Clozapine for the management of persistent catatonia

Abstract

A 42-year-old man with a diagnosis of undifferentiated schizophrenia has been hospitalized several times since age 23 for psychotic relapses, usually in the context of nonadherence to medication.During the last relapse, he was concerned about many plots being planned against him for vague reasons. He experienced catatonic symptoms, including rigid postures, resistance to eating and drinking, immobility, mutism and staring, and displayed periods of unexplained aggressiveness. Physical examination revealed waxy flexibility with no extrapyramidal symptoms or fever. He had a score of 24 on the Bush-Francis Catatonia Rating Scale (BFCRS), which is compatible with a severe form of catatonia.Even in a patient with psychiatric illness, a plethora of medical conditions can be associated with catatonia. This emphasizes the importance of ruling out a somatic cause.1,2 The patient was assessed by an internist and a neurologist, and no clinical abnormalities were identified. Laboratory results, including MRIs and electroencephalography (EEG) scans were unremarkable.Because the patient refused intravenous injections, lorazepam was initiated orally and was rapidly titrated up to 6 mg daily for more than 15 days, without any effect. However, higher doses were not tolerated. Subsequently, the patient accepted intramuscular injections, which resulted in partial and transitory remission of the catatonic symptoms for a few hours. After a gradual discontinuation of benzodiazepines (BZD), electroconvulsive therapy (ECT) was initiated. Two series of treatments of 20 sessions each with unitemporal followed by bitemporal electrode placement were completed with no significant improvement, and the score on the BFCRS remained between 20 and 24.Risperidone (4-6mg/d) and aripiprazole (20mg/d) were each used for a period of at least 6 weeks but were not able to alleviate catatonia symptoms. Parkinsonism was systematically assessed and corrected using anticholinergic agents as needed. Finally clozapine was initiated and gradually titrated to 400 mg over a period of 5 weeks. A significant decrease in the BFCRS score (final score of 4) was observed after 5 weeks, allowing for long-deferred care and discharge from the hospital.In contrast to acute catatonia, chronic catatonia is less responsive to first-line treatments, including lorazepam and ECT, especially in the context of schizophrenia.2-7 Using lorazepam for longterm periods has been proposed as a therapeutic option, although the therapeutic response may be slower, taking months rather than days. 2,4 It is generally recommended to discontinue antipsychotics (APs) in patients presenting with catatonia, as APs increase parkinsonism, leading to a potential aggravation of catatonia and an increase in the risk of neuroleptic malignant syndrome (NMS). 2,4,8However, atypical APs are known to have weak γ-aminobutyric acid (GABA) agonist activity and serotonin (5-HT 2 ) antagonism that could stimulate dopamine release in the prefrontal cortex and alleviate catatonic symptoms. 9 In the event that the...

Catatonia in autism spectrum disorders: A systematic review and meta-analysis

“…Nevertheless, low doses of atypical antipsychotics are known to have weak γaminobutyric acid agonist activity and serotonin antagonism, that could stimulate dopamine release in the prefrontal cortex and thus alleviate catatonic symptoms [75]. There are case reports of successful treatment with atypical antipsychotics [71,76,77]. While this information is useful, further work is needed in larger samples to further gauge the usefulness of different treatments.…”

Therapy of Catatonia in Schizophrenia and Schizophrenia Spectrum Disorders

“…Во-вторых, применение антипсихотиков второго (АВП) и третьего поколения (АТП) сопряжено со значительно меньшей вероятностью развития ЗНС (для некоторых из них, например луразидона, карипразина, таких случаев пока вообще не зарегистрировано). В-третьих, в терапии «хронической» кататонии, дебютирующей в структуре РШС, в отличие от производных бензодиазепина эффективны АВП, особенно с высоким уровнем блокады D2-рецепторов (клозапин, кветиапин и оланзапин) [73,74]. Эти антипсихотики являются, по сути, препаратами выбора при наличии противопоказаний к проведению ЭСТ [75].…”

The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia

“…Several reports suggest a beneficial effect of clozapine and second-generation antipsychotics (SGAs) in the treatment of (chronic) schizophrenic catatonia. SGA with low D2 blockade (quetiapine, olanzapine, clozapine) (Tabbane et al, 2016) or with D2 partial agonism (aripiprazole) (Muneoka et al, 2017) should be favored, and can, of course, be used to treat residual psychotic symptomatology or as a prophylactic treatment in psychotic disorders and mood disorders (Sienaert et al, 2014).…”