Organic Catatonia Following Frontal Lobe Injury: Response to Clozapine
1998; American Psychiatric Association Publishing; Volume: 10; Issue: 2 Linguagem: Inglês
10.1176/jnp.10.2.237
ISSN1545-7222
AutoresO. Rommel, Martin Tegenthoff, W. Widdig, Peter Bräunig, J.-P. Malin,
Tópico(s)Treatment of Major Depression
ResumoBack to table of contents Previous article LetterFull AccessOrganic Catatonia Following Frontal Lobe Injury: Response to ClozapineOliver Rommel, M.D., Martin Tegenthoff, M.D., Walter Widdig, Ph.D., Peter BrÄUnig, M.D., and Jean-Pierre Malin, M.D., Oliver Rommel, M.D., Martin Tegenthoff, M.D., Walter Widdig, Ph.D., Peter BrÄUnig, M.D., and Jean-Pierre Malin, M.D., University Departments of Clinical Neurology and Psychiatry, Ruhr-University Bochum, BG-Kliniken Bergmannsheil, GermanyPublished Online:1 May 1998https://doi.org/10.1176/jnp.10.2.237AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: Catatonia is generally considered to be a subtype of schizophrenia.1 However, many other psychiatric as well as neurological illnesses can give rise to signs of catatonia.1 Treatment of agitated behavior as observed in catatonia presents a therapeutic dilemma. We report the response to clozapine in a patient with organic catatonia following severe frontal lobe injury.Case ReportA 56-year-old native Portuguese woman was involved in a major motor vehicle accident and sustained jaw fractures as well as a left frontal epidural hematoma. Because CT scans demonstrated an increasing bifrontal hygroma, frontal burr holes were administered, and later a frontal subduroperitoneal shunt system was implanted.At the time of referral to our department for early rehabilitation 4 weeks after trauma, the patient was awake but confused. She was able to obey commands, but after a few minutes she became restless and displayed rhythmic repetitive movements of her arms and a rocking motion of the trunk. She then repeatedly screamed, repeated the last words of questions asked, and stereotypically counted a sequence of numbers in Portuguese. She could move her limbs voluntarily, but her knees and elbows were in a flexed position due to high flexor muscle tone.The patient did not respond to neuroleptic agents such as phenothiazine, and haloperidol decanoate caused severe parkinsonian symptoms, even in minor dosages. Lorazepam resulted in diminished stereotypic movements for only a few days. Therefore, clozapine therapy was commenced and gradually increased to 350 mg a day.The catatonic symptoms slowly began to resolve, and periods when the patient was oriented and showed only minor motor abnormalities became increasingly longer. With daily physiotherapy, the patient was able to walk and could write a letter in Portuguese.Two months after catatonic symptoms had resolved, clozapine was discontinued and carbamazepine was started. Two days after discontinuation, stereotypic movements and severe restlessness reappeared. When the patient was asked to write down some words, she could write only repeated syllables, and once she had started, she could not stop writing. Clozapine therapy was resumed, and stereotypic movements resolved within a few days. One year after the trauma, clozapine dosage was gradually decreased without a relapse of catatonic symptoms. Neuropsychological testing demonstrated a prefrontal syndrome with cognitive impersistence, emotional lability, and diminished spontaneity.DiscussionIn this patient, a disinhibited prefrontal syndrome could be observed presenting as organic catatonia with stereotypic movements, iterations, and verbigerations, as well as muscle rigidity. Neuroleptic agents such as haloperidol were inefficacious and produced major side effects. Clozapine was therefore administered and facilitated a marked improvement of catatonic symptoms.Clozapine is an atypical antipsychotic drug that has demonstrated efficacy in patients with treatment-resistant schizophrenia. Several authors have reported that clozapine may also be useful in patients with disinhibition secondary to neurological disorders.2,3 Recurrence of psychotic symptoms after discontinuation of clozapine, as observed in our patient, has been previously described.4,5 Because clozapine has a very short half-life, it has been suggested5 that withdrawal can result in a fairly rapid cessation of antipsychotic activity and recurrence of psychotic or catatonic symptoms.Clozapine may be useful in patients with organic catatonia following orbitofrontal lesions. However, major side effects such as agranulocytosis or dose-related seizures must be taken into account, and the risk of sudden recurrence of symptoms after discontinuation of clozapine should also be considered.References1. Gelenberg AJ: The catatonic syndrome. Lancet 1976; 6:1339–1341Crossref, Google Scholar2. Duffy JD, Kant R: Clinical utility of clozapine in 16 patients with neurological disease. J Neuropsychiatry Clin Neurosci 1996; 8:92–96Link, Google Scholar3. Sajatovic M, Ramirez L: Clozapine therapy in patients with neurological illness. Int J Psychiatry Med 1995; 25:331–344Crossref, Medline, Google Scholar4. Ekblom B, Eriksson K, Lindstrom LH: Supersensitivity psychosis in schizophrenic patients after sudden clozapine withdrawal. Psychopharmacology 1984; 83:293–294Crossref, Medline, Google Scholar5. Tanriverdi N, Yazici KM: Immediate recurrence of psychotic symptoms after discontinuation of clozapine: a case report. Biol Psychiatry 1996; 39:814–815Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byPost-traumatic catatonia in a teenaged patientThe American Journal of Emergency Medicine, Vol. 62Brain mechanisms underlying catatonia: A systematic reviewSchizophrenia Research, Vol. 55Clozapine as a treatment for catatonia: A systematic reviewSchizophrenia Research, Vol. 158Clozapine Withdrawal-Induced Malignant Catatonia or Neuroleptic Malignant Syndrome: A Case Report and a Brief Review of the Literature16 June 2021 | Clinical Neuropharmacology, Vol. 44, No. 4Clozapine: Why Is It So Uniquely Effective in the Treatment of a Range of Neuropsychiatric Disorders?15 July 2021 | Biomolecules, Vol. 11, No. 7A case of developmental pedophilia unmasked by frontotemporal dementia15 April 2021 | Neurocase, Vol. 27, No. 2Review of withdrawal catatonia: what does this reveal about clozapine?31 July 2018 | Translational Psychiatry, Vol. 8, No. 1General Hospital Psychiatry, Vol. 48The Differential Diagnosis and Treatment of Catatonia in Children and AdolescentsHarvard Review of Psychiatry, Vol. 24, No. 6Relapses and recurrences of catatonia: 30-case analysis and literature reviewComprehensive Psychiatry, Vol. 66Frontiers in Psychiatry, Vol. 5Journal of Psychiatric Intensive Care, Vol. 8, No. 01Progress in Neuro-Psychopharmacology and Biological Psychiatry, Vol. 33, No. 4Idiopathic Recurrent Catatonia Needs Maintenance Lorazepam: Case Report and Review26 June 2016 | Australian & New Zealand Journal of Psychiatry, Vol. 41, No. 7El uso de antipsicóticos atípicos en el tratamiento de la catatonía12 May 2020 | European psychiatry (Ed. Española), Vol. 13, No. 1Psychiatry and Clinical Neurosciences, Vol. 60, No. 2The use of atypical antipsychotics in the treatment of catatonia16 April 2020 | European Psychiatry, Vol. 20, No. 5-6Clinical Neuropharmacology, Vol. 27, No. 5Annales de Réadaptation et de Médecine Physique, Vol. 46, No. 1Slowly Progressive AlexiaMario F. Mendez, M.D., Ph.D., 1 February 2002 | The Journal of Neuropsychiatry and Clinical Neurosciences, Vol. 14, No. 1Risperidone and Refusal to Eat After Traumatic Brain InjuryYoshito Mizoguchi, M.D., Akira Monji, M.D., Hiroyuki Isayama, M.D., and Nobutada Tashiro, M.D., 1 February 2002 | The Journal of Neuropsychiatry and Clinical Neurosciences, Vol. 14, No. 1Psychiatric Clinics of North America, Vol. 25, No. 1Clinical Neuropharmacology, Vol. 24, No. 4Neuropsychiatric aspects of traumatic brain injuryCurrent Treatment Options in Neurology, Vol. 2, No. 2Journal of Adolescent Health, Vol. 27, No. 1 Volume 10Issue 2 May 1998Pages 237-238 Metrics History Published online 1 May 1998 Published in print 1 May 1998
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