Cases That Test Your Skills

The treatment-resistant catatonia patient

Current Psychiatry. 2009 March;8(3):66-69

References

1. Aboraya A, Tien A. Schedules for Clinicians’ Interviews in Psychiatry (SCIP): work in progress. International Journal of Mental Health and Addiction. Available at: http://www.ijma-journal.com/pdf/c01a09.pdf. Accessed February 4, 2009.

2. Diagnostic and statistical manual of disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

3. Kahlbaum KL. In: Levi Y, Pridon T, trans. Catatonia. Baltimore, MD: Johns Hopkins University Press; 1973.

4. Hesslinger B, Walden J, Normann C. Acute and long-term treatment of catatonia with risperidone. Pharmacopsychiatry. 2001;34(1):25-26.

5. Bleuler E. Dementia praecox. New York, NY: International University Press; 1950.

6. Blumer D. Catatonia and the neuroleptics: psychobiologic significance of remote and recent findings. Compr Psychiatry. 1997;38(4):193-201.

7. Bush G, Fink M, Petrides G, et al. Catatonia. II Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand. 1996;93(2):137-143.

8. Duggal HS, Gandotra G. Risperidone treatment of periodic catatonia. Can J Psychiatry. 2005;50(4):241-242.

9. Duggal HS. Risperidone treatment of febrile catatonia in first-episode psychosis. Gen Hosp Psychiatry. 2005;27(1):80-81.

10. Rudorfer M, Henry M, Sackeim H. Electroconvulsive therapy. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry: therapeutics. London, UK: John Wiley & Sons; 2003:167-203.

11. Kopala LC, Caudle C. Acute and longer-term effects of risperidone in a case of first-episode catatonic schizophrenia. J Psychopharmacol. 1998;12(3):314-317.

12. Poyurousky M, Bergman J, Weizman A. Risperidone in the treatment of catatonia in a schizophrenic patient. Isr J Psychiatry Relat Sci. 1997;34(4):323-324.

13. Levy WO, Nunez CY. Use of ziprasidone to treat bipolar-associated catatonia. Bipolar Disord. 2004;6(2):166-167.

14. Martenyi F, Metcalfe S, Schausberger B, et al. An efficacy analysis of olanzapine treatment data in schizophrenia patients with catatonic signs and symptoms. J Clin Psychiatry. 2001;62(suppl 2):225-227.

Clinical Point

We recommend using risperidone to treat catatonia in psychotic patients who do not respond to a benzodiazepine

Other atypical antipsychotics—ziprasidone and olanzapine—also have been shown to be effective in treating catatonia. Levy et al¹³ reported successful treatment of a catatonic state (with catalepsy, stupor, and mutism) using intramuscular ziprasidone followed by oral ziprasidone. A data analysis by Martenyi et al¹⁴ showed olanzapine to be effective in treating nonspecific signs and symptoms of catatonia, as measured by the Positive and Negative Syndrome Scale.

TREATMENT: Trying risperidone

Based on case reports showing risperidone’s efficacy for catatonia, we start Ms. R on risperidone, 4 mg/d, and lorazepam, 4 mg/d. Eight days later, her catatonic symptoms decrease substantially—she scores 2/6 on the SCIP catatonia scale (Table)—and she starts to talk with the staff.

We continue this regimen for 30 days, then discontinue lorazepam to avoid long-term side effects—such as dependence—and titrate risperidone to 8 mg/d. Ms. R continues to improve while taking risperidone only. Twenty-three days after stopping lorazepam, she is free of catatonic symptoms, scoring 0/6 on the SCIP catatonia scale.

We discharge Ms. R on risperidone. Because she has a history of medication nonadherence, we prescribe risperidone long-acting injection, 37.5 mg every 2 weeks, while continuing oral risperidone for 3 weeks after the first injection. She does well on this medication, experiencing no catatonic symptoms or adverse effects over the next 15 months as measured by the SCIP assessment.

The authors’ observations

This is the third case report in the literature to show that risperidone is effective in short- and long-term treatment of catatonia.^4,11 Although Ms. R’s initial response can be attributed at least partially to lorazepam—which is known to be effective in treating catatonia—she continued to show improvement while taking risperidone only and remained free from catatonic symptoms for 15 months, until she was readmitted for reasons unrelated to catatonia.

We recommend using risperidone to treat catatonia in patients who do not respond to a benzodiazepine, especially those with other psychotic symptoms such as delusions or hallucinations. While administering risperidone, watch for long-term side effects, such as hyperlipidemia, weight gain, and diabetes. For catatonia in patients who cannot tolerate risperidone, consider olanzapine or ziprasidone.

Related resources

Schedules for Clinicians’ Interview in Psychiatry (SCIP). Available from Ahmed Aboraya, ahmedaboraya@wvdhhr.org.
Valevski A, Loebl T, Keren T, et al. Response of catatonia to risperidone: two case reports. Clin Neuropharmacol. 2001;24(4):228-231.
Van Den Eede F, Van Hecke J, Van Dalfsen A, et al. The use of atypical antipsychotics in the treatment of catatonia. Eur Psychiatry. 2005;20(5-6):422-429.

Drug brand names

Haloperidol • Haldol
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Olanzapine • Zyprexa
Risperidone • Risperdal
Risperidone long-acting injection • Risperdal Consta
Ziprasidone • Geodon

Disclosure

The authors have no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The treatment-resistant catatonia patient

References

Pages

Recommended Reading