A Tale of Two Catatonic States

AIMS: Catatonia is a psychomotor state characterised by a multitude of clinical signs such as abnormal movements, mutism and withdrawal. This condition is usually associated with medical and psychiatric aetiologies with potential of being life-threatening. It is usually managed with benzodiazepines, the commonest being lorazepam. In this piece of work, we would like to focus on the principles of care that should be considered whilst managing such presentations. METHODS: Case 1- 71, male with diagnosis of paranoid schizophrenia was brought to Emergency department (ED) via ambulance, as he was found ‘unresponsive’ in care home. On arrival, he was alert with GCS 11/15 and was observed to be mute, ‘gesturing’ and making purposeless movements. Following our assessment, he was administered 0.5mg of lorazepam whilst in resuscitation bay. Subsequently, he started making sounds and was given another dose of 0.5mg lorazepam. He then vocalised his thoughts and we established that his mental state had relapsed and he was harbouring paranoid delusions. Case 2- 18, male with no prior psychiatric history was brought to ED by his parents following 3 day history of being mute, not ‘responding’, not eating or drinking and insomnia. On arrival, he was alert, pacing in the room, however remained mute. Following our assessment, he was given a 2 mg dose of lorazepam whilst in resuscitation bay as the initial 1mg showed minimal response. On later review, he was smiling, conversant and co-operative, thus allowing assessment of his unmasked mental state which was suggestive of first episode psychosis. Following few hours, both patients reverted back to their original catatonic state. RESULTS: Lorazepam can be used as a diagnostic measure in conjunction to a therapeutic intervention. A positive Lorazepam Challenge test confirms the diagnosis of catatonia. It must be borne in mind that Lorazepam is only used as a temporary holding measure to assess patient's unmasked mental state and they would need further monitoring and interventions to treat the underlying cause. CONCLUSION: Lorazepam Challenge test can be safely used as an assessment technique for patients presenting in acute catatonia. This should be conducted in closely monitored environments namely, resuscitation bay, HDU or ITU with appropriate support and ongoing liaison with psychiatry team. Treating teams should be mindful of various patient characteristics including age, past treatment with benzodiazepines, psychiatric history to inform dose adjustments as necessary. Disclaimer: Unable to obtain patient consent due to unstable mental state but ensured minimal patient identifiable data included.