Takotsubo Cardiomyopathy and Catatonia in the Setting of Benzodiazepine Withdrawal

Peng, Teng J.; Patchett, Nicholas D.; Bernard, Sheilah

doi:10.1155/2016/8153487

Cited by 9 publications

(5 citation statements)

References 15 publications

(14 reference statements)

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“…Eighteen articles 28 , 32 – 48 described 24 cases of benzodiazepine withdrawal catatonia (Table 1 ). The average patient age was 58 years (range 29−88 years) and the male to female ratio was 1:1.4.…”

Section: Resultsmentioning

confidence: 99%

Review of withdrawal catatonia: what does this reveal about clozapine?

2018

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Withdrawal symptoms are common upon discontinuation of psychiatric medications. Catatonia, a neuropsychiatric condition proposed to be associated with gamma-aminobutyric acid (GABA) hypoactivity due to its robust response to benzodiazepines, has been described as a withdrawal syndrome in case reports but is not a well-recognized phenomenon. The authors undertook a review of withdrawal catatonia with an aim to understand its presentation as well as the medications and psychoactive substances it is associated with. The review identified 55 cases of withdrawal catatonia, the majority of which occurred upon discontinuation of benzodiazepines (24 cases) and discontinuation of clozapine (20 cases). No other antipsychotic medications were identified as having been associated with the onset of a catatonic episode within 2 weeks following their discontinuation. Increasing GABA activity and resultant GABA receptor adaptations with prolonged use is postulated as a shared pharmacological mechanism between clozapine and benzodiazepines that underlie their association with withdrawal catatonia. The existing evidence for clozapine’s activity on the GABA system is reviewed. The clinical presentations of benzodiazepine withdrawal catatonia and clozapine withdrawal catatonia appear to differ and reasons for this are explored. One reason is that benzodiazepines act directly on GABAA receptors as allosteric agonists, while clozapine has more complex and indirect interactions, primarily through effects on receptors located on GABA interneurons. Another possible reason for the difference in clinical presentation is that clozapine withdrawal catatonia may also involve receptor adaptations in non-GABA receptors such as dopamine and acetylcholine. The findings from our review have implications for the treatment of withdrawal catatonia, and treatment recommendations are provided. Further research understanding the uniqueness of clozapine withdrawal catatonia among antipsychotic medication may give some insight as to clozapine’s differential mechanism of action.

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Section: Resultsmentioning

confidence: 99%

Review of withdrawal catatonia: what does this reveal about clozapine?

2018

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“…As previously mentioned, malignant catatonia and TTS might both be seen in the context of an extreme autonomic reaction ( 74 ). Interestingly, TTS and catatonia may simultaneously occur, such as in the setting of benzodiazepine withdrawal ( 99 ). Moreover, akinetic catatonia might be associated with glutamic acid decarboxylase 65 (GAD65) autoantibodies ( 100 ), and orexin neurons might activate the GAD65 network ( 101 ).…”

Section: Alternative Explanatory Framework For Pathophysiology Of Tts...mentioning

confidence: 99%

Orexin/hypocretin system dysfunction in patients with Takotsubo syndrome: A novel pathophysiological explanation

Knez

Nikšić

Ömerovic

2022

Front. Cardiovasc. Med.

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Takotsubo syndrome (TTS) is an acute heart failure syndrome. Emotional or physical stressors are believed to precipitate TTS, while the pathophysiological mechanism is not yet completely understood. During the coronavirus disease (COVID-19) pandemic, an increased incidence of TTS has been reported in some countries; however, the precise pathophysiological mechanism for developing TTS with acute COVID-19 infection is unknown. Nevertheless, observing the symptoms of COVID-19 might lead to new perspectives in understanding TTS pathophysiology, as some of the symptoms of the COVID-19 infection could be assessed in the context of an orexin/hypocretin-system dysfunction. Orexin/hypocretin is a cardiorespiratory neuromodulator that acts on two orexin receptors widely distributed in the brain and peripheral tissues. In COVID-19 patients, autoantibodies against one of these orexin receptors have been reported. Orexin-system dysfunction affects a variety of systems in an organism. Here, we review the influence of orexin-system dysfunction on the cardiovascular system to propose its connection with TTS. We propose that orexin-system dysfunction is a potential novel explanation for the pathophysiology of TTS due to direct or indirect dynamics of orexin signaling, which could influence cardiac contractility. This is in line with the conceptualization of TTS as a cardiovascular syndrome rather than merely a cardiac abnormality or cardiomyopathy. To the best of our knowledge, this is the first publication to present a plausible connection between TTS and orexin-system dysfunction. We hope that this novel hypothesis will inspire comprehensive studies regarding orexin's role in TTS pathophysiology. Furthermore, confirmation of this plausible pathophysiological mechanism could contribute to the development of orexin-based therapeutics in the treatment and prevention of TTS.

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“…Such symptoms often prevent the patient from accepting any form of oral treatment, and encourage clinicians to find alternative routes for BZD administration. Only a few case reports have previously described that intravenous (IV) administration of Midazolam could help diagnose catatonia (5) or alleviate its symptoms (6)(7)(8)(9). But as far as we know, the successful use of subcutaneous (SC) Midazolam as a treatment for catatonia has never been reported.…”

Section: Case Report Backgroundmentioning

confidence: 99%

Case Report: Use of Subcutaneous Midazolam During an Episode of Catatonia

Raymond¹,

Véry

Jullien

et al. 2021

Front. Psychiatry

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Midazolam is a benzodiazepine (BZD) mainly used in anesthetic induction due to its pharmacokinetic features. Its place in the therapeutic management of catatonia remains to be determined. Here we present the case of a 65-year-old man who presented with a first episode of catatonia with opposition to any form of oral treatment, where a single dose of 1 mg of subcutaneous (SC) Midazolam permitted clinical improvement allowing oral treatment to be given. The patient's history notably included a renal transplant linked to Polycystic Kidney Disease (PKD) and no history of psychiatric illness nor of any use of psychotropic drugs. As the patient refused to drink or eat and ceased answering basic questions, a psychiatric assessment was required. A diagnosis of Catatonic disorder due to a general medical condition [DSM 5–293.89/ ICD10 [F06.1]] was made. A Bush-Francis Catatonia Rating Scale (BFCRS) analysis returned a score of 15 out of 62, with stupor, mutism, negativism, staring, withdrawal, rigidity, and stereotypy. As the negativism prevented the patient from taking any form of oral treatment, after a brief discussion with the unit's physician, it was decided to administer 1 mg of SC Midazolam. One hour later, the patient was more responsive and compliant, and agreed to drink, eat, and take medication. Thus, the catatonic signs of mutism, negativism, staring, and withdrawal were resolved, but waxy flexibility and catalepsy appeared, leading to a new BFCRS score of 10 out of 62. Oral treatment with 2.5 mg Lorazepam, 4 times a day, was then initiated. Midazolam could be a safer choice compared with the other options available, such as other SC BZD, considering the complex safety profile of this patient with renal insufficiency. This situation represents the first report of using SC Midazolam as an injectable treatment for catatonia. More studies are needed to assess the clinical pertinence of SC Midazolam in the treatment of catatonia.

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Takotsubo Cardiomyopathy and Catatonia in the Setting of Benzodiazepine Withdrawal

Cited by 9 publications

References 15 publications

Review of withdrawal catatonia: what does this reveal about clozapine?

Review of withdrawal catatonia: what does this reveal about clozapine?

Orexin/hypocretin system dysfunction in patients with Takotsubo syndrome: A novel pathophysiological explanation

Case Report: Use of Subcutaneous Midazolam During an Episode of Catatonia

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