Introduction
The diagnosis and assessment of catatonia in the medically ill population can be difficult. This is complicated by the problem that many of the definitions for certain catatonic phenomena have not been standardized, even between different rating scales. Medically ill patients with catatonia may also meet DSM-5 criteria for delirium (see “Definition, Phenomena, and Diagnostic Criteria”).
The BFCRS is the gold standard catatonia rating scale. It consists of 23 items on a 3-point scale. The first 14 items can be used as a screening tool; catatonia should be considered if more than 2 of the first 14 items are present. Severity of catatonia is determined by rating all 23 items. The reliability of the BFCRS is dependent on appropriate use of a standardized examination protocol.[255] Other catatonia scales have also been developed and are generally well correlated. However, no catatonia rating scale has been validated specifically in the medically ill population.
A standardized approach should be used to assess for catatonia in medically ill patients. Given the frequency that catatonic findings are overlooked, we recommend screening every patient for catatonia as part of the routine psychiatric consultation. However, many medically ill patients present with hypoactivity/immobility, and certain behaviors such as automatic obedience, negativism (including refusal to eat or drink), agitation/excitement, or stereotypies may be nonspecific or impossible to determine in the severely ill, patients on diet restriction (nil by mouth), or patients with agitated delirium, major neurocognitive impairment, or in patients with difficulty coping with illness.
Proposed Screen for Catatonia in the Medically Ill
There is no validated screen for detecting catatonia in the medically ill. However, we propose considering the following screening examination when assessing the medically ill patient in the consultation-liaison setting:
Mnemonic: “A SLIME-Posture”
Acute or subacute onset within days, with at least 2 of the following findings on a general psychiatric medical examination (mental status examination):
Speech: Disordered Speech Quality (poverty of speech, decreased volume (whisper), or mutism). Disordered speech represents an acute change and may be intermittent or waxing/waning in severity.
Latency: Increased response latency (>5 seconds) in speech or affect or movement in response to a question or impulse or command.
Interaction (stupor): Decreased interaction with environment out of proportion to relatively preserved alertness, maintained for >1 minute
Muscle: Increased muscle tension (waxy flexibility, rigidity, clonus) on direct physical examination
Eyes: Staring (decreased blinking, deadpan, does not track targets), maintained for >1 minute
Posturing: (including grimacing), maintained for >1 minute
Two or more findings should prompt a more focused examination for catatonic phenomena.
Assessment and Examination
A focused physical examination for catatonia should include testing for catalepsy, echolalia, echopraxia, negativism, automatic obedience, mitgehen, gegenhalten, ambitendency, and grasp reflex. The BFCRS provides a companion standardized examination procedure for these catatonic phenomena. Upon completion of the focused examination, the BFCRS should be used to score severity of the catatonic phenomena.
Once a presumptive diagnosis catatonia has been made, a pharmacologic challenge with a GABA-agonist should be performed and clinical response should be assessed using a standardized instrument. The BFCRS is both highly reliable and sensitive to clinical changes, allowing assessment of clinical response to treatment.
Pharmacologic Challenge
Lorazepam is the preferred pharmacologic agent for determining GABA-agonist responsiveness in catatonia. We recommend an initial dose of 2mg intravenous push. In the patient who may be young, elderly, frail or for whom respiratory compromise is a consideration, an initial intravenous dose of 1mg can be used. Alternatively, zolpidem 10mg via enteral route can be considered in the patient with higher potential for respiratory compromise. A clinical response is defined as a 50% reduction in BFCRS score. Most patients will respond within 10-30 minutes, although some may take hours to respond, and some patients may initially fall asleep before later responding favorably.
If no or minimal response is observed within 20-30 minutes of the initial dose, a second dose should be administered. If the second dose produces no or minimal response within 20-30 minutes, a third dose can be administered. Failure of response to lorazepam does not negate the diagnosis of catatonia. 8mg daily or higher doses of lorazepam may be required.
Initial Recommendations to the Primary Service
As soon a presumptive diagnosis of catatonia is made, recommendations should include gathering history and work-up for causes that could be attributable to another medical condition, including:
- Electroencephalogram to rule out seizure activity
- Lumbar puncture with cerebrospinal fluid examination, viral serologies, and anti-NMDA-R antibodies.
- Serum ANA test and other tests for systemic lupus.
- Paraneoplastic antibody panel
- CT abdomen/pelvis to rule out ovarian mass which could be causing ANRE
- MRI brain with contrast to rule out mass, infection, CVA/hemorrhage, autoimmune process, or PRES.
- Substance use history and urine drug screen
- Serum B12 level
Recommendations should also include prompt identification and/or discontinuation of suspected pro-catatonic agents, including:
- Tacrolimus, cyclosporine
- Flouroquinolones, cephalosporins
- Dopamine antagonists (antiemetics, antipsychotics)
- Corticosteroids
- Disulfiram
- Baclofen
Recommendations may include treatment for withdrawal with the clinically appropriate medication, if the history identifies an agent whose discontinuation may have precipitated a withdrawal-emergent catatonia, including:
- Alcohol
- Barbiturates
- Benzodiazepines
- Gabapentin or pregabalin
- Amantadine or memantine
- Bromocriptine
- Levodopa/carbidopa
Recommendations should also include laboratory work to rule out associated rhabdomyolysis and the risk of developing NMS, including:
- Total Creatine Phosphokinase (CPK) (rhabdomyolysis)
- Serum Iron (risk of NMS, check prior to initiation of dopamine antagonist)
Definitive Treatment
Most patients respond to 3-8mg/day of lorazepam. Some patients, however, may require titration of up to 24mg/day of lorazepam to achieve a sustained response. Rarely, patients may require transfer to the intensive care setting for continuous intravenous infusions of a benzodiazepine.
Once sustained catatonia lysis occurs, the benzodiazepine should be tapered very slowly, slower than a typical taper when treating alcohol withdrawal, approximately 5-10 percent per day, while monitoring for any reemergence of catatonic phenomena.
ECT should be considered if benzodiazepines have failed to dramatically improve catatonia within the first 3 days. If the patient exhibit signs of malignant catatonia/NMS, treatment with ECT should not be delayed.
Memantine can be considered as a secondary or augmentation agent in patients who have failed or plateaued in their clinical response to lorazepam. Memantine can be started at a dosage of 5mg Q12 hours, titrated by 5mg/day up to 10mg Q12 hours. As memantine can prolong the QT interval, an electrocardiogram is recommended before initiation.
Amantadine can be considered as an augmentation agent alternative to memantine. It can be initiated at a dose of 100mg daily and titrated to up to 100mg four times per day. Amantadine does not appear to prolong the QT interval but may be harder to tolerate, possibly necessitating a slower titration.
In cases of catatonia wherein there are no symptoms of malignant catatonia/NMS, (with normal serum iron levels, no fever, no leukocytosis, normal CPK) augmentation with antipsychotics may be warranted. Olanzapine is a preferred option.
