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Catatonia and Liver Transplant

Key Words: Catatonia • Liver Transplant

TO THE EDITOR: To our knowledge, cases of catatonia directly related to situations of organ transplants thus far have not been described. Nowadays, catatonia is no longer regarded just as a subtype of schizophrenia. It corresponds to a psychomotor syndrome that may also be linked with mood disorders as well as general medical conditions (i.e., neurologic disorders, drug-induced and toxic conditions, or metabolic conditions).¹ We report a case of catatonia that emerged after a liver transplant.

A 50-year-old Italian woman who had never experienced any family or personal psychiatric disorders was hospitalized to undergo a liver transplant due to cirrhosis caused by viral hepatitis C contracted posttransfusion. Immediate postoperative reactions were normal and her hepatic and renal metabolic functioning returned to normal within the first 48 hours after the operation. The patient did not show any signs of delirium, found her way in time and space, and made coherent remarks as she spoke with the caregivers despite the language barrier.

It had been decided that she could start drinking and eating again without a feeding tube, but 72 hours after the operation the patient suddenly exhibited behavior problems. She refused what was offered to her (she refused to eat and take food), made stereotypic gestures with her legs, and exhibited cataleptic attitudes, opposionism, rigidity, verbal and physical negativism, staring, and delirious ideas of melancholy and persecution. Faced with these symptoms, we diagnosed a catatonic disorder according to DSM-IV criteria. No organic causes were found; there was no clinical evidence for somatic disease, hyperthermia, benzodiazepine withdrawal, or drug toxicity, and hepatic and renal functioning was normal.

Therefore, we proposed a pharmacological test for catatonia with zolpidem (10 mg p.o.) we described previously.² Thirty minutes later, we started to notice a dramatic improvement in symptoms. The patient spoke fluent Italian with the interpreter, showing no signs of anxious perplexity, describing her own previous state as a daydream. We changed from zolpidem to an oral regimen of oxazepam, 40 mg/ day, because of its weak hepatic toxicity. The situation improved even further, and we gradually brought the doses down to 10 mg/week until we decided to stop. At a 2-month outpatient follow-up visit, the patient was no longer receiving any psychotropic treatment and showed no more signs of catatonia or any other psychiatric disorders.

Our case report confirms that catatonia may emerge with no previous latent psychiatric neurological, toxic, or metabolic disorder. Catatonia could well have been a nonspecific response to intense stress due to transplant surgery, prognosis on life, the language barrier, or the uprooting; so many elements contributed to the psychic vulnerability. Our case also confirms that it is important to recognize catatonia in serious medical situations (such as in an intensive care unit) when faced with unexplained motor, behavioral, or psychic symptoms. Being familiar with this diagnosis enabled us to distinguish it from that of an acute psychotic episode. Prescribing neuroleptics in the case of catatonia might worsen the symptoms and could even bring about a neuroleptic malignant syndrome.³ A test with zolpidem² is an easy one for diagnosis and therapy. It is useful in cases such as those described, especially because of its efficiency and innocuousness before prescribing benzodiazepines.

Last, our case report confirms that catatonia is related to stress insofar as it represents a way to react to severe stress or a sum of stresses and strains (such as the aforementioned traumatizing circumstances) observed in general medical conditions or psychiatric disorders. It is even more so important to identify such clinical cases, since there is now a simple and efficient therapeutic solution.

REFERENCES

1. Carroll BT, Spetie L: Catatonia on the consultation-liaison service: a replication study. Int J Psychiatry Med 1994; 24:329-337[Medline]
2. Thomas P, Rascle C, Mastain B, Maron M, Vaiva G: Test for catatonia with zolpidem (letter). Lancet 1997; 349:702[Medline]
3. Fink M: Neuroleptic malignant syndrome and catatonia : one entity or two? Biol Psychiatry 1996; 39: 1-4

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