Psychiatry

Catatonia

Case

An 82 year-old female presents to the ED with her daughter due to altered mental status. On EMS arrival to the patient’s home, she is somnolent and unable to speak. She is activated as a Code Stroke and brought immediately to CT scan upon arrival. After returning from the CT scan, you go in to perform a comprehensive neurologic exam. The patient is lying in bed with her eyes closed, she does not arouse to voice. She does grimace with painful stimulation such as sternal rub. She groans and mumbles words but does not make coherent sentences. She does not follow commands. Her extremities do localize to painful stimulation. Despite her concerning neurologic exam, she is maintaining O2 saturations at 98% on room air and a respiratory rate of 14 with full deep breaths. While performing her neurologic exam, you lift her arm into the air and she holds it there indefinitely until you move the arm again. The radiologist calls to inform you of her normal non-contrast CT and CTA of the brain and neck. All laboratory work returns reassuring. On re-examination, she continues leave her limbs in the exact position you place them in until re-positioned. This reminds you of a condition that you learned about in medical school… catatonia!


Clinical Presentation

Catatonia is a syndrome characterized by psychomotor abnormalities and often associated with a variety of psychiatric and neurologic conditions, classically schizophrenia. The syndrome can present with a variety of psychomotor symptoms and often decreased mental state. Although it was originally thought to be associated solely with schizophrenia, it has now been found to be associated with any psychiatric condition including PTSD, bipolar disorder, depression as well as neurologic conditions such as encephalitis, stroke, malignancy, or dementia. Catatonia can be a difficult diagnosis to make due to a variety of presentations. Some of the classic features of catatonia are listed below.


In the DSM-V definition of catatonia, the patient must present with at least three of the following:

  • Stupor – overall decreased activity or decreased interaction with the environment

  • Catalepsy – muscular rigidity, i.e. a limb stays where it is positioned

  • Waxy flexibility – resistance to positioning, like a feeling of bending a candle

  • Mutism – no verbal response

  • Negativism – no response to external stimuli

  • Posturing – maintaining a specific position for prolonged periods of time

  • Mannerisms – odd movements

  • Stereotypy – repetitive movements

  • Agitation

  • Grimacing

  • Echolalia – mimicking speech

  • Echopraxia – mimicking movements


Diagnosis

The diagnosis of catatonia is based on recognition of these classic clinical findings. Appropriate medical workup to exclude organic etiology is also very important. For example, common mimics could include acute intracranial processes such as ischemic or hemorrhagic stroke, meningitis/encephalitis, electrolyte derangement, neuroleptic malignant syndrome, serotonin syndrome, delirium, and many other causes. Consideration to medical workup to exclude these causes is of utmost importance to make the diagnosis and not miss a life-threatening process. Detailed history and physical exam should be performed, including specific attention to complete neurologic exam, evaluation of reflexes, and any signs of autonomic instability. Additional testing should include broad laboratory work, brain imaging including CT or MRI, and consideration of CSF studies.

 

Treatment

Once a diagnosis of catatonia is suspected, the treatment should be initiated as soon as possible. The simplest treatment for an ED physician to perform is termed the “benzodiazepine challenge.” This can help with diagnostic uncertainty and rapidly improve symptoms in a majority of patients. Lorazepam is most often cited as the agent of choice due to its evaluation in the literature and the ease of use for ED physicians. It is estimated that about 60-80% of patients will achieve remission with benzodiazepine monotherapy. In a patient with suspect catatonia, the ED physician can give 2 mg IV lorazepam and observe the patient. Rapid improvement can be seen in their symptoms within a few minutes. After approximately 20-30 minutes, the patient may have recurrence of their catatonia symptoms and regress. Additional IV lorazepam can be given as needed. Besides IV benzodiazepines, the alternative treatment of choice is ECT. This should be started as soon as feasible, ideally within 24 to 48 hours of diagnosis. Antipsychotic drugs should be avoided in patients with catatonia, even for aggression or agitated patients.  If not properly and promptly treated catatonia can proceed to malignant catatonia which carriers an associated mortality of up to 20%.

 

Disposition

All patients with suspected diagnosis of catatonia should be admitted to the hospital for aggressive management of catatonia as well as the underlying psychiatric or medical disorder. Patients who have autonomic instability or hyperthermia should be admitted to the intensive care unit for close supportive care. Long term catatonia carriers a favorable prognosis.

 

Case Conclusion

Our patient was given a single dose of 1 mg IV lorazepam and soon after, began to speak and interact with her daughter, who had accompanied to the ED. Within one hour, she had return of mutism and cataplexy so an additional dose of IV lorazepam was given with rapid improvement of her symptoms. She was admitted to internal medicine with psychiatry consulting and was transitioned to an oral lorazepam regimen. She ultimately had good recovery and was discharged back to home with her daughter after an inpatient stay.

  

Teaching points

  • Catatonia is a purely clinical diagnosis that can be made in the ED

  • Recognize the characteristic clinical findings to keep this syndrome on your differential diagnosis of patients with mental changes

  • The treatment of catatonia should be initiated in the ED with IV lorazepam and rapid clinical improvement can help confirm your diagnosis


Faculty Reviewer: Dr. Kristina McAteer


References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013

  2. Fink, Max, and Michael A. Taylor. "The many varieties of catatonia." European archives of psychiatry and clinical neuroscience 251.1 (2001): I8-I13.

  3. HUANG, TIAO‐LAI. "Lorazepam and diazepam rapidly relieve catatonic signs in patients with schizophrenia." Psychiatry and clinical neurosciences 59.1 (2005): 52-55.

  4.  Jaimes-Albornoz, Walter, and Jordi Serra-Mestres. "Catatonia in the emergency department." Emerg Med J (2012): emermed-2011. 

  5. Sharma, Puja, et al. "Catatonia in patients with dementia admitted to a geriatric psychiatry ward." Journal of neurosciences in rural practice 8.Suppl 1 (2017): S103.

  6. Wilcox, James Allen, and Pam Reid Duffy. "The syndrome of catatonia." Behavioral Sciences 5.4 (2015): 576-588.

AEM Early Access 17: Post-Traumatic Symptoms and Acute Pain Following Injury

Welcome to the seventeenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

AEM Podcasts logo[3].png

DISCUSSING: (OPEN ACCESS THROUGH JULY 31, 2018; CLICK ON TITLE TO ACCESS.)

The Association between Daily Posttraumatic Stress Symptoms and Pain over the First 14‐days after Injury: An Experience Sampling Study. Maria L. Pacella PhD,  Jeffrey M. Girard MS,  Aidan G.C. Wright PhD,  Brian Suffoletto MD, Clifton W. Callaway MD,PhD.

listen now: author interview with Dr. maria pacella

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Maria Pacella, PhD

Research Assistant Professor

Department of Emergency Medicine

University of Pittsburgh

article abstract:

Objectives
Psychosocial factors and responses to injury modify the transition from acute to chronic pain. Specifically, posttraumatic stress disorder symptoms (PTSS; reexperiencing, avoidance, and hyperarousal symptoms) exacerbate and co‐occur with chronic pain. Yet no study has prospectively considered the associations among these psychological processes and pain reports using experience sampling methods (ESM) during the acute aftermath of injury.

This study applied ESM via daily text messaging to monitor and detect relationships among psychosocial factors and post‐injury pain across the first 14‐days after emergency department (ED) discharge.

Methods
We recruited 75 adults (59% male; M age = 33) who experienced a potentially traumatic injury (i.e., involving life threat or serious injury) in the past 24‐hours from the EDs of two Level 1 trauma centers. Participants received 5 questions per day via text messaging from Day‐1 to Day‐14 post‐ED discharge; three questions measured PTSS, one question measured perceived social support, and one question measured physical pain.

Results
Sixty‐seven participants provided sufficient data for inclusion in the final analyses, and the average response rate per subject was 86%. Pain severity score decreased from a mean of 7.2 to 4.4 over 14 days and 50% of the variance in daily pain scores was within‐person. In multilevel structural equation models, pain scores decreased over time, and daily fluctuations of hyperarousal (b = 0.22, 95% CI [0.08, 0.36]) were uniquely associated with daily fluctuations in reported pain level within each person.

Conclusions
Daily hyperarousal symptoms predict same‐day pain severity over the acute post‐injury recovery period. We also demonstrated feasibility to screen and identify patients at risk for pain chronicity in the acute aftermath of injury. Early interventions aimed at addressing hyperarousal (e.g. anxiolytics) could potentially aid in reducing experience of pain.

ADDITIONAL READING:

Bryant, R.A., et al., The psychiatric sequelae of traumatic injury. American Journal of Psychiatry, 2010.

Gatchel, R.J., et al., The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull, 2007. 133(4): p. 581-624.

Rosenbloom, B.N., et al., Predicting pain outcomes after traumatic musculoskeletal injury. Pain, 2016. 157(8): p. 1733-1743.

O'Donnell, M.L., et al., Disability after injury: the cumulative burden of physical and mental health. J Clin Psychiatry, 2013. 74(2): p. e137-43.

Feinberg, R.K., et al., Stress-related psychological symptoms contribute to axial pain persistence after motor vehicle collision: path analysis results from a prospective longitudinal study. Pain, 2017. 158(4): p.682-690.

Price, M., et al., A feasibility pilot study on the use of text messages to track PTSD symptoms after a traumatic injury. Gen Hosp Psychiatry, 2014. 36(3): p. 249-54.

AEM Early Access 14: Cannabis and Mental Health ED Visits in Colorado

Welcome to the fourteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:(Click title for open access through may 31, 2018)

Mental Health-Related Emergency Department Visits Associated with Cannabis in Colorado. Katelyn E. Hall MPH, Andrew A. Monte MD, Tae Chang, Jacob Fox, Cody Brevik, Daniel I. Vigil MD, MPH,  Mike Van Dyke PhD, CIH,  Katherine A. James PhD, MSPH. Academic Emergency Medicine, 2018.

LISTEN NOW: AUTHOR INTERVIEW

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Andrew A. Monte, MD

Associate Professor, Departments of Emergency Medicine & PharmaceuticaLSciences
University of Colorado Denver-Anschutz Medical Center Aurora, CO and Rocky Mountain Poison & Drug Center
Denver Health & Hospital Authority
Denver, CO

ARTICLE SUMMARY: 

Objectives:
Across the United States, the liberalization of marijuana use has resulted in a rapid increase in the social acceptability of its use.  Colorado has been at the forefront of marijuana legalization, allowing recreational use beginning in 2014.  Since then, Colorado has positioned itself as the optimal environment to study health-related impacts from marijuana use.  Cannabis use is well-known to exacerbate mental health illness such as schizophrenia, mood disorders, anxiety, and depression.  Since legalization in Colorado, increased healthcare utilization has been associated with acute and chronic marijuana use.  It is currently unknown if cannabis use is associated with increased ED visits in patients with mental illness.  The primary objective of this study was to determine the prevalence ratios of mental health diagnoses among ED visits with cannabis-associated diagnosis compared to those without cannabis-associated diagnoses in Colorado.

Methods:
The study was cross-sectional in design, with discharge diagnostic codes collected from Colorado emergency departments from 2012 to 2014.  Diagnosis codes identified visits associated with both mental health conditions and cannabis.  Prevalence ratios of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis.  Rates of mental health and cannabis-associated ED discharges were examined of the study period.  

Results:
State-wide data demonstrated a five-fold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR: 5.35, 95% CI: 5.27-5.43) compared to visits without cannabis. In the study’s secondary outcome, state-wide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p<0.0001).

Conclusion:
In Colorado from 2012 to 2014 the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis.  Due to the nature of the study design, it is unclear if these findings are attributable to cannabis or coincident with increased use and availability.  Per the authors of the paper, ED physicians nationwide should be aware of the detriments of marijuana use on pre-existing mental health conditions and ED management should include counseling on cessation and rehabilitation.