Cases That Test Your Skills

A depressed adolescent who won’t eat and reacts slowly

Current Psychiatry. 2015 August;14(8):49, 54-59

References

1. Dhossche D, Wilson C, Wachtel LE. Catatonia in childhood and adolescence: implications for the DSM-5. Primary Psychiatry. http://primarypsychiatry.com/catatonia-in-childhood-and-adolescence-implications-for-the-dsm-5. Published May 21, 2013. Accessed July 2, 2015.
2. Lahutte B, Cornic F, Bonnot O, et al. Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making. Prog Neuropsychopharmacol Biol Psychiatry. 2008;32(6):1393-1398.
3. Brake JA, Abidi S. A case of adolescent catatonia. J Can Acad Child Adolesc Psychiatry. 2010;19(2):138-140.
4. Consoli A, Raffin M, Laurent C, et al. Medical and developmental risk factors of catatonia in children and adolescents: a prospective case-control study. Schizophr Res. 2012;137(1-3):151-158.
5. Zaider TI, Johnson JG, Cockell SJ. Psychiatric comorbidity associated with eating disorder symptomatology among adolescents in the community. Int J Eat Disord. 2000;28(1):58-67.
6. Forsén Mantilla E, Bergsten K, Birgegård A. Self-image and eating disorder symptoms in normal and clinical adolescents. Eat Behav. 2014;15(1):125-131.
7. Bonnot O, Tanguy ML, Consoli A, et al. Does catatonia influence the phenomenology of childhood onset schizophrenia beyond motor symptoms? Psychiatry Res. 2008;158(3):356-362.
8. Singh LK, Praharaj SK. Immediate response to lorazepam in a patient with 17 years of chronic catatonia. J Neuropsychiatry Clin Neurosci. 2013;25(3):E47-E48.
9. Sienaert P, Rooseleer J, De Fruyt J. Measuring catatonia: a systematic review of rating scales. J Affect Disord. 2011;135(1-3):1-9.
10. Cottencin O, Warembourg F, de Chouly de Lenclave MB, et al. Catatonia and consultation-liaison psychiatry study of 12 cases. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(6):1170-1176.
11. Wachtel LE, Hermida A, Dhossche DM. Maintenance electroconvulsive therapy in autistic catatonia: a case series review. Prog Neuropsychopharmacol Biol Psychiatry. 2010;34(4):581-587.
12. Wachtel LE, Dhossche DM, Kellner CH. When is electroconvulsive therapy appropriate for children and adolescents? Med Hypotheses. 2011;76(3):395-399.
13. Takaoka K, Takata T. Catatonia in childhood and adolescence. Psychiatry Clin Neurosci. 2003;57(2):129-137.
14. Ceylan MF, Kul M, Kultur SE, et al. Major depression with catatonic features in a child remitted with olanzapine. J Child Adolesc Psychopharmacol. 2010;20(3):225-227.
15. Consoli A, Gheorghiev C, Jutard C, et al. Lorazepam, fluoxetine and packing therapy in an adolescent with pervasive developmental disorder and catatonia. J Physiol Paris. 2010;104(6):309-314.
16. Dhossche D, Cohen D, Ghaziuddin N, et al. The study of pediatric catatonia supports a home of its own for catatonia in DSM-5. Med Hypotheses. 2010;75(6):558-560.
17. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160(7):1233-1241.
18. Cornic F, Consoli A, Tanguy ML, et al. Association of adolescent catatonia with increased mortality and morbidity: evidence from a prospective follow-up study. Schizophr Res. 2009;113(2-3):233-240.
19. Quigley J, Lommel KM, Coffey B. Catatonia in an adolescent with Asperger’s disorder. J Child Adolesc Psychopharmacol. 2009;19(1):93-96.
20. Ghaziuddin N, Dhossche D, Marcotte K. Retrospective chart review of catatonia in child and adolescent psychiatric patients. Acta Psychiatr Scand. 2012;125(1):33-38.
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How would you treat Ms. A’s symptoms?
a) aggressively treat catatonia
b) address her eating disorder
c) work to resolve her depression

The authors’ observations
The challenge was to choose the psychotropic medication that would target her depression, obsessive, rigid thoughts, and catatonia. Administering an antidepressant with an antipsychotic would have relieved her depressive and obsessive symptoms but would not have improved her catatonia. The psychosomatic medicine team recommended starting a selective serotonin reuptake inhibitor and a benzodiazepine to target both the depression and the catatonic symptoms. Ms. A received sertraline, 12.5 mg/d, which was increased to 25 mg/d on the third day. IV lorazepam, 1 mg, 3 times a day, was recommended but the pediatric team prescribed an oral formulation. The hospital’s eating disorder protocol was instituted on the day of admission.

Treatment options for catatonia
Benzodiazepines are the first line of treatment for catatonia and other neuroleptics, specifically antipsychotics, have been considered dangerous.¹⁰ Benzodiazepine-resistant catatonia, which is sometimes seen in patients with autism, might respond to electroconvulsive therapy (ECT),¹¹ although in some states it cannot be administered to children age <18.¹² Benzodiazepines have shown dramatic improvement within hours, as has ECT.^8,13 Additionally, if patients do not respond to a benzodiazepine or ECT, consider other options such as zolpidem, olanzapine,¹⁴ or sensory integration system (in adolescents with autism).¹⁵

Ms. A did not need ECT or an alternative treatment because she responded well to 3 doses of oral lorazepam. Her amotivation, negativism, and rigidity with prolonged posturing improved. Her psychomotor retardation improved overall, although she reported some dizziness and had some postural hypotension, which was attributed to her eating issues and dehydration.

OUTCOME Feeling motivated
Ms. A is transferred to psychiatric inpatient unit. She tolerates sertraline, which is titrated to 50 mg/d. She is placed on the hospital’s standard eating disorder protocol. She continues to eat well with adequate intake of solids and liquid and exhibits only some anxiety associated with meals. During the course of hospitalization, she attends group therapy and her catatonic symptoms completely resolve. She says she thinks that her thoughts are improving and that she is not longer feeling confused. She reports being motivated to continue to improve her eating disorder symptoms.

The treatment team holds a family session during which family dynamic issues that are stressful to Ms. A are discussed, such as some conflict with her parents as well as some negative interactions between Ms. A and her father. Repeat comprehensive metabolic panel on admission to the inpatient psychiatric hospital reveals persistent elevation of AST at 92 U/L and ALT at 143 U/L. Ms. A is discharged home with follow-up with a psychiatrist and a therapist. The treatment team also recommends that she follow up in a program that specializes in eating disorders.

4-month follow-up. Ms. A returns to inpatient psychiatric hospital after overdose of sertraline and aripiprazole, which were started by an outpatient psychiatrist. She reports severe depressive symptoms because of school stressors. She denies any problems eating and did not show any symptoms of catatonia. In her chart, there is a mention of “cloudy thoughts” and quietness. At this admission, her ALT is 17 U/L and AST is 19 U/L. Sertraline is increased to 150 mg/d and aripiprazole is reduced to 2 mg/d and then later increased to 5 mg/d, after which she is discharged home with an outpatient psychiatric follow-up.

1-year follow-up. Ms. A has been following up with an outpatient psychiatrist and is receiving sertraline, 150 mg/d, aripiprazole, 2.5 mg/d, and extended-release methylphenidate, 36 mg/d, along with L-methylfolate, multivitamins, and omega-3 fish oil as adjuvants for her depressive symptoms. Ms. A does not show symptoms of an eating disorder or catatonia, and her depression and psychomotor activity have improved, with better overall functionality, after adding the stimulant and adjunctives to the antidepressant.

The authors’ observations
The importance of including catatonia NOS with its various specifiers, such as medical, metabolic, toxic, affective, etc., has been discussed.^16,17 In Ms. A’s case, instead of treating the specific symptoms—affective or eating disorder or obsessive quality of thought content, mimicking psychotic-like symptoms—addressing the catatonia initially had a better outcome. More studies related to chronic and acute catatonia in adolescents are needed because of the risk of increased morbidity and premature death.¹⁸ Early recognition of catatonia is needed¹⁹ because it often is underdiagnosed.²⁰

Eating disorders often become worse over the first 5 years, and close monitoring and assessment is needed for adolescents.²¹ Also, prodromal psychotic symptoms require follow-up because techniques for early detection and intervention for children and adolescents are still in their infancy.²²

References

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A depressed adolescent who won’t eat and reacts slowly

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