Long-term maintenance lorazepam for catatonia: a case report

doi:10.1016/j.genhosppsych.2010.06.006

General Hospital Psychiatry

Volume 33, Issue 1, January–February 2011, Pages 82.e1-82.e3

https://doi.org/10.1016/j.genhosppsych.2010.06.006 Get rights and content

Abstract

Catatonia is described as a syndrome of motor abnormality associated with the disorder of thought, behavior and emotions. Lorazepam has been shown to be useful in the short-term management of catatonia [Ungvari G.S., Kau L.S., Wai-Kwong T., Shing N.F., The pharmacological treatment of catatonia: an overview. Eur Arch Psychiatry Clin Neurosci 2001;251(suppl 1):31–34; Daniels J., Catatonia: clinical aspects and neurobiological correlates. J Neuropsychiatry Clin Neurosci 2009;21:371–380]. However, there is sparse literature with respect to patients requiring long-term maintenance lorazepam for catatonia. Manjunatha et al. [Manjunatha N., Saddichha S., Khess C.R.J., Idiopathic recurrent catatonia needs maintenance lorazepam: case report and review. Aust NZ J Psychiatry 2007;41:625–627] described a case which required long-term maintenance lorazepam for recurrent catatonia that was unresponsive to most antipsychotics. Gaind et al. [Gaind G.S., Rosebush P.I., Mazurek M.F., Lorazepam treatment of acute and chronic catatonia in two mentally retarded brothers. J Clin Psychiatry 1994;55:20–23] described the use of maintenance lorazepam in a mentally retarded boy with catatonia of 5 years' duration, which improved slowly over a period of 5 months.

We present a case of recurrent catatonia, in which symptoms relapsed whenever an attempt was made to taper off lorazepam.

Section snippets

Case

Mrs. A, 38 years old, presented with an episodic mental illness since 6 years. The first episode was characterized by refusal to eat, decreased interaction, mutism, negativism, stupor, decreased emotional reactivity, poor self-care and significant weight loss. After about 2 years of being symptomatic, she was treated with electroconvulsive therapy (ECT), imipramine 200 mg/day, risperidone 4 mg/day and trihexyphenidyl 2 mg with which she improved completely. Later, she maintained well on

Discussion

Data with respect to long-term use of lorazepam in recurrent catatonia are sparse Northoff [1] postulated the central role of GABA in catatonia, with down-regulation of GABA-A receptors in orbitofrontal cortex, which further leads to dysregulation of dopamine. This hypothesis may explain the response to lorazepam and the requirement of lorazepam in some of the subjects in the long run. At present, there is no consensus with respect to dosing schedule and duration of treatment of catatonia with

References (4)

NorthoffG.
What catatonia can tell us about “top-down modulation”: a neuropsychiatric hypothesis
Behav Brain Sci
(2002)
DanielsJ.
Catatonia: clinical aspects and neurobiological correlates
J Neuropsychiatry Clin Neurosci
(2009)

There are more references available in the full text version of this article.

Cited by (21)

The multi-modal treatment of catatonia: Targeting multiple receptors when GABA-based benzodiazepines fail
2024, Personalized Medicine in Psychiatry
The family brought a 48-year-old woman with major depressive disorder to the emergency room due to unresponsiveness and bizarre behavior. Catatonia was suspected and confirmed by a positive lorazepam challenge test. The patient’s home regimen included bupropion, though the family reported non-adherence. Intravenous lorazepam was scheduled, and the patient’s catatonic symptoms gradually improved. Gradual tapering of lorazepam caused the re-appearance of catatonic symptoms. Each attempt at tapering lorazepam resulted in catatonic symptoms resurfacing and requiring higher scheduled doses of lorazepam. Electroconvulsive treatment was not an option as (1) it was not easily accessible, and (2) the patient did not consent. Multiple anti-depressants were tried and discontinued due to intolerable side effects, and the patient eventually partially improved with mirtazapine, zolpidem, memantine, and lorazepam. Catatonia is a complex neuropsychiatric syndrome that requires prompt recognition, diagnosis, and treatment. Such cases pose a challenge to physicians. Our case emphasizes considering the uniqueness of each individual’s presentation of chronic catatonia during treatment.
The State of the Catatonia Literature: Employing Bibliometric Analysis of Articles From 1965–2020 to Identify Current Research Gaps
2023, Journal of the Academy of Consultation-Liaison Psychiatry
Citation Excerpt :
A 1965 review on periodic catatonia with notes regarding a decrease in the number of cases of periodic catatonia at that time “suggests that the great majority of patients suffering from periodic catatonia are helped sufficiently by means of ECT or phenothiazines to escape notice.”53 It is our experience that recurrent catatonia is commonly encountered and that clinicians often struggle with how to prevent relapses, particularly when it comes to the question of standing benzodiazepines on an outpatient basis.54 The field would benefit from further studies of this issue, as well as studies on the use of ECT,55 lithium,56 clozapine,57 and other medications to prevent recurrence and relapse.
Since Kahlbaum's classic 19th-century description of catatonia, our conceptualization of this syndrome, as well treatment options for it, has advanced considerably. However, little is known about the current state of the catatonia literature since a comprehensive bibliometric analysis of it has not yet been undertaken.
The purpose of this study was to conduct a bibliometric analysis, along with a content analysis of articles reporting new findings, to better understand the catatonia literature and how catatonia research is changing.
Using the search term “Title(catatoni∗)” in Web of Science Core Collection for all available years (1965–2020), all available publications (articles, proceeding papers, reviews) pertaining directly to catatonia were identified, and metadata extracted. Semantic and coauthorship network analyses were conducted. A content analysis was also conducted on all available case reports, case series, and research articles written in English.
A total of 1015 articles were identified representing 2861 authors, 346 journals, and 15,639 references. The average number of publications per year over the last 20 years (31.3) more than doubled in comparison to that in the 20 years prior (12.8). The top 3 most common journals were Psychosomatics/Journal of the Academy of Consultation-Liaison Psychiatry, Journal of ECT, and Schizophrenia Research, which represented 12.6% of all publications. Content analysis revealed that catatonia articles are increasingly published in nonpsychiatric journals. There was a notable paucity of clinical trials throughout the study period. Since 2003, articles on catatonia secondary to a general medical condition, as well as articles including child/adolescent patients and patients with autism spectrum disorder or intellectual disability, have made up increasing shares of the literature, with a smaller proportion of articles reporting periodic or recurrent catatonia. We noted a decrease in the proportion of articles detailing animal/in vitro studies, genetic/heredity studies, and clinical trials, along with stagnation in the proportion of neuroimaging studies.
The catatonia literature is growing through contributions from authors and institutions across multiple countries. However, recent growth has largely been driven by increased case reports, with significant downturns observed in both clinical and basic science research articles. A dearth of clinical trials evaluating potential treatments remain a critical gap in the catatonia literature.
The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia
2019, Handbook of Clinical Neurology
Citation Excerpt :
There is no consensus on how long benzodiazepines are to be continued, and generally they are discontinued once the underlying illness has remitted. In a number of cases, however, catatonic symptoms will reemerge each time lorazepam is tapered off, urging the clinician to continue benzodiazepines for an extended period of time (Grover and Aggarwal, 2011). Interestingly, lorazepam seems to be effective, regardless of the underlying condition, although catatonia in mood disorders responds more frequently (92%–97%) than catatonia in the context of medical conditions (82%) or schizophrenia (59%) (Sienaert et al., 2014).
Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.
Resurgence of catatonia following tapering or stoppage of lorazepam – A case series and implications
2017, Asian Journal of Psychiatry
Citation Excerpt :
Those patients having multiple resurgences required maintenance dose of 4–6 mg/day of lorazepam for a long period variying from 3 months to 5 years as per existing studies. ( Grover and Aggarwal, 2011; Lin et al., 2016; Sivakumar et al., 2013; Thamizh et al., 2016). Adding to the existing literature, we are reporting case series of seven such patients.
The resurgence of catatonia following tapering of lorazepam is a common clinical phenomenon. However, there is limited evidence on the relationship between tapering method of lorazepam and resurgence of catatonic state. We report seven (0.6%) such patients who were found to have resurgence of catatonia. The mean age is 35.7 years; five of them had schizophrenia and other psychotic spectrum disorders. Five of them had resurgence within one week of stoppage, and three of them had multiple resurgences and required maintenance treatment with lorazepam. So gradual tapering and maintenance treatment with lorazepam might be effective in preventing resurgence of catatonia.
Maintenance lorazepam for treatment of recurrent catatonic states: A case series and implications
2016, Asian Journal of Psychiatry
Catatonic syndrome: From detection to therapy
2016, Encephale
Citation Excerpt :
One case report describes the evolution of a case of idiopathic periodic catatonia that was unresponsive to most neuroleptics, and required long-term use of lorazepam [46]. However a case of periodic catatonia without symptom return after the progressive discontinuation of lorazepam has also been described [47]. According to a study in 2011, clozapine could be efficacious on catatonic symptoms in schizophrenic spectrum disorders in case of failure of lorazepam and other atypical neuroleptics [31].
Catatonia is a psychomotor syndrome which can include motor, mental, behavioral and vegetative symptoms. Exclusively associated with schizophrenia until the 1970s, catatonia still remains an under-diagnosed syndrome with significant morbidity and mortality.
As a result of its different forms and developments, catatonic syndrome can be associated with many organic and psychiatric etiologies and confused with a variety of diagnoses. In addition to its organic complications, malignant catatonia can also be extremely severe. Several diagnostic scales are described, those of Bush and Peralta being the most widely used. Despite the recent development of the DSM-5, we can regret the lack of progress in the international classifications concerning both the recognition of the etiological diversity of this syndrome and in the clinical and therapeutic approaches to it. The diagnosis is based solely on clinical data, and needs to be completed by information from paraclinical settings, particularly with respect to detecting organic etiology. The first-line treatment is still based on the use of certain benzodiazepines or benzodiazepine-like agents such as lorazepam, diazepam and zolpidem. If the first or second line fails, or in case of malignant catatonia, electroconvulsive therapy is recommended. For the periodic form, no large-sample study has been performed on long-term treatment. A few case reports suggest the use of lithium in periodic catatonia, specifically to prevent recurrent episodes or at least to extend the inter-episode intervals. Other studies are in favor of the use of benzodiazepines, with disagreement between gradual discontinuation and long-term treatment. Concerning the management of catatonia in patients with schizophrenia, for whom first-line benzodiazepines are often insufficient, certain atypical antipsychotics such as clozapine or quetiapine appear efficient. These data are also applicable to children and adolescents.
Often neglected by practitioners, catatonic syndrome remains a common entity of which it is important to be aware, especially in case of rapid installation of the symptoms. Diagnostic scales should be used and a lorazepam test should be performed to avoid delaying the diagnosis. Second-line therapy requires further study. This concerns in particular diazepam, anti-NMDA (N-methyl-D-aspartate) and rTMS (repetitive transcranial magnetic stimulation). Some specificities of catatonia, such as the periodic form and cases in patients with schizophrenia, also require further evaluations.
La catatonie est un syndrome psychomoteur qui comprend des symptômes moteurs, mentaux, comportementaux et neurovégétatifs. Exclusivement rattaché à la schizophrénie jusque dans les années 1970, ce syndrome reste sous-diagnostiqué malgré une morbi-mortalité relativement importante.
Pouvant présenter différentes formes et évolutions, le syndrome catatonique s’associe à de multiples étiologies organiques ou psychiatriques et possède plusieurs diagnostics différentiels. En dehors de ses complications organiques, la catatonie maligne peut mettre en jeu le pronostic vital. Parmi de multiples échelles, celles de Bush et de Peralta sont les plus utilisées. Malgré les récentes évolutions du DSM-5, les classifications internationales ne décrivent encore que partiellement la diversité étiologique et les approches cliniques et thérapeutiques qu’elle revêt. Le diagnostic est exclusivement clinique mais peut être complété paracliniquement pour un étayage étiologique. Le traitement de première intention comprend quelques benzodiazépines ou agents apparentés qui sont le lorazepam, le zolpidem et le diazépam. En cas de forme maligne ou d’échec des traitements médicamenteux, l’électroconvulsivothérapie est recommandée. Pour la forme périodique, aucune étude à grande échelle n’étaye la prise en charge au long cours. Quelques études de cas suggèrent pour cette forme l’emploi du lithium pour prévenir un épisode ultérieur ou tout au moins pour élargir les intervalles de temps inter-épisodiques. D’autres études de cas suggèrent plutôt l’emploi de benzodiazépines au long cours tandis que d’autres rapportent l’intérêt d’une suspension progressive. Dans le cas du syndrome catatonique chez les patients atteints de schizophrénie, seuls quelques antipsychotiques atypiques comme la quétiapine et la clozapine semblent montrer une réelle efficacité. L’ensemble de ces données seraient applicables chez l’enfant et l’adolescent.
Souvent négligé par le praticien, le syndrome catatonique reste une entité importante à connaître, en particulier lors d’une installation symptomatologique rapide. Au moindre doute, une échelle diagnostique peut être utilisée et un test au lorazepam réalisé. L’étude des autres traitements pharmacologiques devrait être approfondie et concerne le diazépam et les antagonistes des récepteurs au NMDA (N-methyl-D-aspartate). L’usage de la r-TMS (stimulation magnétique transcrânienne répétée) devrait lui aussi être davantage évalué. Il en est de même pour les spécificités des formes périodiques et de la catatonie chez les patients atteints de schizophrénie.

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Case ReportLong-term maintenance lorazepam for catatonia: a case report

Abstract

Section snippets

Case

Discussion

What catatonia can tell us about “top-down modulation”: a neuropsychiatric hypothesis

Behav Brain Sci

Catatonia: clinical aspects and neurobiological correlates

J Neuropsychiatry Clin Neurosci

Case Report
Long-term maintenance lorazepam for catatonia: a case report