Psychiatric Case Study Schizophrenia

course of disease, benzodiazepines, electroconvulsive therapy

Introduction

Catatonia is a syndrome characterized by the coexistence of psychiatric and motor symptoms.1 It is associated with a wide range of psychiatric, medical, neurological, and drug-induced disorders.2 The concept of catatonia was first described by the German psychiatrist Kahlbaum in 1874.3 It is more frequently found among patients diagnosed with mania, depression, and neurotoxic syndromes than among those with schizophrenia. Yet, it is mainly classified as a form of schizophrenia.4 The exact cause of catatonia has not been elucidated.

The syndrome of catatonia is defined by the objective presence of motor signs, over 40 of which have been described. These catatonic signs are listed in table 1. There is no agreed threshold for the number or duration of symptoms that should be present to justify a diagnosis of catatonia. Research has suffered from this, and studies can rarely be compared with confidence.7

Table 1.

Principal Features of Catatonia5,6

Clinical Feature Description 
Stupor Altered arousal during which the patient fails to respond directly to queries (similar in presentation to the effects of dissociative anesthesia); when severe, the patient is mute and immobile and does not withdraw from painful stimuli. 
Posturing (catalepsy) Maintaining postures for long periods. Includes facial postures, such as grimacing or Schnauzkrampf (lips in an exaggerated pucker). Body postures, such as psychological pillow (patient lying in bed with his or her head elevated as if on a pillow), lying in a jackknifed position, sitting with upper and lower portions of the body twisted at right angles, holding arms above the head or raised in prayer-like manner, and holding fingers and hands in odd positions; prolonged mundane positions are common examples. 
Flexibilitas cerea The patient’s initial resistance to an induced movement before gradually allowing himself or herself to be postured, similar to bending a candle. 
Mutism Verbal unresponsiveness, not always complete nor always associated with immobility. 
Staring Fixed gaze. 
Negativism The refusal of orders without any specific motive. 
Autonomic instability Abnormalities in body temperature, pulse, blood pressure, respiration rate, and sweating. 
Echophenomena Includes echolalia, in which the patient repeats the examiner’s utterances, and echopraxia, in which the patient spontaneously copies the examiner’s movements or is unable to refrain from copying the examiner’s test movements, despite instruction to the contrary. 
Stereotypy Non–goal-directed, repetitive motor behavior. The repetition of phrases and sentences in an automatic fashion, similar to a scratched record, termed “verbigeration,” is a verbal stereotypy. The neurological term for similar speech is “palilalia,” during which the patient repeats the sentence just uttered, usually with increasing speed. 
Mannerisms Odd, purposeful movements, such as holding hands as if they were handguns, saluting passersby, or exaggerations or stilted caricatures of mundane movements; odd speech cadences and feigned accents are other examples. 
Automatic obedience Despite instructions to the contrary, the patient permits the examiner’s light pressure to move his or her limbs into a new position (posture), which may then be maintained by the patient despite instructions to the contrary. 
Motoric opposition (Gegenhalten) Resistance to the examiner’s manipulations, whether light or vigorous, with strength equal to that applied, as if bound to the stimulus of the examiner’s actions. 
Motoric cooperation (Mitmachen) Exaggerated cooperation in the examiner’s manipulations, even when asked not to do so. Needs to be repeatable. 
Ambitendency The patient appears “stuck” in an indecisive, hesitant movement, resulting from the examiner verbally contradicting his or her own strong nonverbal signal, such as offering his or her hand as if to shake hands while stating, “Don’t shake my hand. I don’t want you to shake it.” 
Clinical Feature Description 
Stupor Altered arousal during which the patient fails to respond directly to queries (similar in presentation to the effects of dissociative anesthesia); when severe, the patient is mute and immobile and does not withdraw from painful stimuli. 
Posturing (catalepsy) Maintaining postures for long periods. Includes facial postures, such as grimacing or Schnauzkrampf (lips in an exaggerated pucker). Body postures, such as psychological pillow (patient lying in bed with his or her head elevated as if on a pillow), lying in a jackknifed position, sitting with upper and lower portions of the body twisted at right angles, holding arms above the head or raised in prayer-like manner, and holding fingers and hands in odd positions; prolonged mundane positions are common examples. 
Flexibilitas cerea The patient’s initial resistance to an induced movement before gradually allowing himself or herself to be postured, similar to bending a candle. 
Mutism Verbal unresponsiveness, not always complete nor always associated with immobility. 
Staring Fixed gaze. 
Negativism The refusal of orders without any specific motive. 
Autonomic instability Abnormalities in body temperature, pulse, blood pressure, respiration rate, and sweating. 
Echophenomena Includes echolalia, in which the patient repeats the examiner’s utterances, and echopraxia, in which the patient spontaneously copies the examiner’s movements or is unable to refrain from copying the examiner’s test movements, despite instruction to the contrary. 
Stereotypy Non–goal-directed, repetitive motor behavior. The repetition of phrases and sentences in an automatic fashion, similar to a scratched record, termed “verbigeration,” is a verbal stereotypy. The neurological term for similar speech is “palilalia,” during which the patient repeats the sentence just uttered, usually with increasing speed. 
Mannerisms Odd, purposeful movements, such as holding hands as if they were handguns, saluting passersby, or exaggerations or stilted caricatures of mundane movements; odd speech cadences and feigned accents are other examples. 
Automatic obedience Despite instructions to the contrary, the patient permits the examiner’s light pressure to move his or her limbs into a new position (posture), which may then be maintained by the patient despite instructions to the contrary. 
Motoric opposition (Gegenhalten) Resistance to the examiner’s manipulations, whether light or vigorous, with strength equal to that applied, as if bound to the stimulus of the examiner’s actions. 
Motoric cooperation (Mitmachen) Exaggerated cooperation in the examiner’s manipulations, even when asked not to do so. Needs to be repeatable. 
Ambitendency The patient appears “stuck” in an indecisive, hesitant movement, resulting from the examiner verbally contradicting his or her own strong nonverbal signal, such as offering his or her hand as if to shake hands while stating, “Don’t shake my hand. I don’t want you to shake it.” 

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There are consistent clinical reports that benzodiazepines are effective in acute catatonia syndromes, particularly stuporous conditions, but no placebo-controlled randomized studies have been published.8,9 However, benzodiazepines are the drugs of choice for catatonia.10 In most cases, lorazepam is administered parenterally or orally beginning with 3 mg/d and increasing rapidly to effective resolution. Dosages of 20–30 mg/d are occasionally necessary.5 Patients who are unresponsive or insufficiently responsive to benzodiazepines need electroconvulsive therapy (ECT).5,10

Case Report

Patient A is a 28-year-old male of Mediterranean origin diagnosed with paranoid schizophrenia at the age of 23. He was hospitalized several times due to psychotic episodes characterized by religious delusions and auditory and visual hallucinations. He is living in an assisted living facility, where the medication is offered to the residents, but where they have to take it by themselves. He uses cannabis daily and does not use any other substances. Drug history mentions the use of risperidone and flupentixol decanoate, the latter since 2008 up to the present. At the end of 2008, he developed a progressive condition in which he showed less mimicry, staring, negativism, mutism, and immobility. There were no signs of autonomic dysregulation, such as increased body temperature or unstable blood pressure.

Because catatonia was assumed in April 2009, he was orally treated with lorazepam, starting at 2 mg a day. The lorazepam dose was increased based on the clinical state until 40 mg a day without any subjective or objective effects. He was admitted to the psychiatric ward to receive parenterally administered lorazepam up to 60 mg daily. After 2 days, there still was no measurable effect nor was there any effect on his consciousness. We resumed oral treatment with lorazepam 40 mgs daily and patient agreed to undergo ECT. During the lorazepam and ECT treatment, the patient continued to receive 30 mg of flupentixol decanoate every 2 weeks. After 3 ECT sessions (Mecta 5000, bilateral, 1 ms, 40 hz 2 s, 128 mC, 800 mA, [a relatively low, common, dosage]), the catatonic signs receded rapidly and patient refused to take the lorazepam, because “he was cured.” He soon afterward developed an acute catatonic state, in which he was found completely immobile next to his bed. He received lorazepam immediately and ECT the following days. After 2 more ECT sessions, the catatonic signs receded again. During the weeks afterward, patient received 40 mgs lorazepam daily, which was reduced and finally stopped on his demand.

A few months afterward, patient presented to the acute psychiatric service with signs of acute dystonia (cervical dystonia and dysphagia). He was treated with biperiden 2 mg and the dystonia almost immediately disappeared. Flupentixol decanoate dosage was lowered to 20 mgs every 2 weeks. Patient denied the use of any drugs except cannabis and urine examination confirmed this. After this episode, patient experienced several other episodes of dystonia, each time successfully treated with biperiden 2 mgs.

Considerations

This case has many remarkable features. To begin with, the simple fact of a slowly progressive, during multiple months, catatonic state emerging elicited our curiosity. We could not relate it to a mood disorder nor to excessive cannabis use. Then again, the administration of doses of lorazepam up to 60 mg per day without any effects whatsoever seems remarkable, especially in the case of a young man not habituated to benzodiazepines. Of interest to those practicing ECT is the remarkable fact that the quality of the ECT did not suffer under the administration of high doses of benzodiazepines. We used the dosage titration method to determine the energy level needed for the ECT. We chose to temporarily halt the action of the lorazepam with the administration of 0.5 mg of flumazenil i.v. immediately prior to the ECT and achieved a therapeutically sufficient convulsion at a relatively low energy level. After 2 ECT sessions in this manner, we chose to try a treatment session without the use of flumazenil. This had no influence on the energy necessary for the ECT; on the contrary, we obtained a convulsion of the same length and electroencephalogram waveform as we did using the flumazenil, at precisely the same energy level. After the fifth treatment session, the patient did not return for further treatment sessions, in spite of his incomplete remission and in spite of his having been warned of the possibility of relapse. He was observed to be in worse condition in his home, but he himself seemed to be less distressed by his condition than his caregivers did, in spite of the many observations that catatonia is usually accompanied by anxiety. Because of the outpatient situation, there were limitations according to physical and blood examinations and the medication intake during the (acute) catatonic state of our patient. We have had our doubts of his acceptance of the benzodiazepines, but during his stay on the ward, the administration has been closely supervised by trained psychiatric nursing staff. Unfortunately, we did not determine a plasma level of benzodiazepines. Other laboratory results were unremarkable.

Questions

Should we consider other diagnoses than catatonia, and, if so, which? Perhaps a syndrome caused by cannabis consumption?

Does such a diagnosis explain the progression, over months, of the “catatonic-like” state?

How is the absence of an effect on the necessary ECT energy level by benzodiazepines to be explained?

How should we interpret the absence of distress?

Have we used the correct treatments or should we have had other considerations?

Submissions should be sent to the email address as listed in the author information. Any outcome will subsequently be published in this journal.

The Authors have declared that there are no conflicts of interest in relation to the subject of this study.

References

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Catatonia: a review of a behavioral neurologic syndrome

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Clinical relevance of chronic catatonic schizophrenia in children and adolescents: evidence from a prospective naturalistic study

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3.

Die Katatonie oder das Spannungsirresein

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Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature

Schizophr Bull

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Catatonia: a syndrome to be remembered

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8.

The catatonia conundrum: evidence of psychomotor phenomena as a symptom dimension in psychotic disorders

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© The Author 2010. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.

By DeepDiveAdmin, Wed, December 02, 2015

Sample Case Studies and Diagnoses

Following are four examples of patient descriptions with a link to the corresponding diagnosis.

These sample case studies are for illustration only. They should not be used to make a diagnosis. If the symptoms sound similar to those that you (or a loved one) are experiencing, please contact your primary physician or a mental health professional for an evaluation as soon as possible.

Case Study 1

Jessica is a 28 year-old married female. She has a very demanding, high stress job as a second year medical resident in a large hospital. Jessica has always been a high achiever. She graduated with top honors in both college and medical school. She has very high standards for herself and can be very self-critical when she fails to meet them. Lately, she has struggled with significant feelings of worthlessness and shame due to her inability to perform as well as she always has in the past.

For the past few weeks Jessica has felt unusually fatigued and found it increasingly difficult to concentrate at work. Her coworkers have noticed that she is often irritable and withdrawn, which is quite different from her typically upbeat and friendly disposition. She has called in sick on several occasions, which is completely unlike her. On those days she stays in bed all day, watching TV or sleeping.

At home, Jessica’s husband has noticed changes as well. She’s shown little interest in sex and has had difficulties falling asleep at night. Her insomnia has been keeping him awake as she tosses and turns for an hour or two after they go to bed. He’s overheard her having frequent tearful phone conversations with her closest friend, which have him worried. When he tries to get her to open up about what’s bothering her, she pushes him away with an abrupt “everything’s fine”.

Although she hasn’t ever considered suicide, Jessica has found herself increasingly dissatisfied with her life. She’s been having frequent thoughts of wishing she was dead. She gets frustrated with herself because she feels like she has every reason to be happy, yet can’t seem to shake the sense of doom and gloom that has been clouding each day as of late. [Click here for Diagnosis]

 

Case Study 2

Kristen is a 38 year-old divorced mother of two teenagers. She has had a successful, well-paying career for the past several years in upper-level management. Even though she has worked for the same, thriving company for over 6 years, she’s found herself worrying constantly about losing her job and being unable to provide for her children. This worry has been troubling her for the past 8 months. Despite her best efforts, she hasn’t been able to shake the negative thoughts.

Ever since the worry started, Kristen has found herself feeling restless, tired, and tense. She often paces in her office when she’s there alone. She’s had several embarrassing moments in meetings where she has lost track of what she was trying to say. When she goes to bed at night, it’s as if her brain won’t shut off. She finds herself mentally rehearsing all the worse-case scenarios regarding losing her job, including ending up homeless. [Click here for Diagnosis]

 

Case Study 3

Josh is a 27 year-old male who recently moved back in with his parents after his fiancée was killed by a drunk driver 3 months ago. His fiancée, a beautiful young woman he’d been dating for the past 4 years, was walking across a busy intersection to meet him for lunch one day. He still vividly remembers the horrific scene as the drunk driver ran the red light, plowing down his fiancée right before his eyes. He raced to her side, embracing her crumpled, bloody body as she died in his arms in the middle of the crosswalk. No matter how hard he tries to forget, he frequently finds himself reliving the entire incident as if it was happening all over.

Since the accident, Josh has been plagued with nightmares about the accident almost every night. He had to quit his job because his office was located in the building right next to the little café where he was meeting his fiancée for lunch the day she died. The few times he attempted to return to work were unbearable for him. He has since avoided that entire area of town.

Normally an outgoing, fun-loving guy, Josh has become increasingly withdrawn, “jumpy”, and irritable since his fiancé’s death. He’s stopped working out, playing his guitar, or playing basketball with his friends – all activities he once really enjoyed. His parents worry about how detached and emotionally flat he’s become. [Click here for Diagnosis]

 

Case Study 4

Martin is a 21 year-old business major at a large university. Over the past few weeks his family and friends have noticed increasingly bizarre behaviors. On many occasions they’ve overheard him whispering in an agitated voice, even though there is no one nearby. Lately, he has refused to answer or make calls on his cell phone, claiming that if he does it will activate a deadly chip that was implanted in his brain by evil aliens.

His parents have tried to get him to go with them to a psychiatrist for an evaluation, but he refuses. He has accused them on several occasions of conspiring with the aliens to have him killed so they can remove his brain and put it inside one of their own. He has stopped attended classes altogether. He is now so far behind in his coursework that he will fail if something doesn’t change very soon.

Although Martin occasionally has a few beers with his friends, he’s never been known to abuse alcohol or use drugs. He does, however, have an estranged aunt who has been in and out of psychiatric hospitals over the years due to erratic and bizarre behavior. [Click here for Diagnosis]

 

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