What is the diagnosis and treatment for a catatonic reaction?

From the Guidelines

A catatonic reaction is a severe psychomotor disturbance that should be treated promptly with benzodiazepines, specifically lorazepam 1-2mg given orally or intramuscularly every 4-6 hours, as it is the most effective initial treatment approach 1. The diagnosis of catatonia is characterized by the occurrence of several different symptoms including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia, as defined in the ICD-11 classification system 1. If no response occurs within 24-48 hours, electroconvulsive therapy (ECT) should be considered as it's highly effective for catatonia, especially in patients with severe, persistent, and significantly disabling symptoms, including life-threatening symptoms such as refusal to eat or drink, severe suicidality, uncontrollable mania, and florid psychosis 1. For patients with underlying mood disorders, adding mood stabilizers like valproate (500-1500mg/day) or antipsychotics may help, though high-potency antipsychotics should be used cautiously as they can worsen catatonia. Some key points to consider when administering ECT include:

• Using unilateral electrode application to the nondominant hemisphere as the preferred method
• Starting treatment at either two or three times weekly, with changes to the schedule if the patient experiences a significant degree of confusion
• Using brief pulse and an adequate dose of electricity
• Having a treatment team that includes a psychiatrist, personnel experienced in anesthesia, and nursing staff trained in the use of ECT 1. Supportive care is essential, including hydration, nutrition (possibly via nasogastric tube if prolonged), DVT prophylaxis, and repositioning to prevent pressure ulcers. Catatonia results from dysregulation in GABA and glutamate neurotransmitter systems, which explains why GABA-enhancing medications like benzodiazepines are effective 1. Prompt treatment is crucial as prolonged catatonia can lead to medical complications including malnutrition, thrombosis, and aspiration pneumonia.

From the FDA Drug Label

More severe acute withdrawal signs and symptoms, including life-threatening reactions, have included catatonia, convulsions, delirium tremens, depression, hallucinations, mania, psychosis, seizures and suicidality

• Catatonic reaction is a possible severe adverse reaction associated with benzodiazepine withdrawal, including lorazepam.
• This reaction can occur as part of acute withdrawal signs and symptoms, which can be life-threatening.
• To reduce the risk of withdrawal reactions, including catatonic reaction, a gradual taper should be used to discontinue lorazepam or reduce the dosage 2.

From the Research

Definition and Causes of Catatonic Reaction

• Catatonia is a syndrome associated with several mental illness disorders, including schizophrenia, mania, and depression 3
• It can also be caused by medical conditions such as hyponatremia, cerebral venous sinus thrombosis, and liver transplantation 3
• Neuroleptic Malignant Syndrome and anti-NMDA receptor encephalitis are also prominent causes of catatonia 3
• Withdrawal of benzodiazepines or clozapine can also lead to catatonia 3

Treatment of Catatonic Reaction

• Benzodiazepines, such as lorazepam, are commonly used to treat catatonia 4, 5, 6, 7
• Lorazepam has been shown to be effective in rapidly relieving catatonic features in patients with schizophrenia, major depression, and mood disorders 4, 5, 6, 7
• Electroconvulsive therapy (ECT) is also a definitive treatment for catatonia, especially in cases where benzodiazepines are not effective 4, 3
• A combination of benzodiazepines and antipsychotics can also be used to treat catatonia 3

Response to Treatment

• The response rate to lorazepam has been reported to be between 70% to 100% in various studies 4, 5, 6, 7
• The response to lorazepam can be rapid, with some patients showing improvement within 2 hours 5, 6, 7
• The total complete remission rate to benzodiazepines, including lorazepam and diazepam, has been reported to be 100% in some studies 5, 6, 7