Can Excited Catatonia Present Episodically?
Yes, excited catatonia can present in an episodic pattern, though this is less common than continuous presentations. The literature describes both periodic catatonia with cyclic episodes and excited catatonia occurring as discrete events in various underlying conditions.
Episodic Patterns of Catatonia
Periodic Catatonia
- Periodic catatonia is a recognized rare form characterized by episodes occurring in a cyclic pattern with combined stupor and excitement features, separated by intervals of remission 1
- This episodic presentation requires hospitalization during acute episodes for evaluation and treatment 1
- Long-term prophylactic treatment (such as lamotrigine in case reports) may reduce the occurrence and severity of recurrent catatonic episodes 1
Excited Catatonia as an Episodic Syndrome
- Catatonia itself is described as "an episodic syndrome" with specific affective, behavioral, and motor symptoms 2
- Excited catatonia specifically involves prolonged periods of psychomotor agitation, distinguishing it from the more common retarded type 3
Clinical Context and Triggers
Association with Bipolar Disorder
- Severe depressive episodes in bipolar disorder are particularly prone to progressing to catatonia, especially with psychomotor features 4
- Bipolar disorder tends to have a cyclical course, which could result in episodic catatonic presentations 5
Secondary Medical Causes
- Various medical conditions can precipitate episodic catatonia including viral encephalitis, seizure disorders, and endocrinopathies 4
- Anti-NMDA receptor encephalitis can present with excited catatonia as the initial symptom, potentially in an episodic fashion 6
Important Clinical Pitfalls
- Do not confuse excited catatonia with delirium, psychosis, or mania - excited catatonia can mimic these conditions with agitation, disinhibition, and bizarre behavior, particularly in patients with no prior psychiatric history 6
- The diagnosis may be delayed because excited catatonia is less recognized than retarded catatonia, and clinicians may not suspect it initially 3, 7
- In autism spectrum disorder, excited catatonia may have a slow, progressive onset over months to years rather than sudden episodic presentation 7
Treatment Implications for Episodic Presentations
- Acute episodes typically respond to benzodiazepines (lorazepam challenge), though electroconvulsive therapy may be required for severe or refractory cases 3, 6, 7
- For recurrent episodic catatonia, maintenance ECT or prophylactic medications may be necessary to prevent relapse - one case required weekly maintenance ECT when symptoms returned after treatment taper 7
- The pathophysiology of periodic/episodic catatonia remains poorly understood, making prevention of recurrent episodes challenging 1