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Letters   |    
Immediate Response to Lorazepam in a Patient With 17 years of Chronic Catatonia
Lokesh K. Singh, M.B.B.S., D.P.M., M.D., F.I.P.S.; Samir Kumar Praharaj, M.B.B.S., M.D., D.P.M.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:E47-E48. doi:10.1176/appi.neuropsych.12070181
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Dept. of Psychiatry All India Institute of Medical Sciences Raipur, India - 492099
Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India - 576104

Correspondence: Dr. Singh; e-mail: singhlokesh123@gmail.com

Copyright © 2013 American Psychiatric Association

To the Editor: The prevalence of catatonia among psychiatric patients ranges from 7.6% to 38%.1 The concurrent or underlying diagnoses in these catatonic patients can be affective disorder, schizophrenia, schizoaffective disorder, a range of medical/neurological illnesses, and benzodiazepines withdrawal. The most common signs are mutism, posturing, negativism, staring, rigidity, echolalia, and echopraxia. Benzodiazepine and electroconvulsive therapy have been the first-line treatments for almost all types of catatonia.2 This case is interesting as it established the utility of short course of lorazepam in a chronic case of catatonia without further recurrence of the condition.

A 49-year-old, married man from a rural background presented with complaints of not speaking and maintaining posture for the past 17 years. He had a past history of a psychotic episode 1 year earlier, characterized by fearfulness, suspiciousness, aggressive outbursts, tendency to run away, and disturbed biological functions. He had received treatment for 3 months, and was manageable at home. After discontinuation of medications, he remained asymptomatic for about 6 months. Thereafter, he gradually stopped talking, was often seen staring for a long time while standing, was not working, remained aloof most of the time, and did not respond adequately to the events in his surroundings. On a few occasions, he was seen following his wife when she went out for some work. Over the next 2–3 years, he followed a simple routine (e.g., taking food at scheduled times) and would maintain his personal hygiene. He was admitted to our hospital and, in view of presence of chronic catatonic symptoms, was given 4 mg of lorazepam injection slowly by intravenous route. After 10–15 minutes, he became tearful and responsive. It was an emotional moment for the accompanying family members, as he responded after 17 years. Full diagnostic work-up, including biochemical investigations, urinalysis, electroencephalography, and computed tomography of brain did not reveal any abnormalities. He was administered injectable lorazepam 8 mg/day for an initial 3 days and, subsequently, tablets from the 4th day, which was tapered and stopped over the next 12 days. During serial mental status examinations, delusion of infidelity was elicited, and tablet olanzapine 15 mg/day was also started, on the 10th day of hospitalization. He was discharged in asymptomatic state after 45 days on tablet olanzapine 15 mg/day. Subsequently, over a follow-up period of 1 year, in which he was examined on three occasions, there was no emergence of catatonic symptom or any other psychotic symptoms, while he remained on regular dosage of olanzapine 15 mg/day.

Lorazepam is the most commonly used benzodiazepine in the treatment of catatonia, but other benzodiazepines such as diazepam, oxazepam, and clonazepam have also been reported to be effective in catatonia.3 Existing literature suggests that benzodiazepines are effective in acutely-emerging catatonia and their effectiveness is limited by chronicity of symptoms.4,5 Emerging data also emphasized the need for long-term benzodiazepine maintenance therapy for chronic catatonic states.68 In contrast, our patient with catatonia of 17 years’ duration showed a fast response to lorazepam, with complete resolution of all catatonic signs. He was maintained thereafter on olanzapine only, without long-term requirement of benzodiazepines. This case study highlights the possibility of complete resolution of longstanding catatonia with a brief course of lorazepam.

Thanks to Dr. Sharda B. Pasari and Anya Singh for their critical inputs during preparation of manuscript.

Taylor  MA;  Fink  M:  Catatonia in psychiatric classification: a home of its own.  Am J Psychiatry 2003; 160:1233–1241
[CrossRef] | [PubMed]
 
Rosebush  PI;  Mazurek  MF:  Catatonia and its treatment.  Schizophr Bull 2010; 36:239–242
[CrossRef] | [PubMed]
 
Daniels  J:  Catatonia: clinical aspects and neurobiological correlates.  J Neuropsychiatry Clin Neurosci 2009; 21:371–380
[CrossRef] | [PubMed]
 
Weder  ND;  Muralee  S;  Penland  H  et al:  Catatonia: a review.  Ann Clin Psychiatry 2008; 20:97–107
[CrossRef] | [PubMed]
 
Ungvari  GS;  Chiu  HF;  Chow  LY  et al:  Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study.  Psychopharmacology (Berl) 1999; 142:393–398
[CrossRef] | [PubMed]
 
Gaind  GS;  Rosebush  PI;  Mazurek  MF:  Lorazepam treatment of acute and chronic catatonia in two mentally retarded brothers.  J Clin Psychiatry 1994; 55:20–23
[PubMed]
 
Manjunatha  N;  Saddichha  S;  Khess  CR:  Idiopathic recurrent catatonia needs maintenance lorazepam: case report and review.  Aust N Z J Psychiatry 2007; 41:625–627
[CrossRef] | [PubMed]
 
Grover  S;  Aggarwal  M: Long-term maintenance lorazepam for catatonia: a case report. Gen Hosp Psychiatry 2011; 33: 82.e1–3
 
References Container
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References

Taylor  MA;  Fink  M:  Catatonia in psychiatric classification: a home of its own.  Am J Psychiatry 2003; 160:1233–1241
[CrossRef] | [PubMed]
 
Rosebush  PI;  Mazurek  MF:  Catatonia and its treatment.  Schizophr Bull 2010; 36:239–242
[CrossRef] | [PubMed]
 
Daniels  J:  Catatonia: clinical aspects and neurobiological correlates.  J Neuropsychiatry Clin Neurosci 2009; 21:371–380
[CrossRef] | [PubMed]
 
Weder  ND;  Muralee  S;  Penland  H  et al:  Catatonia: a review.  Ann Clin Psychiatry 2008; 20:97–107
[CrossRef] | [PubMed]
 
Ungvari  GS;  Chiu  HF;  Chow  LY  et al:  Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study.  Psychopharmacology (Berl) 1999; 142:393–398
[CrossRef] | [PubMed]
 
Gaind  GS;  Rosebush  PI;  Mazurek  MF:  Lorazepam treatment of acute and chronic catatonia in two mentally retarded brothers.  J Clin Psychiatry 1994; 55:20–23
[PubMed]
 
Manjunatha  N;  Saddichha  S;  Khess  CR:  Idiopathic recurrent catatonia needs maintenance lorazepam: case report and review.  Aust N Z J Psychiatry 2007; 41:625–627
[CrossRef] | [PubMed]
 
Grover  S;  Aggarwal  M: Long-term maintenance lorazepam for catatonia: a case report. Gen Hosp Psychiatry 2011; 33: 82.e1–3
 
References Container
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