Case Report: Adolescent Catatonia Successfully Treated With Lorazepam and Aripiprazole
Case Report: Adolescent Catatonia Successfully Treated With Lorazepam and Aripiprazole
Case Report
Adolescent Catatonia Successfully Treated with
Lorazepam and Aripiprazole
Aaron J. Roberto,1 Subhash Pinnaka,1 Abhishek Mohan,2
Hiejin Yoon,1 and Kyle A. B. Lapidus3
1
1. Introduction
2. Case Report
2
pleasure seeking, goal-oriented behavior, grandiosity, delusional thoughts, or other symptoms suspicious for potential
mania or psychotic disorder, prior to this episode. There were
no previous or pending disciplinary school issues or legal
actions. The patient had no known drug or environmental
allergies. There was no history of catatonia, dystonia, stiffness,
mutism, tic disorder, obsessive-compulsive disorder, or involuntary movements.
On presentation to our pediatric ER, the patient appeared
suspicious, agitated, and confused. He was restless and not
verbal nor otherwise communicative and was sitting up,
hunched over with rigid, flexed, inwardly rotated extremities;
he retained a stiff posture throughout the encounter. His eyes
were at first closed although he was awake and responding
to painful stimuli. He was initially confused, perplexed, and
internally preoccupied. On physical examination, upper and
lower extremities were hyperreflexic. Signs of cogwheeling or
clasp-knife rigidity were not found on physical examination.
Blood alcohol and urine toxicology returned negative.
The patient was then transferred to the pediatric medical inpatient unit. Computerized tomography, chest X-ray,
and blood labs, including N-methyl-D-aspartate (NMDA)
antibodies, all were within normal limits. Sedation was
administered to manage agitation and lumbar puncture was
performed; cerebrospinal fluid was sent for cell counts,
cultures, and chemistries, which returned negative. Magnetic
resonance imaging (MRI) was performed, under sedation
due to agitation, on the second day of admission, and
electroencephalogram was obtained, both of which were
found to be normal.
On the second day of admission, lorazepam 1 mg intramuscularly (IM) was provided for continued agitation. After
one dose, the patient became slightly more responsive to
verbal commands, with a minimal decrease in rigidity for
approximately 30 minutes, though he remained disoriented.
Three hours later, after another dose of lorazepam 1 mg,
rigidity decreased further and the patient became more
lucid, able to move his head minimally in response to
sounds and commands, though in a very slow and repetitive, stereotyped manner. His presentation and response to
lorazepam, with negative workup, led to the diagnosis of
catatonia by the psychosomatic medicine team consulting
to the pediatric medical unit. On day 3, a standing dose
of lorazepam, beginning with 0.5 mg daily, was initiated.
He also received additional doses, as needed, for continued
rigidity and stiffness. After each dose he became less rigid
and his extremities were progressively less flexed, though he
remained internally preoccupied and only able to respond
minimally to commands. On day 5, the standing lorazepam
dose was increased to 0.5 mg three times daily (TID), and the
patients mental status continued to improve; he became more
lucid and better able to engage the interviewer. His fixed,
flexed posture improved significantly, and he became able to
weakly grasp the examiners finger with his right hand (yet
not with the left hand). He also was able to weakly and slowly
move his toes bilaterally on command. He was hyperreflexic,
with L3-L4 knee jerk and upper extremity reflexes rated 3+.
On day 6, the patient was minimally verbal and continued
to have decreased oral intake. He had lost 13 pounds since
3. Discussion
Catatonia is a syndrome of motor dysregulation that includes
excessive motoric activity, stereotypical movements, extreme
negativism or mutism, echolalia or echopraxia, and other
involuntary movements [1, 6, 11, 12]. Catatonia has been
associated with a wide variety of psychiatric, medical,
neurological, substance-related, endocrine, infectious, and
metabolic conditions [13]. In psychiatry, it is traditionally
linked to schizophrenia, though catatonia is not uncommon
in mood disorders [1416]. In a significant minority, no cause
is identified [15].
3
adolescent population [10]. In this case, the administration
of lorazapam was effective in treating our patients catatonia,
while delusional and paranoid thoughts were relieved by
concomitant treatment with aripiprazole, which has also
been effective in treating catatonia based on cases in the
literature. Here, catatonia was diagnosed efficiently, which
facilitated successful treatment, beginning with lorazepam
administration. Clinicians should maintain a low threshold
for initiating benzodiazepine treatment for children and
adolescents experiencing first episode catatonic symptoms.
Conflict of Interests
Aaron J. Roberto, Subhash Pinnaka, Abhishek Mohan, and
Hiejin Yoon have no financial support or other disclosures.
Kyle A. B. Lapidus received research support from Brain and
Behavior Research Foundation and Simons Foundation. Kyle
A. B. Lapidus serves on the advisory board for Halo Neuro,
Inc., has received devices from Medtronic, and consults for
LCN Consulting, Inc.
Acknowledgments
The authors would like to express gratitude to the patient
who provided assent and to the mother (legal guardian) of
the patient, who provided permission for both research and
anonymous publication.
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