Case 12: A young man who has stopped talking and eating and stands motionless

01The case

A 21-year-old man is brought to the psychiatric clinic as an emergency. His relatives say that over the last few weeks he has stopped talking and eating. He lies still, staring fixedly. He keeps stiff postures, or stands upright without moving for hours, and resists when anyone tries to move him. A dermatologist has seen him for seborrhoea.

02Summary

Diagnosis

Catatonia, in its stuporous form. In ICD-11 catatonia is diagnosed in its own right and coded with the disorder it comes with.

What points to it

• Reduced movement reaching stupor, with a fixed stare.
• Mutism and refusal to eat.
• Posturing and waxy flexibility: he holds rigid poses for hours.
• Negativism: he resists being moved.
• An oily, seborrhoeic face, which older texts link with catatonic stupor.

What else it could be

Catatonia is a syndrome, not a cause. It most often comes with a mood disorder, mania above all, or with schizophrenia, but medical causes must be looked for: autoimmune (anti-NMDA receptor) encephalitis, non-convulsive status epilepticus, metabolic and endocrine disorders, and drugs. Neuroleptic malignant syndrome looks much the same, with fever, rigidity, unstable pulse and blood pressure and a raised creatine kinase. Examine him fully, check temperature, pulse, blood pressure, bloods with creatine kinase, and consider an EEG and brain imaging.

Management

• Admission is mandatory: he is not eating or drinking, and is at risk of dehydration, kidney injury, clots in the legs, pressure sores and aspiration. Give fluids and nutrition and prevent clots.
• A lorazepam challenge first: a benzodiazepine by mouth, or intramuscular or intravenous if he cannot swallow, then regular doses if he responds.
• Electroconvulsive therapy if lorazepam does not work within a few days, and at once in malignant catatonia (fever, autonomic instability).
• Once the catatonia lifts, treat the disorder underneath; if it is schizophrenia, an antipsychotic is started with care.
• Watch for a sudden switch from stupor to catatonic excitement, which can be dangerous.

Outlook

Good for this episode: most catatonia resolves with benzodiazepines or ECT. Relapse is likely, either as catatonia again or as another psychotic or mood episode.