A Curious Case of Catatonia? Trixie Lipke, MD Child Psychiatry & Adolescent Fellow

Reason for Admission Leaves classroom and appears confused, EMS called. Family requests that child not treated as “if he’s sick”

Consult Question? 1.) Confirm diagnosis of conversion? 2.) Management?

History odd,bizarre comments: “my parents are zombies” 10 year-old boy with admission two weeks ago for organophospate poisioning and conversion Sx: selectively mute odd,bizarre comments: “my parents are zombies” oriented only to name PE: siallorhea, healed old scars on arms

History from Family oldest of five children, gets As in fourth grade No health issues for child or known family psychiatric history Symptoms began two weeks ago when he complained of abdominal pain, being hypnotized at school, and then had a seizure witnessed by mom with eyes rolling back and all four limbs jerking Complains of gait change in past two weeks.

History from Parents Mom attributes behavioral changes to “eating a pepper that was sprayed” with all symptoms beginning a day later Mt Sinai lists “Conversion” and “Organophosphate poisioning” as discharge diagnsis.

1st Hospitalization Normal EEG LP negative for: WNV, HSV ½. RPR negative. Negative UA Neurology consulted and signs off. Psychiatry finds worsened physical exam, now standing as if a statue and with difficulty following commands. Diagnosis: delirium

Consults Obtained Neurology: Psychiatry: Delirium Social Work: follow-up with alleged medical neglect reported by school related to admission

Differential Delirium? Conversion? MDD? GAD? Cultural values? Inadvertent Exposure? MDD? GAD? Cultural values?

Second Hospitalization Admitted one month later, again with siallorhea, mutism, and paranoid thoughts of poisioning, being hypnotized, and potentially killed Now has autonomic instability with HR at 120 and abruptly stops speaking Transferred to PICU

UofC Care Consults: Neurology Psychiatry Rheumatology ID

Most appropriate setting for care Trial of ativan with partial response Pursue further work-up or psychiatrically hospitalize? Aggression on floor and how to manage?

Catatonia Criteria three or more of the following 1. Catalepsy (i.e., passive induction of a posture held against gravity) 2. Waxy flexibility (i.e., slight and even resistance to positioning by examiner) 3. Stupor (no psychomotor activity; not actively relating to environment) 4. Agitation, not influenced by external stimuli 5. Mutism (i.e., no, or very little, verbal response [Note: not applicable if there is an established aphasia]) 6. Negativism (i.e., opposing or not responding to instructions or external stimuli) 7. Posturing (i.e., spontaneous and active maintenance of a posture against gravity) 8. Mannerisms (i.e., odd caricature of normal actions) 9. Stereotypies (i.e., repetitive, abnormally frequent, non-goal directed movements) 10. Grimacing 11. Echolalia (i.e., mimicking another's speech) 12. Echopraxia (i.e., mimicking another's movements) Table 2

The catatonia diagnosis in DSM 5. 1 The catatonia diagnosis in DSM 5. 1. Catatonic disorder due to a GMC (293.89) 2. Specifier “with Catatonia” for a. Schizophrenia b. Schizoaffective disorder c. Schizophreniform disorder d. Brief psychotic disorder e. Substance-induced psychotic disorder 3. Specifier “with Catatonia” for current or most recent major depressive episode or manic episode in a. Major depressive disorder, b. Bipolar I disorder, or c. Bipolar II disorder 4. Catatonic disorder NOS Use of the same set of criteria to diagnose catatonia across DSM-5

Psychiatric Hospitalization Taper Ativan Start Phenytoin and Risperidone “Awakening”

One year later Follow-up 3 months after hospitalization

References Hauptman AJ, Benjamin S. The Differential Diagnosis and Treatment of Catatonia in Children and Adolescents. Hauptman AJ, Benjamin S. Harv Rev Psychiatry. 2016 Nov/Dec;24(6):379-395. Validation of the Pediatric Catatonia Rating Scale (PCRS). Benarous X, Consoli A, Raffin M, Bodeau N, Giannitelli M, Cohen D, Olliac B. Schizophr Res. 2016 Oct;176(2-3):378-86. doi: 10.1016/j.schres.2016.06.020. Catatonia and Autoimmune Conditions in Children and Adolescents: Should We Consider a Therapeutic Challenge? Ferrafiat V, Raffin M, Deiva K, Salle-Collemiche X, Lepine A, Spodenkiewicz M, Michelet I, Haroche J, Amoura Z, Gerardin P, Cohen D, Consoli A. J Child Adolesc Psychopharmacol. 2016 Apr 19. [Epub ahead of print]