COVID-19 and Catatonia: A Case Series and Systematic Review of Existing Literature

Abstract

Background Current observational literature on the mental health impact of the COVID-19 pandemic has focused on anxiety, depression, and sleep-disturbance among the public, healthcare workers, and COVID-19 patients. Case reports suggest catatonia and psychosis may be presenting symptoms of COVID-19 disease with a mechanism postulated to involve central nervous system changes in response to inflammation. There is a lack of robust evidence examining catatonia in this context. We sought to systematically review available case data and contextualize our findings. Case Presentations We present three cases of patients with catatonia seen at a large metropolitan tertiary care hospital in which their catatonia was likely attributable to SARS-CoV-2 infection. Ms. A is a female in her 50s with no psychiatric history who presented with self-inflicted stab wounds following her COVID-19 diagnosis. Ms. B is a female in her 50s with a history of schizophrenia, but no history of catatonia, who presented with akinetic catatonia, SARS-CoV-2 infection, and Clostridium difficile infection, without respiratory manifestations of COVID-19. Ms. C is a female in her 20s with a history of bipolar disorder (type 1) without catatonic features who presented with akinetic catatonia without the physical symptoms of SARS-CoV-2 infection. Discussion We present a brief review of six case reports detailing co-occurring catatonia and SARS-CoV-2 infection and one case report of catatonia attributed to the psychological stress of the COVID-19 pandemic in a patient without SARS-CoV-2 infection. We note one additional case of co-occurring catatonia and SARS-CoV-2 infection for which details are not available. COVID-19-associated catatonia may develop secondary to psychological and physical factors. Cases often report anxiety preceding catatonic symptoms. Developing evidence also suggests SARS-CoV-2 may act directly on the central nervous system or via a systemic inflammatory response. One of our cases featured significant anxiety preceding symptoms, and two had co-occurring elevated serum inflammatory markers. We suggest that clinicians should keep a high index of suspicion for both clinically significant anxiety disorders and catatonia.

Delayed onset catatonia after COVID-19

“…The virus may enter the central nervous system from the nares through the cribriform plate or via hematogenous spread across the blood-brain barrier ( Torrico et al, 2021 , Spiegel, 2022 ). Given the morbidity and mortality associated with catatonia, it has been emphasized that inpatient providers should keep a high index of suspicion for catatonia when consulted for abnormal behavior or altered mental status in COVID-19 patients ( Scheiner et al, 2021 ), however it is equally important that outpatient providers also keep a high index of suspicion as catatonia is often underrecognized and misdiagnosed and that collaboration between primary care and psychiatry is vital. New-onset catatonia with or without pre-existing psychiatric illness and concurrent COVID-19 can be safely and effectively managed with lorazepam and/or ECTs ( Sakhardande et al, 2022 ).…”

New-Onset Catatonia and Delirium in a COVID-Positive Patient

“…It then enters through the olfactory bulb to replicate in neurons [8]. Post-mortem examinations of COVID-19 patients have shown cerebral inflammation from an overwhelming cytokine inflammatory response [9,10]. Cytokine elevation and glial activation increase the level of amino acids like glutamate, which reduces neurotransmitter levels and induces hypoxic injury by way of increased coagulation, thus causing neuronal loss [5].…”

A case of catatonia in the aftermath of the COVID-19 pandemic: does autism spectrum matter?

“…Several outpatient services were halted, as most of resources were diverted to the management of urgent cases or to the treatment of COVID-19 infection, leading to an overall increase of psychiatric disorders. A number of reports have been recently published describing cases of catatonia sprouting during the pandemic [ 26 – 32 ] and focusing on the use of ECT in the treatment of neuropsychiatric symptoms associated with COVID-19 [ 33 ]. While most of them discuss the direct or immune-mediated effect of COVID-19 on peripheral and central nervous system impairments, a handful of studies focus instead on the role of pandemic-related stressors (enforced self-isolation, changes to usual routines, financial strain) as precipitating factors for new-onset or recurring mental illnesses leading to catatonia, especially among people with predisposing traits.…”