CASE: Nude and mute
Mr. M, age 45, is found naked outside his apartment. He has a history of schizophrenia, paranoid type, hypertension, and diet-controlled type 2 diabetes mellitus. His schizophrenia has been treated with ziprasidone, 160 mg/d, but 2 months ago he stopped taking his medication and seeing his psychiatrist. He does not respond to questions from police and is taken to a local emergency department for medical workup of altered mental status.
Mr. M is noted to have bilateral conjunctival discharge and a white blood cell (WBC) count of 15,000/mm3. Vital signs, physical examination, laboratory studies, and head CT are otherwise within normal limits. Mr. M is medically cleared for his 15th admission to our inpatient psychiatric facility in the last 7 years. He is divorced, has 2 adult sons, and receives Social Security disability benefits.
Mr. M is alert but guarded and mute and appears to be internally preoccupied. His mood is euthymic and his facial expressions do not vary much and are similar to a blank stare. His grooming and hygiene are poor, but there is no evidence of delusions or suicidal or homicidal ideation. He paces around the unit or sits in his bed staring straight ahead, occasionally mouthing inaudible words but remaining nonverbal.
Mr. M is restarted on his previous dose of ziprasidone and referred to the primary care physician in our inpatient psychiatric facility for further evaluation. His admission vitals and laboratory values show a platelet count of 124,000/mm3, glucose of 113 mg/dL, triglycerides of 160 mg/dL, high-density lipoprotein of 37 mg/dL, and hemoglobin A1c of 6%. Mr. M needs help drinking fluids but resists solid foods as well as medications, including lorazepam, 3 mg/d, and most scheduled doses of ziprasidone. On day 3, Mr. M’s extremities are rigid and he has poor oral intake. We diagnose Mr. M with catatonia based on his immobility, negativity, and mutism.
The authors’ observations
The literature describes >40 signs of catatonia.1-11 According to DSM-IV-TR, catatonia may occur in the context of schizophrenia, a mood disorder, or a general medical condition. DSM-IV-TR criteria for catatonia include:
- motor immobility as evidenced by catalepsy or stupor
- excessive motor activity
- extreme negativism or mutism
- peculiarities of voluntary movements as evidenced by posturing, stereotypic movements, or grimacing
- echolalia or echopraxia.12
Only 2 signs are necessary to meet the diagnostic criteria for catatonia.11,12 Several catatonia rating scales—including the Bush-Francis Catatonia Rating Scale (BFCRS)—have been found to be highly reliable for screening for and rating the severity of catatonia. Such tools also can be used serially to monitor treatment efficacy. The BFCRS takes 5 minutes to administer; the screen is considered positive if ≥2 of the first 14 items on the scale are present.13 Mr. M exhibits immobility and mutism, which are the most common signs of catatonia.
In patients with catatonia, poor oral intake may result in malnutrition that often requires parenteral nutrition or intravenous fluids1,10 and dehydration that may lead to dental caries, gum disease, constipation, and ileus.1 Pneumonia may occur secondary to atelectasis or buildup of respiratory secretions and possibly aspiration.7 Vaginal infections may develop secondary to poor hygiene.1 Immobility and malnutrition may lead to infection and decubitus ulcers.1 Finally, immobility also may cause urinary incontinence,2,10 nerve palsies, flexion contractions, and rhabdomyolysis.1
EVALUATION: Venous complications
On day 3, Mr. M is referred to a local emergency department, where he is assessed for delirium and dehydration because of increased WBC count and diaphoresis. The medical staff finds bilateral pulmonary embolisms and a deep vein thrombosis (DVT) of his left lower leg.
The authors’ observations
Catatonia is associated with an increased risk of venous thromboembolism because of the increased risk of venous stasis and hypercoagulability, both elements of Virchow’s triad for thrombogenesis.1-10,14,15 The third element of Virchow’s triad, vascular injury, does not appear to directly increase the risk for thromboembolic events in catatonic states.
Catatonia-specific causes for venous stasis include immobility, prolonged use of physical restraints, and sedation as a side effect of antipsychotic use.16
Causes for hypercoagulability during catatonic states include:
- increased catecholamine levels during excited states3
- hyperhomocysteinemia secondary to poor diet, smoking, and/or high caffeine consumption16
- increased anticardiolipin and/or anti-phospholipid antibody levels secondary to use of specific antipsychotics, such as chlorpromazine and clozapine16
- increased platelet aggregation secondary to hyperprolactinemia caused by low-potency conventional antipsychotics, such as chlorpromazine16,17
- increased platelet activation caused by altered levels of platelet serotonin in depressed patients.18
Patients taking low-potency conventional antipsychotics may have a 7-fold greater risk for thromboembolic events compared with those who do not use these medications.16