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Catatonia After Liver Transplantation

TO THE EDITOR: We present below the case of a 50-year-old male patient who developed catatonia after a liver transplant procedure.

Case Report

"Mr. L" was a 50-year-old Filipino man, status post-orthotopic liver transplant. On Postoperative Day 1, he behaved normally and posted encouraging initial liver-function tests. However, on Postoperative Day 2, he learned that the donor was an 18-year-old victim, and he became agitated, in apparent distress that a young patient’s death was associated with his receiving this donor liver. On Postoperative Day 3, he was acting "sluggish," and "staring into space." On Postoperative Day 4, he was nonverbal and grunting unintelligible sounds. He held and chewed on his incentive spirometer and refused to surrender it.

When seen by the Psychosomatic Medicine service, he was chewing repetitively and apparently purposelessly on his spirometer. He was alert but made poor eye contact. He was also noted to have flat affect and psychomotor retardation. He was started on intravenous lorazepam, 1 mg every 4 hours, and oral quetiapine, 50 mg every 6 hours. One hour after the first lorazepam dose, he spoke, but was suspicious and guarded. He was only willing to speak after his Filipina nurse, speaking in Tagalog, confirmed the identities of the psychosomatic medicine team. He spoke of his "top secret operation" and the "special surgeons’ team" who had operated on him. On Postoperative Day 5, he was still paranoid.

On Postoperative Day 6, he agreed to talk with Psychosomatic Medicine staff more cooperatively. He endorsed minimal memory of events during the catatonic episode. He stated that he felt "separate from the other people" in the hospital and was seeing things that he described as the "soundwaves which are stopped at every country’s port of entry." He exhibited no more stereotypic movements. Intravenous lorazepam was tapered to 1 mg every 4 hours. On Postoperative Day 7, he further described his memories from his catatonic episode. He described auditory hallucinations in the form of "voices asking for information and guidance" and visual hallucinations of an "immigration man" outside his room. He stated he had thought if he released his grip on his spirometer, he would somehow lose his new liver. Lorazepam was discontinued.

On Postoperative Day 8, he denied hallucinations as well as suicidality or homicidality, and he was discharged on Postoperative Day 9. When seen for clinical follow-up 7 weeks later, he continued to take oral quetiapine, 100 mg bid. There was been no recurrence of catatonia or paranoia. Oral quetiapine was tapered to 100 mg hs.

Discussion

Kahlbaum coined the term catatonia in 1869 and described it in detail in 1874.¹ He described catatonia as "insanity of tension" representing a distinct neurological motor syndrome.² Bleuler identified catatonia as a secondary symptom in a subform of schizophrenia characterized by psychogenic motor abnormalities.²

In 1966, Joyston-Bechal³ reviewed 100 cases and found many associated psychiatric diagnoses; catatonia due to depression had a better prognosis than catatonic schizophrenia. Abrams and Taylor (as cited in Pfuhlmann and Stober²) studied 55 cases and found that only a small percentage had schizophrenia; rather, 71% had affective disorders. Gelenberg described catatonia associated with multiple neurological, psychiatric, and systemic conditions.⁴ Northoff⁵ argues that although catatonia and neuroleptic malignant syndrome present with similar motor signs, neuroleptic malignant syndrome lacks the affective and behavioral abnormalities of catatonia. Fink⁶ views catatonia as a motor syndrome (with neuroleptic malignant syndrome as a subtype) and supports the use of benzodiazepines and electroconvulsive therapy (ECT) for treatment. Fink and Taylor^7,8 believe there are many presentations of catatonia that should be combined in order to help with treatment and to advance research efforts. DSM-IV⁹ criteria include the following: motoric immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia, or echopraxia.

In a case of catatonia linked to vitamin B₁₂ deficiency, a 52-year-old woman was treated with cyancobalamin and recovered within 8 weeks.¹⁰ In another case of catatonia, a 37-year-old woman with HIV infection was taking abacavir, nevirapine, and combivir; cessation of antiretrovirals and initiation of low-dose antipsychotic therapy led to her recovery.¹¹

In a MEDLINE search, one other case of catatonia linked to liver transplant was found. The patient was a 50-year-old woman with stereotypies, posturing, rigidity, negativism, staring, and delusions of melancholy and persecution 72 hours posttransplant. She was treated with oral zolpidem, 10 mg, followed by oxazepam, 40 mg/day, and she showed dramatic improvement within 30 minutes of taking the zolpidem.¹² Our case exhibited a similar course. Both patients initially did well postoperatively; both patients had persecutory delusions in addition to catatonia; and both patients experienced complete reversal of catatonia with treatment.

Catatonia should be included in the differential diagnosis whenever its signs and symptoms present themselves, especially given the success of treatment with sedative anticonvulsants and ECT and the favorable outcome associated with prompt treatment.

REFERENCES

1. Moskowitz AK: "Scared stiff:" catatonia as an evolutionary-based fear response. Psychol Rev 2005; 111:984–1002
2. Pfuhlmann B, Stober G: The different conceptions of catatonia: historical overview and critical discussion. Eur Arch Psychiatry Clin Neurosci 2001; 251(suppl1):I4-I7
3. Carroll BT: Kahlbaum’s catatonia revisited. Psychiatry Clin Neurosci 2001; 55:431–436[Medline]
4. Ungvari GS, Kau LS, Wai-Kwong T, et al: The pharmacological treatment of catatonia: an overview. Eur Arch Psychiatry Clin Neurosci 2001; 251(suppl1):I31-I34
5. Northoff G: Catatonia and neuroleptic malignant syndrome: psychopathology and pathophysiology. J Neural Transm 2002; 109:1453–1467[CrossRef][Medline]
6. Fink M: Catatonia: syndrome or schizophrenic subtype? recognition and treatment. J Neural Transm 2001; 108:637–644[CrossRef][Medline]
7. Fink M, Taylor MA: The many varieties of catatonia. Eur Arch Psychiatry Clin Neurosci 2001; 251(suppl1):I8-I13
8. Taylor MA, Fink B: Catatonia in psychiatric classification: a home of its own. Am J Psychiatry 2003; 160:1233–1241[Abstract/Free Full Text]
9. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
10. Barry N, Sagar R, Tripathi BM: Catatonia and other psychiatric symptoms with vitamin B₁₂ deficiency. Acta Psychiatr Scand 2003; 108:156–159[CrossRef][Medline]
11. Foster R, Olajide D, Everall IP: Antiretroviral therapy-induced psychosis: case report and brief review of the literature. HIV Med 2003; 4:139–144[CrossRef][Medline]
12. Cottencin O, Debien C, Vaiva G, et al: Catatonia and liver transplant. Psychosomatics 2002; 45:338–339[CrossRef]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by HUANG, A. S. Articles by BOURGEOIS, J. A. Search for Related Content PubMed Citation Articles by HUANG, A. S. Articles by BOURGEOIS, J. A. Delirium Other Neuropsychiatric Disorders Syndromes Secondary to General Medical Disorders

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