Treatment of Catatonia
How successfully can Catatonia be treated?
Treatment for Catatonia has been shown to be highly successful (80 to 100%). What's encouraging about receiving a diagnosis of Catatonia is that it is highly curable. Treatment options are dependent on several factors and should be discussed with a physician or healthcare team that has expertise and experience with Catatonia.
If a patient receives a diagnosis of Catatonia and does not receive highly curative treatment, they will needlessly suffer. In addition, they may lose their quality of life, may lose their livelihood, may be institutionalized and could die.
It’s important for all physicians to be aware of these highly curative treatment options and to refer a patient to a provider who has expertise and experience with treating Catatonia.
It’s also important for patients and families or caregivers to be educated on the high cure rates for treatment. There may be obstacles to receiving treatment and families may have to advocate for referrals for proper treatment.
The resources page has a list of providers with expertise in diagnosing and treating Catatonia as well as links to articles, books, other websites, videos and podcasts.
What are the treatment options for Catatonia?
Treatment options may depend on whether (i) it is determined that there is an underlying cause of the symptoms of Catatonia (encephalitis, a hormone imbalance, an underlying disease process or medication) or (ii) no underlying cause has been identified. The healthcare provider will determine the appropriate steps to make this determination with:
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A thorough examination
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A comprehensive health history provided by the patient (and caregivers) and/or obtained through medical records (both electronic and paper)
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An evaluation using a Catatonia rating scale
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Possible medical tests, including lab work, a spinal tap, and/or scans or ultrasounds to determine whether there are any underlying causes of Catatonia
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1
Benzodiazepines
Benzodiazepine medications are often a first-choice treatment for patients who present with symptoms of Catatonia for the following reasons:
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Benzodiazepines are frequently effective in the treatment of Catatonia. Between 60 and 90% of patients with Catatonia will improve when treated with benzodiazepines.
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Typically Lorazepam (brand name Ativan) is the treatment of choice but other benzodiazepines have been used, including Clonazepam and Diazepam.
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Benzodiazepines are generally safe and patients with Catatonia are able to tolerate high doses.
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Lorazepam may be helpful in determining whether the patient has Catatonia. Following a specific protocol for administering Lorazepam, either intravenously or orally, a reduction in the symptoms of Catatonia may be observed. This is known as the Lorazepam (or Ativan) Challenge. NOTE - The Lorazepam Challenge should be performed under the supervision of a healthcare provider. For an excellent explanation of the Lorazepam Challenge, click here.
Providers may be hesitant to prescribe Benzodiazepines
They are unaware of the research on the effectiveness of high-dose benzodiazepines (especially Lorazepam) in the treatment of Catatonia.
They are concerned about the addictive nature of benzodiazepines.
Benzodiazepines are Schedule IV controlled substances and prescribers are subject to the rules and restrictions of the Controlled Substances Act.
They are concerned about the cost of high-dose Lorazepam to patients.
The FDA recommends daily doses of Lorazepam in amounts from 1 to 10 mg a day for generalized anxiety disorder and patients with Catatonia need and can tolerate much higher doses.
High-dose treatment requires prior authorization from a patient’s insurance and potential appeals.
2
Electroconvulsive Therapy (ECT)
Click here for an informative video on ECT.
How effective is ECT?
ECT is highly effective in treating Catatonia with an 80 to 100% response rate.
Not only is ECT highly effective for Catatonia, it may resolve Catatonia rapidly.
What is ECT?
ECT is a medical procedure in which an electric stimulus is delivered to the patient’s brain through flat electrodes applied to (i) both temples (bilateral) or (ii) one temple and the top of the head (unilateral) with the intention of producing a brain seizure. The energy level is individualized to the patient and takes into account age, gender, and prescribed medications. The devices used in ECT have circuitry to prevent the delivery of excessive energy, meaning they deliver safe amounts of energy. In addition, both the brain seizure and the heart rhythm are monitored through EEG and ECG/EKG.
A person receiving ECT receives anesthesia prior to the treatment so they are not awake during the procedure. In addition, they will receive medication to relax their muscles, as well as very high concentrations of oxygen. A bite guard will be put in their mouth to protect the patient’s lips, teeth and tongue. The seizure typically lasts between 20 to 60 seconds but can last as long as 3 minutes and the patient generally wakes up soon after the procedure is complete.
An ECT treatment takes approximately one hour in total, including a patient assessment, anesthesia and the treatment itself. After the treatment is completed, patients are then transferred to the recovery area.
Dr. Max Fink explains ECT.
When might ECT be recommended for a patient with Catatonia?
Benzodiazepines are not effective.
The Catatonia is severe.
The person has had Catatonia before.
Quick action is needed to save the patient’s life.
Why is there so much stigma around ECT?
There is a negative stigma attached to ECT as the result of “shock therapy” portrayals in movies, television, and books. ECT has been presented as something used for punitive purposes, against a patient’s will and causing violent seizures, as shown in the 1975 movie One Flew Over the Cuckoo’s Nest starring Jack Nicholson.
As medical specialists have written about since then, that movie, unfortunately, reinforces untrue stereotypes about ECT. What has been portrayed in many movies, television, and books does NOT represent modern day use of ECT which is only done (i) with consent (ii) in a controlled environment with medical professionals monitoring vital signs and seizure length and (iii) under anesthesia and with the use of paralytics so the patient is comfortable and safe.
ECT has evolved into a safe, relatively painless procedure with proven effectiveness in treating many illnesses, including treatment-resistant depression, certain forms of mania, and Catatonia.
"ECT has a poor reputation except for those physicians and families that recognize the benefit."
- Dr. Max Fink
Each founding member of The Catatonia Foundation’s Board of Directors
has a loved one or friend who received ECT. In each case, ECT treatment
was effective and their loved ones recovered from Catatonia that was threatening their lives.
3
Treatment specific to Anti-NMDA Receptor Encephalitis
Catatonia may occur as the result of an autoimmune disease where the body creates antibodies against the NMDA receptors in the brain. When this diagnosis is confirmed by analysis of spinal fluid or brain tissue, the treatment protocols recommended are specific to this disease and include:
Supportive measures
Tumor Removal
Immunotherapy
Adjuvant ECT
First Line Immunotherapies - either alone or in combination
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High-dose Steroids
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IV immunoglobulin (IVIG)
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Plasma Exchange (PE)
Second Line Immunotherapies
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Rituximab - Monoclonal antibody
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Cyclophosphamide - Chemotherapy and immunosuppressive drug
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Other treatment possibilities
Published literature reports novel treatments for Catatonia with varying efficacy, including:
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Other benzodiazepines, including diazepam, oxazepam, and clonazepam
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Zolpidem (Ambien)
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Glutamate antagonists (amantadine and memantine)
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Bromocriptine and biperiden (in bipolar patients)
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Valproate, carbamazepine, and topiramate
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rTMS (repetitive transcranial magnetic stimulation)
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Atypical antipsychotics in combination with a benzodiazepine (used with caution as they can actually worsen Catatonia or cause a conversion to Malignant Catatonia)
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Clozapine in patients who have schizophrenia with Catatonia
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Flurothyl (medication that can induce a seizure without electricity)
5
Treatments that may worsen or cause Catatonia
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Antipsychotic medication may worsen Catatonia or cause Malignant Catatonia.
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Atypical antipsychotics should be used with caution.
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Serotonergic medication may cause Malignant Catatonia.
What circumstance may cause recurrence of Catatonia?
The following circumstances may cause recurrence of Catatonia:
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If treatment is discontinued too soon
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If treatment is administered unilaterally, instead of bilaterally
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If treatment does not take place frequently enough
Recurrence may occur in Agitated Catatonia in individuals on the autism spectrum. In those cases, a maintenance schedule of ECT is followed.