catatonia - 1 Flashcards
Complications of catatonia?
Pulmonary embolism
DVT
Pneumonia
Dehydration
1st line Rx in catatonia
Benzodiazepines
name a protocol that is used to treat catatonia
The lorazepam-diazepam protocol
when the lorazepam-diazepam protocol is commonly used?
general medical disorders or substance
catatonia sub-types,
1-A stuporous form with decreased psychomotor behaviour
2- An excited form characterized by agitation, impulsivity, and purposeless overactivity.
key features of stuporous catatonia
Mutism
Rigidity
Psychomotor Retardation
Negativism
Posturing
Waxy flexibility
Catalepsy
psychiatric causes of stuporous catatonia
Schizophrenia ( historically)
Depression
Mania (less common)
Alcohol or Benzo withdrawal
systemic and toxic causes of stuporous catatonia
subarachnoid haemorrhages
basal ganglia disorders
non-convulsive status epilepticus
locked-in and akinetic mutism states
endocrine and metabolic disorders, e.g. Wilson’s
Prader–Willi syndrome
antiphospholipid syndrome
autoimmune encephalitis
systemic lupus erythematosus
infections (especially CNS infections)
dementia
drug withdrawal and toxic drug states
Drug of choice for stupor catatonia occuring in context of affective and conduct disorder?
Benzodiazepine
how does benzodiazepine works (postulations)?
Increase GABAnergic transmissions
or
Reduce BDNFs
Which benzo has been clinically experimented most in treatment of catatonia?
Lorazepam
at what dose do patients seem to response to lorazepam
some at 4mg /day
but repeated and higher doses may be needed [upt to 24 mg/day] (Maudsley 14th edition)
how we can predict response to benzos in catatonia
1- a test dose of zolpidem 10 mg
2-IV lorazepam
(Maudsley 14th edition)
Response rate of catatonia in schizophrenian to benzodiazepine?
40-50%
what are lethal catatonia and malignant catatonia?
Coined terms for catatonia, which is accompanied by
- Autonomic instability or hyperthermia
challenges with lethal catatonia /malignant catatonia?
cannot be distinguished from neuroleptic malignant syndrome
how can one probably be able to rule out NMS in cases of malignant catatonia?
in the absence of prior or recent administration of dopamine antagonists
MOST successful Rx for catatonia?
ECT
Where ECT seem to work well with catatonia?
In context of
NMS
Delirious Mania
Self-Injurious behaviours in autism
Limbic encephalitis
Where ECT might not work for catatonia despite remaing to be a 2nd choice after benzos failed?
schizophrenia
best evidence based antipsychotic treatments available for catatonic schizophrenia?
Clozapine and Olanzapine ( Use with careful considerations)
Also (aripiprazole, Risperion and Ziprasidone have been reported to be effective)
what should you consider before treating catatonia with antipsychotics?
Compliance
History of response to antipsychotics
Previous diagnosis
what can history of antipsychotic treatment tell us in catatonia?
if a patient develops catatonia while on antipsychotics, we should not give more antipsychotics
when antipsychotics should be avoided complete regardless of history?
when there malignant catatonia (rigidity + autonomic instability which might be NMS)
ALgorithm for treating catatonia —starts with?
Ruling out underlying physical illness (systemic ones and toxic ones)
2nd leg in algorith for treating catatonia?
see if catatonia is in psychotic context or affective/conversion disorder
what if catatonia is in context of psychotic?
Rule out NMS & hx of being on antipsychotics
What if catatonia is due to psychosis and NMS is ruled out?
consider Clozapine or Olanzapine
Some suggest to cotherapy benzodiazepine (Mausdley 14th ediction, page 133-134)
what if treating psychosis induced catatonia did not respond to antipsychotics in 1-2 days?
follow the Benzodiazepine/ECT protocol
going back up in algorithm of treating catatonia, what if catatonia is in psychosis context and NMS is not ruled out?
go to other side of the algorithm: catatonia in context of affective/conversion disorder!
On the affective/conversion catatonia side of algorithm what do we do?
Lorazepam up to 4 mg / day
how is lorazepam in given in affective/conversion catatonia ( or NMS +)
start with 2 mg (sublingual in non-compliant patients)
add another 2 mg if no response is achieved in 3 hours
Then, switch to the IV route subsequently.
