A Case of Childhood Catatonia

Habiba Begum¹, Dip J Deori², Dhrubajit Boro³

¹Department of Psychiatry, Jorhat Medical College and Hospital, Jorhat, Assam, India

^2,3Department of Psychiatry, Dhubri Medical College and Hospital, Dhubri, Assam, India

Corresponding Author: Habiba Begum, Department of Psychiatry, Jorhat Medical College and Hospital, Jorhat, Assam, India, e-mail: habiba717864@gmai.com

Received on: 28 June 2024; Accepted on: 25 September 2024; Published on: 16 November 2024

ABSTRACT

Catatonia is a marked disturbance in the voluntary control of movements, characterized by several of the following: extreme slowing or absence of motor activity, mutism, purposeless motor activity unrelated to external stimuli, assumption and maintenance of rigid, unusual, or bizarre postures, resistance to instructions or attempts to be moved, or automatic compliance with instructions. A 12-year-old boy presented with this presentation and was planned for a lorazepam challenge test (4 mg IV, 30-minute intervals) and clonazepam (0.25 mg as needed), along with nutritional correction. The patient improved completely on the second day. The patient had first visited a private pediatrician for this condition, but he did not improve with lorazepam (1.5 mg daily dosing). The patient had a computed tomography (CT) brain finding—a hypodense area of attenuation close to the cerebrospinal fluid (CSF) at the left cerebellar hemisphere. It is a matter of debate whether the catatonia is of organic origin or something else.

How to cite this article: Begum H, Deori DJ, Boro D. A Case of Childhood Catatonia. East J Psychiatry 2024;24(2):56-57.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Case report, Catatonia, Childhood, Lorazepam.

INTRODUCTION

Catatonia is a rare clinical syndrome in children and adolescents. The prevalence of catatonia in inpatient youths varies from 0.6 to 17% (Cohen et al., 2005; Takaoka and Takata, 2003; Thakur et al., 2003; Wing and Shah, 2000).¹ In the overwhelming majority of cases, catatonic episodes occur in patients at pubertal ages and exceptionally at prepubertal ages.² Catatonia is a potentially life-threatening but treatable syndrome that also occurs in children and adolescents with autistic, developmental, and tic disorders, as well as in its idiopathic form. The creation of a separate diagnostic class for catatonia is the safest approach to ensure proper diagnosis and treatment of this syndrome in patients of all ages and the best approach to promote research.³ There is no history of prior medication for any kind of illness, as reported by the parents.

CASE DESCRIPTION

A 12-year-old male child presented to the Psychiatry department of Dhubri Medical College and Hospital with his parents on March 19, 2024, with chief complaints of abnormal posturing of the whole body, no speech output, inability to eat, and intermittent crying and laughing for the past 24 days. On mental status examination (MSE), the patient had poor eye contact, rapport could not be established, he was unable to talk, and further MSE could not be conducted. He was first seen by a pediatrician privately in Goalpara and was treated on an outpatient basis with lorazepam 1.5 mg tablet. He did not show any signs of improvement. The pediatrician also advised a computed tomography (CT) brain scan and electroencephalogram (EEG). According to the parents, they could not afford repeated visits to the private clinician, so they came to Dhubri Medical College for better treatment with comprehensive interdepartmental consultation. An ear, nose, and throat (ENT) consultation was obtained to rule out any organic pathology related to his speech problem. There was no organic cause identified by the ENT department. The patient was admitted under the pediatric department for nutritional correction and was referred to our department for further management of catatonia. The patient was diagnosed with catatonia (Block L1-6A4) according to the International Classification of Diseases, 11th Revision (ICD-11). The patient was advised to undergo routine investigations, along with a whole abdomen ultrasound by the pediatric department. We advised lorazepam 4 mg IV at 30-minute intervals and clonazepam 0.25 mg as needed. The patient showed improvement on the second day with full recovery. Non-contrast computed tomography (NCCT) brain showed hypodense area attenuation close to cerebrospinal fluid (CSF) at the left cerebellar hemisphere. The whole abdomen ultrasound showed no significant findings, chest X-ray showed no abnormalities, EEG was normal, and the complete hemogram revealed: hemoglobin 9.9 gm/dL, sodium 148 mmol/L, potassium 3.62 mmol/L, calcium 9.3 mg/dL, and TSH 2.47 mIU/L. On the second day, with lorazepam 4 mg, the patient showed complete improvement. We gradually titrated the dose of lorazepam orally and stopped after 10 days. The patient was reviewed in the outpatient department of Psychiatry after 3 weeks and was completely symptom-free. We advised them to undergo a magnetic resonance imaging (MRI) of the brain for further evaluation of any other organic pathology, as the patient is vulnerable to catatonic presentations in the future. According to Consoli et al., 13 (22.4%) patients had medical conditions, and 18 (31%) had a history of developmental disorders in the catatonia group, whereas 1 (1.3%) and 17 (22.6%) patients had the same conditions in the bipolar group (p < 0.001; p = 0.17, respectively). Medical conditions associated with catatonia included autoimmune encephalitis [systemic lupus erythematosus (N = 3) and anti-NMDA-receptor encephalitis (N = 1)], seizures (N = 1), ciclosporin encephalitis (N = 1), posthypoglycemic coma encephalitis (N = 1), and genetic or metabolic conditions [chorea (N = 2), 5HT cerebrospinal fluid deficit (N = 1), storage disease (N = 1), fatal familial insomnia (FFI; N = 1), and proline dehydrogenase (PRODH) mutations (N = 1)]. Six patients responded to a specific treatment approach related to their medical condition (e.g., plasma exchange in the case of autoimmune encephalitis).⁴

DISCUSSION

Traumatic events are also important risk factors for the onset of catatonia in children and adolescents.⁵ Pediatric catatonia is also associated with neurodevelopmental disorders. In a review of six studies, an incidence rate of 4–17% of catatonia was found in adolescents and adults with autism spectrum disorder.⁶ Childhood disintegrative disorder, Tourette’s syndrome, Down syndrome, and Prader–Willi syndrome were also associated with higher rates of pediatric catatonia.² Often, in cases with developmental disorders, the diagnosis can be more difficult due to the overlap of symptoms. In this case, there was no clear identifiable cause initially, and often it is necessary to rule out possible organic causes of pediatric catatonia. An underlying organic condition could be identified in approximately 20% of pediatric catatonia cases.⁷ It is always an important issue to investigate these possible contributing conditions, as there are specific treatments for some of them that can improve catatonic symptoms.⁴

CONCLUSION

Catatonia in children and adolescents is associated with a high prevalence of medical conditions in our country. This needs to be acknowledged with full effort, as it may greatly delay the treatment and management of catatonia and the diagnosis of medically related catatonia as a whole. This may, in turn, deny patients treatment opportunities, especially in remote areas where emergency management is a matter of concern due to poor infrastructure.

Declaration of Consent from Parents

We have obtained all appropriate parental consent forms. In the form, the parents have given their consent for their child’s images and other clinical information to be reported in the journal. The parents understand that their child’s name and initials will not be published, and due efforts will be made to conceal their identity.

REFERENCES

1. World Health Organization (WHO). Eleventh revision of the mental and behavioural disorders. In: International Classification of Diseases and Related Health Problems (ICD-11).

2. Benarous X, Raffin M, Ferrafiat V, et al. Catatonia in children and adolescents: new perspectives. Schizophr Res 2018;200:56’67. DOI: 10.1016/j.schres.2017.07.028

3. 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. DOI: 10.1016/j.mehy.2010.07.029

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. DOI: 10.1016/j.schres.2012.02.012

5. Dhossche DM, Ross CA, Stoppelbein L. The role of deprivation, abuse, and trauma in pediatric catatonia, without a clear medical cause. Acta Psychiatr Scand 2012;125:25’32. DOI: 10.1111/j.1600-0447.2011.01779.x

6. Dhossche DM, Shah A, Wing L. Blueprints for the assessment, treatment and future study of catatonia in autism spectrum disorders. Int Rev Neurobiol 2006;72:267’284. DOI: 10.1016/S0074-7742(05)72016-X

7. 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;32:1393’1398. DOI: 10.1016/j.pnpbp.2008.02.015

________________________
© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.