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Letters   |    
Can Electroconvulsive Therapy Induce Catatonia?
Samir Kumar Praharaj, M.B.B.S., M.D., D.P.M.; Sujit Sarkhel, M.B.B.S., M.D., D.P.M.; Surjit Prasad, M.B.B.S., M.D.; Vinod Kumar Sinha, M.B.B.S., M.D., D.P.M.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E08-E09. doi:10.1176/appi.neuropsych.12010002
View Author and Article Information

Conflicts of Interest: None

Dept. of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India
Institute of Psychiatry, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Dept. of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India
Institute of Psychiatry, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Dept. of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India
Institute of Psychiatry, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Dept. of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India
Institute of Psychiatry, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Correspondence: Dr. Praharaj; e-mail: samirpsyche@yahoo.co.in

Copyright © 2013 American Psychiatric Association

To the Editor: Catatonia is a psychomotor syndrome in which motor, behavioral, and emotional changes may occur due to various causes.1 Affective psychoses and schizophrenia happen to be common causes of catatonia. In most cases, catatonia is treated either with benzodiazepines or electroconvulsive therapy (ECT).2

A PubMed search supplemented with manual search revealed only five case reports3,4 in which catatonia appeared after ECT administration. We report a case in which catatonia emerged after ECT and improved transiently as ECT was continued, but worsened thereafter.

“Mr. A,” a 31-year-old single man diagnosed with paranoid schizophrenia, presented with 8 years of continuous illness characterized by reduced social interaction, irritability, suspiciousness, and unprovoked outbursts of anger. He was admitted to Central Institute of Psychiatry, a tertiary psychiatric referral center at Ranchi, India, for further evaluation and management. He had made a suicide attempt of high lethality 4 years earlier. He had received treatment with typical antipsychotics previously without much benefit. His grandfather had bipolar affective disorder. He had schizoid traits premorbidly, characterized by preference for solitary activities, had few friends, and low emotional reactivity, which were apparent during adolescence. There were no features suggestive of autistic spectrum disorder. Mental status revealed psychomotor retardation, persecutory delusion, and prominent auditory hallucination with commanding and derogatory voices, depressed affect, and death wishes. Detailed physical and neurological examination did not reveal any abnormality. Baseline investigations were normal. After giving written informed consent, he was put on direct ECT 3 times weekly for suicidal ideas associated with command hallucinations. Also, he received injection haloperidol 10 mg bid and injection promethazine 50 mg bid intramuscularly to control agitation. ECT was administered using a brief pulse device with bitemporal electrode placement. Dosing was calculated empirically. After 3 days, regular injectables were stopped, and he was put on oral olanzapine 15 mg daily along with ECT. After the fourth ECT treatment, catatonic signs appeared in the form of posturing and mutism. There were no features suggestive of drug-induced parkinsonism. After the sixth ECT treatment, mutism improved, although posturing persisted. As ECT was continued, catatonia worsened further as the patient developed automatic obedience and staring in addition to mutism and posturing. The Bush-Francis catatonia rating scale5 score was 8, which remained constant until the 13th ECT session. Finally, ECT was discontinued, and, in view of the minimal clinical improvement, olanzapine was cross-tapered with clozapine. Within 2 weeks of ECT discontinuation, the catatonic symptoms resolved gradually. On 300 mg per day of clozapine, there was improvement in psychopathology without recurrence of catatonic signs.

ECT has been recognized as one of the most effective and time-tested modalities of therapy in catatonia. The response to ECT in catatonia approaches 80%.6 ECT improves catatonia refractory or only partially responsive to lorazepam79 and nonresponsive to other benzodiazepines8,10 Furthermore, ECT is often effective in emergency treatment of lethal catatonia11 and neuroleptic malignant syndrome,12 both of which are potentially life-threatening. Our patient, who did not have previous history of catatonia, showed emergence of catatonic signs during ECT treatment in a case of paranoid schizophrenia. This appears antithetical in light of the current evidence, which overwhelmingly favors the use ECT in catatonia. Previous cases reporting emergence of catatonia during ECT3,4 were also associated with concomitant benzodiazepine withdrawal, which is known to precipitate catatonia.1315 Such an underlying mechanism of catatonia is discounted in our case, as there was no exposure to benzodiazepines.

Various medications, such as disulfiram, corticosteroids, and antipsychotics have been reported to cause catatonia.6 Such drug-induced cases present as retarded catatonia, with mutism, staring, posturing, and withdrawal being the most common manifestations. Our case, as well as previously reported cases of catatonia emerging during ECT, also presented with retarded catatonia with similar symptoms, which suggests that ECT-induced catatonia can be regarded as a variant of drug-induced catatonia.

ECT in catatonia causes changes in perfusion in several areas of brain, which differs according to causes of catatonia. For example, Escobar et al.16 reported an improvement in brain perfusion using single photon-emission computed tomography (SPECT) imaging in those treated with ECT for catatonia in the parietal, temporal, and occipital areas in patients with mood disorder, whereas no change was seen in those with schizophrenia. On the contrary, Galynker et al.17 reported increased perfusion during SPECT imaging in the left parietal and motor cortices in a patient with schizoaffective disorder and catatonia after ECT treatment. Such variations in brain perfusion can cause unpredictable changes, leading to emergence of catatonic symptoms during ECT. Also, pre-medications such as atropine could contribute to the emergence of catatonic features associated with ECT.18 Future studies using functional neuroimaging techniques will shed further light on this uncommon phenomenon.

Northoff  G;  Koch  A;  Wenke  J  et al:  Catatonia as a psychomotor syndrome: a rating scale and extrapyramidal motor symptoms.  Mov Disord 1999; 14:404–416
[CrossRef] | [PubMed]
 
Francis  A;  Divadeenam  KM;  Petrides  G:  Advances in the diagnosis and treatment of catatonia.  Convuls Ther 1996; 12:259–261
[PubMed]
 
Pandey  RS;  Sharma  P:  ECT-induced catatonia: a case report.  Indian J Psychiatry 1988; 30:105–107
[PubMed]
 
Malur  C;  Francis  A:  Emergence of catatonia during ECT.  J ECT 2001; 17:201–204
[CrossRef] | [PubMed]
 
Bush  G;  Fink  M;  Petrides  G  et al:  Catatonia, I: rating scale and standardized examination.  Acta Psychiatr Scand 1996; 93:129–136
[CrossRef] | [PubMed]
 
Lopez-Canino  A;  Francis  A:  Drug-induced catatonia, in  Catatonia: From Psychopathology to Neurobiology . Edited by Caroff  SN;  Mann  SC;  Francis  A  et al.  Arlington, VA,  American Psychiatric Publishing,2004, pp 129–139
 
Ungvari  GS;  Leung  CM;  Wong  MK  et al:  Benzodiazepines in the treatment of catatonic syndrome.  Acta Psychiatr Scand 1994; 89:285–288
[CrossRef] | [PubMed]
 
Bush  G;  Fink  M;  Petrides  G  et al:  Catatonia, II: treatment with lorazepam and electroconvulsive therapy.  Acta Psychiatr Scand 1996; 93:137–143
[CrossRef] | [PubMed]
 
Yeung  PP;  Milstein  RM;  Daniels  DC  et al:  ECT for lorazepam-refractory catatonia.  Convuls Ther 1996; 12:31–35
[PubMed]
 
Malur  C;  Pasol  E;  Francis  A:  ECT for prolonged catatonia.  J ECT 2001; 17:55–59
[CrossRef] | [PubMed]
 
Mann  SC;  Caroff  SN;  Bleier  HR  et al:  Electroconvulsive therapy for lethal catatonia syndrome.  Convuls Ther 1990; 6:239–247
[PubMed]
 
Pearlman  C:  Neuroleptic malignant syndrome and electroconvulsive therapy.  Convuls Ther 1990; 6:251–253
[PubMed]
 
Deuschle  M;  Lederbogen  F:  Benzodiazepine withdrawal-induced catatonia.  Pharmacopsychiatry 2001; 34:41–42
[CrossRef] | [PubMed]
 
Rosebush  PI;  Mazurek  MF:  Catatonia after benzodiazepine withdrawal.  J Clin Psychopharmacol 1996; 16:315–319
[CrossRef] | [PubMed]
 
Zalsman  G;  Hermesh  H;  Munitz  H:  Alprazolam withdrawal delirium: a case report.  Clin Neuropharmacol 1998; 21:201–202
[PubMed]
 
Escobar  R;  Rios  A;  Montoya  ID  et al:  Clinical and cerebral blood flow changes in catatonic patients treated with ECT.  J Psychosom Res 2000; 49:423–429
[CrossRef] | [PubMed]
 
Galynker  II;  Weiss  J;  Ongseng  F  et al:  ECT treatment and cerebral perfusion in catatonia.  J Nucl Med 1997; 38:251–254
[PubMed]
 
Heath  RG:  Schizophrenia: biochemical and physiologic aberrations.  Int J Neuropsychiatry 1966; 1:597–610
 
References Container
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References

Northoff  G;  Koch  A;  Wenke  J  et al:  Catatonia as a psychomotor syndrome: a rating scale and extrapyramidal motor symptoms.  Mov Disord 1999; 14:404–416
[CrossRef] | [PubMed]
 
Francis  A;  Divadeenam  KM;  Petrides  G:  Advances in the diagnosis and treatment of catatonia.  Convuls Ther 1996; 12:259–261
[PubMed]
 
Pandey  RS;  Sharma  P:  ECT-induced catatonia: a case report.  Indian J Psychiatry 1988; 30:105–107
[PubMed]
 
Malur  C;  Francis  A:  Emergence of catatonia during ECT.  J ECT 2001; 17:201–204
[CrossRef] | [PubMed]
 
Bush  G;  Fink  M;  Petrides  G  et al:  Catatonia, I: rating scale and standardized examination.  Acta Psychiatr Scand 1996; 93:129–136
[CrossRef] | [PubMed]
 
Lopez-Canino  A;  Francis  A:  Drug-induced catatonia, in  Catatonia: From Psychopathology to Neurobiology . Edited by Caroff  SN;  Mann  SC;  Francis  A  et al.  Arlington, VA,  American Psychiatric Publishing,2004, pp 129–139
 
Ungvari  GS;  Leung  CM;  Wong  MK  et al:  Benzodiazepines in the treatment of catatonic syndrome.  Acta Psychiatr Scand 1994; 89:285–288
[CrossRef] | [PubMed]
 
Bush  G;  Fink  M;  Petrides  G  et al:  Catatonia, II: treatment with lorazepam and electroconvulsive therapy.  Acta Psychiatr Scand 1996; 93:137–143
[CrossRef] | [PubMed]
 
Yeung  PP;  Milstein  RM;  Daniels  DC  et al:  ECT for lorazepam-refractory catatonia.  Convuls Ther 1996; 12:31–35
[PubMed]
 
Malur  C;  Pasol  E;  Francis  A:  ECT for prolonged catatonia.  J ECT 2001; 17:55–59
[CrossRef] | [PubMed]
 
Mann  SC;  Caroff  SN;  Bleier  HR  et al:  Electroconvulsive therapy for lethal catatonia syndrome.  Convuls Ther 1990; 6:239–247
[PubMed]
 
Pearlman  C:  Neuroleptic malignant syndrome and electroconvulsive therapy.  Convuls Ther 1990; 6:251–253
[PubMed]
 
Deuschle  M;  Lederbogen  F:  Benzodiazepine withdrawal-induced catatonia.  Pharmacopsychiatry 2001; 34:41–42
[CrossRef] | [PubMed]
 
Rosebush  PI;  Mazurek  MF:  Catatonia after benzodiazepine withdrawal.  J Clin Psychopharmacol 1996; 16:315–319
[CrossRef] | [PubMed]
 
Zalsman  G;  Hermesh  H;  Munitz  H:  Alprazolam withdrawal delirium: a case report.  Clin Neuropharmacol 1998; 21:201–202
[PubMed]
 
Escobar  R;  Rios  A;  Montoya  ID  et al:  Clinical and cerebral blood flow changes in catatonic patients treated with ECT.  J Psychosom Res 2000; 49:423–429
[CrossRef] | [PubMed]
 
Galynker  II;  Weiss  J;  Ongseng  F  et al:  ECT treatment and cerebral perfusion in catatonia.  J Nucl Med 1997; 38:251–254
[PubMed]
 
Heath  RG:  Schizophrenia: biochemical and physiologic aberrations.  Int J Neuropsychiatry 1966; 1:597–610
 
References Container
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