‘A State of Excited Catatonia’
A newlywed couple wanted to commemorate their weddings, they both had a plan; their shared car obsession meant capturing the moment in a beautiful red Mustang. There was a drifting track at rural Toutle, in Washington. One friend would be the stuntman performing the drift while the other snapped on the camera. The couples were smiling in each others arms, this is the happiest they could’ve possibly be as they were getting married after all.
When they packed up the car to go home, that’s when the 27 year old woman started to feel strange. It was the jitters and the uncontrollable talking all day. She’d blame it on the excitement of her own wedding. All of a sudden, the excitement took over her heart, it went into overdrive, the pounding of the heart was so loud that it hurt in her throat or chest. Her husband started to get worried and confused, this was the day after the wedding. There was a hospital after a couple of towns. The doctors in that hospital had diagnosed it with a panic attack. The birth of her daughter had occurred a year before and this could possibly mean that the young woman had suffered from depression and anxiety. She’s married now and the excitement of it all was the culprit. She accepted the diagnosis but she couldn’t shake the feeling that this was very different from the usual. She was administered on antibiotics should it ever happen again and sent home. The pills didn’t do much. The next day, she had the same jitters and the heart pounding in her throat. Despite, taking the pills again, her memory turned to fragments. She couldn’t remember her emergency trips to the ER over the next few days. There was no doubt that something was off. Even though doctors would keep on pressing that it was probably anxiety and depression. After a week of ER visits, a social worker suggested another psychiatric hospital in the Vancouver area of Washington called Telecare. And after more than 2 weeks, doctors were convinced that it was not a psychiatric illness at all. She was then transferred to the Peace-Health Southwest Medical Center. After 3 days of evaluation, there was no explanation for the medical cause of her symptoms, she was later admitted to the hospital’s psychiatric unit. The psychiatrist thought that it could be a uniquely rare case of excited catatonia. Dr Michael Rothenfluch, the psychiatrist in-charge of her care felt that is wasn’t usual cases of catatonia, he’s seen in the 7 years of providing healthcare. There were three atypical symptoms that she’s had; confusion, speech garbling and there were seizure-like episodes of shaking and inattention. To top it all off, her medication seemed to be ineffective. He was getting more and more worried and so had tasked his senior to look into her case, Dr Michael Bernstein was to see her.
He had to visit her in the most locked part of the ward, the one where patients posed an utmost risk to themselves. There she was lying on her bed, with her eyes closed and being naked and disheveled. The sitter assigned to her tried repeatedly to cover her modesty with a sheet but she would throw it off. She moved constantly and relentlessly on the thin mattress, the psychiatrist squatted right next to the patient and spoke gently of her name. She opened her eyes but didn’t look directly to his side. She replied ok when she was asked how she was doing. She asked to call her parents when he asked her why she was here. She started to gag when trying to speak as if her own body was stopping her.
Catatonia is a distinct syndrome marked by a heterogenous constellation of hallmark signs and symptoms. The characteristic signs and symptoms of catatonia are excitement, immobility or stupor, mutism, staring, posturing/catalepsy, grimacing, echopraxia/echolalia, sterotypy, mannerisms, verbigeration, rigidity, negativism, waxy flexibility, withdrawal, impulsitivity, automatic obedience, mitgehen, gegenhalten, ambitendency, grasp reflex, preservation, combativeness, autonomic abnormality. Subtypes of catatonia are stuporous, excited, malignant, delirious mania, periodic. Excited catatonia consists of hyperactivity, verbigeration, sterotyped movements, negativism and impulsivity. Patients are highly agitated and could be combative. The mainstays of treatment for catatonia involve pharmacologic treatment as well as supportive care to manage the physical complications associated with immobility and poor oral intake. The initial approach to non-malignant forms of catatonia involves a dose of 2 mg of IV lorazepam. If IV access is not available, an IM route can be used, though this is not preferred given risks of iatrogenic harm.
The benzodiazepines didn’t do much of a miracle either. The two psychiatrists discussed together, the other possible causes of her psychiatric symptoms. Dr Bernstein recalled of patients in the past who had suffered from psychosis as a result of a tumour being involved. A paraneoplastic syndrome, triggered by antibodies to an ovarian growth known as a teratoma. A neurologist at PeaceHealth had also considered it to be a possibility. This disease was commonly seen in young female patients. Her MRI was somehow normal. Her results took six days to come back positive. She indeed did have paraneoplastic syndrome. A CT scan showed a walnut sized tumour on her ovary. She was transferred back to the hospital wherein the medical team had the tumour removed. The recovery period took 6 months but she still had memory issues. A teratoma-triggered psychosis is rare and the 1st two cases were reported 20 years ago. This made him wonder about the other two women who died decades earlier from brain disorders.
Credit: All clinical cases from Diagnosis: Solving the Most Baffling Medical Mysteries-Lisa Sanders. (Cases go in no particular order!)
Source: https://www.psychiatrictimes.com/view/the-many-faces-of-catatonia-an-under-recognized-clinical-syndrome, https://www.alamy.com/stock-photo-corridor-in-a-new-secure-residential-psychiatric-unit-shows-bedroom-137520491.html?imageid=E4596A48-2DA5-4B77-9D27-418335E81400&p=150047&pn=1&searchId=5ce69e6a75592459a0e979d51a20a8c5&searchtype=0
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