in the catatonia.

Type of study: (EBM guide):
Retrospective cohort study

Also of interest – PUBLICATION #3 — Catatonia

Catatonia in obsessive-compulsive disorder: A systematic review of case studies.

Jaimes-Albornoz W, Serra-Mestres J, Lee E, Ferrafiat V, Isetta M.

Annotation (unstructured)

This paper combines 16 adult cases of OCD with catatonia and illustrates symptom variety, treatment strategies, and response. The series describes treatment resistance to benzodiazepines or ECT alone and reinforces the need to treat underlying OCD aggressively as well. It is theorized that before the occurrence of the catatonia, patient experience a spike in anxiety symptoms.

Type of study (EBM guide):
Letter to the Editor: Systematic review of case studies

Also of interest – PUBLICATION #4 — Catatonia

Non-N-methyl-D-aspartate Autoimmune Encephalopathy and Catatonia Treated With Electroconvulsive Therapy: A Pediatric Case Series and Treatment Guidelines.

Mischel NA, Mooneyham GC, Lau C, Van Mater H, Weiner RD.

Annotation (unstructured)

This is a pediatric case series of 4 patients with non-NMDA autoimmune encephalopathy and catatonia treated with ECT; each case describes the workup and treatment for psychiatric symptoms, catatonia, and autoimmune pathology. Recommendations in autoimmune-associated catatonia are organized by workup, choice of anesthetics and muscle relaxants when administering ECT, the application and frequency of ECT, and need for multidisciplinary care.

Type of study (EBM guide):
Case series