CLINICAL
The BY
AND
Catatonic IRA
can
pyramidal catatonia
tion
for
during
AND
neuroleptic
WILLIAM
J. RHEUBAN,
treatment
(1) because
complications, (7). The catatonic catatonia.
nation, although been reported
of
schizophne-
such
patients
e.g., pulmonary following case details schizophrenia and To
it has been previously.
our
knowledge,
assumed
are
prone
to
emboli and our dilemma superimposed this
combi-
to occur,
has
not
Report
A 19-year-old college student, previously in excellent health but with a family history of schizophrenia, developed increasing inability to concentrate, anxiety, anorexia, and indecisiveness several weeks before his admission. He became preoccupied with his sexual identity, and tension developed between him and his roommates regarding whether or not he should move out. He decompensated to the point that food had to be placed in front ofhim. He was referred to the emergency room, where he exhibited motor ambivalence, agitation, and loosened associations. He refused to be admitted and was given haloperidol, 5 mg p.o. The next day he agreed to admission; he was almost mute, with fixed staring, posturing, ideas of reference, thought rushing, and auditory hallucinations. Physical examination, CBC, SMA-12, SMA-6, EEG, CT scan, and a neurology consultation ruled out organicity. Halopenidol was increased to 30 mg/day, resuIting in an acute dystonic reaction. Benztropine, 2 mg I.M. , was effective in treating the reaction and 4 mg/day p.o. was added. His stupor worsened, and he demonstrated waxy flexibility, automatic obedience, rigidity, reaction at the last moment, abnormal compliance, and forced grasping. Halopenidol was increased to 80 mg/day on day 4 and amantadine, 200 mg/day, replaced benztropine. The patient became progressively more autistic and developed a ‘ ‘ paralysis’ ‘ of the left arm. He believed that moving his left side made him a woman and moving his right side made him a homosexual. Male aides made him agitated, and we wondered whether he might erupt into catatonic excitement. Amantadine was discontinued on day 7 and the patient regressed further. Urinary incontinence and food refusal coincided with family visits. The patient appeared to have difficulty with secretions and the gag reflex was decreased, although his lungs remained clear. Halopenidol was discontinued and IVs were started. By day 10, there was gradual improvement in motor activity and the patient began to eat, but his difficulty with secretions continued. His WBC increased to 16,000 and a
/978
chest X ray showed bilateral lower lobe infiltrates. Pulmonary consultants confirmed the diagnosis of aspiration pneumonia and felt that the psychiatric service had missed an underlying systemic illness that warranted further evaluation. The patient was then transferred to the medical ward for treatment. The patient’s rigidity, mutism, and posturing continued to improve gradually without medication. Penicillin, 10 U/day in continuous infusion, was started, and the infiltrates resolved uneventfully. He was transferred back to the psychiatnic service 6 days later, at which time there was marked improvement in his rigidity and mutism. Hallucinations and thought rushing disappeared, but loosened associations, perplexity, denial of illness, and “paralysis” persisted. He also remained delusional about the consequences of moving his body. Thionidazine was instituted in a dosage of 75 mg/day, which was slowly increased to 500 mg/day over 3 weeks. At the time ofdischarge, his thought disturbance was improved and his motor involvement resolved, except for weakness of the left arm. Discussion
conflict
oven
analogic action, (8). Moving out
The
which of his
is seen apartment
he equated a woman
being
a failure
patient’s
return
home
The authors wish to thank Salman Akhtar, sor of Psychiatry, University of Virginia help with the manuscript.
M.D. , Assistant Medical Center,
0002-953X/78/0010-
I 242$0.35
is AsCenProfesfor his
© American
to
poses image.
his
his
to
a
as
lifetime
his psychosis, Such volitional
rated,
experience
ing
staffbegan
helpless
and
the increasing very difficult. his
he
staffexpenienced
when
regressed
sequently, were
by
consultants
he
of seen
deteniofeelbetween
to
implied
relieved,
and
the
treatment?
the and
we
our ‘ ‘
was was
or
indignation
to
in a
dilemma,
pneumonia,
about
to over
the psychosis catatonia,
returned
feelings
male
seemed
be
the underlying patient remained
staff’s
had
loss
failed
illness. ‘ ‘ Alpsychotic wand.
the
missing
iatnogenic
overlay
Con-
diagbe-
clear.
Catatonia accounts noses of schizophrenia leptic-induced cians with
his
refractory
followed
when the
arm
not
aspiration
have missed improved, the
pun-
his
Distinguishing
developed the
Con-
progressively
indecisive.
guilt
and “must though he and
are
to
magical
his struggle characteristic
would
schizophrenia
when
of esteem
and stupor. course
have brother,
psychosis. dual
drug side effects and Did he have iatrogenic
underlying
Then,
to
and
of his
(8)
the
mother
preserving
encapsulating conflicts
catatonic schizophrenia pure neuroleptic-induced As the patient’s clinical
volition which
becoming
would
of and
and
he
the
move weakness
of failure,
a man
felt
served his
demonstrated
in disorders meant
He
immobility
of preventing The persistent
contain moving.
movement
schizophrenic
himself
sequently,
nosis” Dr. Brenner is Chief Resident in Psychiatry and Dr. Rheuban sistant Professor of Psychiatry, University of Virginia Medical ter, P.O. Box 203, Charlottesville, Va. 22901.
with
on a homosexual.
submitting
came
1242
J Psychiatry 135:10, October
M.D.
by the onset of putative extrasigns, which can be indistinguishable from (1-7). Clinicians are warned to stop medicanoncatatonic patients who become catatonic
neuroleptic
Case
M.D.,
be complicated
treatment
serious pneumonia in treating
Am
REPORTS
Dilemma
BRENNER,
High-potency nia
RESEARCH
to be Salman Psychiatric
for
catatonia less than Akhtar, Association
more
(9)
and is
.5% M.D.,
than the
estimated (personal David
5% incidence by
of
first diagof neunosome
clini-
communication Rosenman, M.D.,
Am
J Psychiatry
135:10,
October
/978
CLINICAL
and William J. Rheuban, M.D.), so the probability of encountering this combination is quite small. Even though catatonic features do not appear to predispose patients to extrapynamidal effects such as akinesia and rigidity (10), high-potency drugs should be used cautiously in catatonics until methods are developed to predict those especially at risk. One possibility is assay
of
pretreatment
urinary
dopamine
excretion,
which is negatively correlated with the probability of developing such toxicity (10). If neuroleptic catatonia is indeed a severe extnapynamidal reaction, such measurements could identify the low dopamine excnetens, who might comprise the high-risk group.
REFERENCES 1. Weinberger DR, Hyatt drugs. JAMA 239:1846,
Ri: Catatonic 1978
stupor
and
neuroleptic
AND
RESEARCH
REPORTS
2. Gelenberg neuroleptic 3. Behrman
Ai, Mandel MR: Catatonic reactions to high-potency drugs. Arch Gen Psychiatry 34:947-950, 1977 S: Mutism induced by phenothiazines. Br i Psychiatry 121:599-604, 1972 4. May RH: Catatonic-like states following phenothiazine therapy. Am
I Psychiatry
115:1119-1120,
1959
5. Rifkin A, Quitkin F, Klein DF: Akinesia: a poorly drug induced extrapyramidal behavioral disorder. Psychiatry 32:672-674, 1975 6. Weinberger DR, Kelley Ml: Catatonia and malignant a possible complication of neuroleptic administration. Ment
Dis 165:263-268,
recognized Arch Gen syndrome: J Nerv
1977
7. Regenstein GR, Alpert IS, Reich P: Sudden catatonic stupor with disastrous outcome. JAMA 238:618-620, 1977 8. Arieti 5: Interpretation of Schizophrenia, 2nd ed. New York, Basic Books, 1974 9. Guggenheim FG, Babigian HM: Catatonic schizophrenia: epidemiology and clinical course. I Nerv Ment Dis 158:291-305, 1974 10. Crowley TJ, Hoehn MM, Rutledge CO, et al: Dopamine excretion and vulnerability to drug-induced parkinsonism. Arch Gen Psychiatry 35:97-104, 1978
1243
The BY
AND
Catatonic IRA
can
pyramidal catatonia
tion
for
during
AND
neuroleptic
WILLIAM
J. RHEUBAN,
treatment
(1) because
complications, (7). The catatonic catatonia.
nation, although been reported
of
schizophne-
such
patients
e.g., pulmonary following case details schizophrenia and To
it has been previously.
our
knowledge,
assumed
are
prone
to
emboli and our dilemma superimposed this
combi-
to occur,
has
not
Report
A 19-year-old college student, previously in excellent health but with a family history of schizophrenia, developed increasing inability to concentrate, anxiety, anorexia, and indecisiveness several weeks before his admission. He became preoccupied with his sexual identity, and tension developed between him and his roommates regarding whether or not he should move out. He decompensated to the point that food had to be placed in front ofhim. He was referred to the emergency room, where he exhibited motor ambivalence, agitation, and loosened associations. He refused to be admitted and was given haloperidol, 5 mg p.o. The next day he agreed to admission; he was almost mute, with fixed staring, posturing, ideas of reference, thought rushing, and auditory hallucinations. Physical examination, CBC, SMA-12, SMA-6, EEG, CT scan, and a neurology consultation ruled out organicity. Halopenidol was increased to 30 mg/day, resuIting in an acute dystonic reaction. Benztropine, 2 mg I.M. , was effective in treating the reaction and 4 mg/day p.o. was added. His stupor worsened, and he demonstrated waxy flexibility, automatic obedience, rigidity, reaction at the last moment, abnormal compliance, and forced grasping. Halopenidol was increased to 80 mg/day on day 4 and amantadine, 200 mg/day, replaced benztropine. The patient became progressively more autistic and developed a ‘ ‘ paralysis’ ‘ of the left arm. He believed that moving his left side made him a woman and moving his right side made him a homosexual. Male aides made him agitated, and we wondered whether he might erupt into catatonic excitement. Amantadine was discontinued on day 7 and the patient regressed further. Urinary incontinence and food refusal coincided with family visits. The patient appeared to have difficulty with secretions and the gag reflex was decreased, although his lungs remained clear. Halopenidol was discontinued and IVs were started. By day 10, there was gradual improvement in motor activity and the patient began to eat, but his difficulty with secretions continued. His WBC increased to 16,000 and a
/978
chest X ray showed bilateral lower lobe infiltrates. Pulmonary consultants confirmed the diagnosis of aspiration pneumonia and felt that the psychiatric service had missed an underlying systemic illness that warranted further evaluation. The patient was then transferred to the medical ward for treatment. The patient’s rigidity, mutism, and posturing continued to improve gradually without medication. Penicillin, 10 U/day in continuous infusion, was started, and the infiltrates resolved uneventfully. He was transferred back to the psychiatnic service 6 days later, at which time there was marked improvement in his rigidity and mutism. Hallucinations and thought rushing disappeared, but loosened associations, perplexity, denial of illness, and “paralysis” persisted. He also remained delusional about the consequences of moving his body. Thionidazine was instituted in a dosage of 75 mg/day, which was slowly increased to 500 mg/day over 3 weeks. At the time ofdischarge, his thought disturbance was improved and his motor involvement resolved, except for weakness of the left arm. Discussion
conflict
oven
analogic action, (8). Moving out
The
which of his
is seen apartment
he equated a woman
being
a failure
patient’s
return
home
The authors wish to thank Salman Akhtar, sor of Psychiatry, University of Virginia help with the manuscript.
M.D. , Assistant Medical Center,
0002-953X/78/0010-
I 242$0.35
is AsCenProfesfor his
© American
to
poses image.
his
his
to
a
as
lifetime
his psychosis, Such volitional
rated,
experience
ing
staffbegan
helpless
and
the increasing very difficult. his
he
staffexpenienced
when
regressed
sequently, were
by
consultants
he
of seen
deteniofeelbetween
to
implied
relieved,
and
the
treatment?
the and
we
our ‘ ‘
was was
or
indignation
to
in a
dilemma,
pneumonia,
about
to over
the psychosis catatonia,
returned
feelings
male
seemed
be
the underlying patient remained
staff’s
had
loss
failed
illness. ‘ ‘ Alpsychotic wand.
the
missing
iatnogenic
overlay
Con-
diagbe-
clear.
Catatonia accounts noses of schizophrenia leptic-induced cians with
his
refractory
followed
when the
arm
not
aspiration
have missed improved, the
pun-
his
Distinguishing
developed the
Con-
progressively
indecisive.
guilt
and “must though he and
are
to
magical
his struggle characteristic
would
schizophrenia
when
of esteem
and stupor. course
have brother,
psychosis. dual
drug side effects and Did he have iatrogenic
underlying
Then,
to
and
of his
(8)
the
mother
preserving
encapsulating conflicts
catatonic schizophrenia pure neuroleptic-induced As the patient’s clinical
volition which
becoming
would
of and
and
he
the
move weakness
of failure,
a man
felt
served his
demonstrated
in disorders meant
He
immobility
of preventing The persistent
contain moving.
movement
schizophrenic
himself
sequently,
nosis” Dr. Brenner is Chief Resident in Psychiatry and Dr. Rheuban sistant Professor of Psychiatry, University of Virginia Medical ter, P.O. Box 203, Charlottesville, Va. 22901.
with
on a homosexual.
submitting
came
1242
J Psychiatry 135:10, October
M.D.
by the onset of putative extrasigns, which can be indistinguishable from (1-7). Clinicians are warned to stop medicanoncatatonic patients who become catatonic
neuroleptic
Case
M.D.,
be complicated
treatment
serious pneumonia in treating
Am
REPORTS
Dilemma
BRENNER,
High-potency nia
RESEARCH
to be Salman Psychiatric
for
catatonia less than Akhtar, Association
more
(9)
and is
.5% M.D.,
than the
estimated (personal David
5% incidence by
of
first diagof neunosome
clini-
communication Rosenman, M.D.,
Am
J Psychiatry
135:10,
October
/978
CLINICAL
and William J. Rheuban, M.D.), so the probability of encountering this combination is quite small. Even though catatonic features do not appear to predispose patients to extrapynamidal effects such as akinesia and rigidity (10), high-potency drugs should be used cautiously in catatonics until methods are developed to predict those especially at risk. One possibility is assay
of
pretreatment
urinary
dopamine
excretion,
which is negatively correlated with the probability of developing such toxicity (10). If neuroleptic catatonia is indeed a severe extnapynamidal reaction, such measurements could identify the low dopamine excnetens, who might comprise the high-risk group.
REFERENCES 1. Weinberger DR, Hyatt drugs. JAMA 239:1846,
Ri: Catatonic 1978
stupor
and
neuroleptic
AND
RESEARCH
REPORTS
2. Gelenberg neuroleptic 3. Behrman
Ai, Mandel MR: Catatonic reactions to high-potency drugs. Arch Gen Psychiatry 34:947-950, 1977 S: Mutism induced by phenothiazines. Br i Psychiatry 121:599-604, 1972 4. May RH: Catatonic-like states following phenothiazine therapy. Am
I Psychiatry
115:1119-1120,
1959
5. Rifkin A, Quitkin F, Klein DF: Akinesia: a poorly drug induced extrapyramidal behavioral disorder. Psychiatry 32:672-674, 1975 6. Weinberger DR, Kelley Ml: Catatonia and malignant a possible complication of neuroleptic administration. Ment
Dis 165:263-268,
recognized Arch Gen syndrome: J Nerv
1977
7. Regenstein GR, Alpert IS, Reich P: Sudden catatonic stupor with disastrous outcome. JAMA 238:618-620, 1977 8. Arieti 5: Interpretation of Schizophrenia, 2nd ed. New York, Basic Books, 1974 9. Guggenheim FG, Babigian HM: Catatonic schizophrenia: epidemiology and clinical course. I Nerv Ment Dis 158:291-305, 1974 10. Crowley TJ, Hoehn MM, Rutledge CO, et al: Dopamine excretion and vulnerability to drug-induced parkinsonism. Arch Gen Psychiatry 35:97-104, 1978
1243
