Catatonia Following a Traumatic Brain Injury: A Case Report with Positive Findings after an Ativan Trial

Abstract

Following a traumatic brain injury, a 24-year-old Caucasian male presents with a recent onset of generalized spasticity, contractures, severe cognitive defects, and other features, suggesting a diagnosis of catatonia. The patient was immobile and would demonstrate intermittent periods of screaming and emotional arousal when asked questions or touched. An Ativan (lorazepam) trial was performed on the patient, in which his arousal, attention, alertness, and cognition were monitored when the drug was administered and removed from his treatment protocol. The patient’s catatonic features were assessed according to the Bush-Francis Catatonia Rating Scale, with daily evaluation of responses during rounds and therapy. The patient demonstrated improvements in attention, arousal, concordance with therapy, and cognition after the application of lorazepam. Once lorazepam was removed from treatment, the patient displayed periodic bouts of emotional arousal, screaming, and was non-compliant with therapy. The findings in this case report suggest that a lorazepam treatment protocol could rapidly and efficiently relieve catatoniclike symptoms in a TBI patient without the presence of a mental disorder. The findings in this case-report also suggest the possible existence of a positive correlation between catatonia and acetaminophen toxicity. Future research should investigate the application of this treatment specifically in TBI patients without a previous medical history significant for psychiatric disorders, similar to the patient presented in the current report.

Keywords: Traumatic brain injury; Catatonia; Lorazepam; Benzodiazepines; Pain management

Abbreviations

TBI: Traumatic Brain Injury; TIRR: The Institute for Rehabilitation and Research at Memorial Hermann; ITB: Intrathecal Baclofen; BFCRS: Bush-Francis Catatonia Rating Scale

Introduction

Traumatic brain injury (TBI) represents one of the most common causes of death and disabilities among the younger population [1]. Under most circumstances, a TBI can result from a physical blow to the head due to falls, motor vehicle collisions, or sports related injuries [1,2]. Individuals with a history of a TBI have a significantly higher incidence of psychiatric disorders than the general population [3].

A systematic review from the journal of Neuropsychiatric Disease and Treatment, examined the epidemiology, diagnosis, associated factors, and treatments of the main psychiatric disorders that occur after TBI [4]. The most prevalent findings following TBI that were suggested in this review included depression, post-traumatic stress, disorders related to alcohol, changes in personality, and psychotic disorders [4]. Among the findings related to psychotic disorders, catatonia was suggested to be an important diagnostic feature of TBI patients, and was associated with a higher prevalence in the male population [5].

Catatonia has been identified in a variety of psychiatric, medical and neurological disorders, and drug-induced states, and is described as a syndrome of motor abnormalities accompanied with mood and behavior disorders [6,7]. Benzodizepines have been used to effectively treat catatonia, and are considered as a first-line treatment application, due to their favorable characteristic of producing few adverse side effects [7]. Although, the use of benzodiazepines at high doses has been associated with adverse side effects on the central nervous system as well as respiratory depression [8].

Here, we present the first case report of successful treatment with the benzodiazepine, lorazepam, for catatonia in a patient without a history of psychiatric disorders following a TBI. Written consent was obtained from the patient’s family for the publication of the case report.

Case Presentation

Mr. K, a 24-year-old caucasian male was admitted to the Institute for Rehabilitation and Research at Memorial Hermann (TIRR) with a history significant for a TBI due to a motorcycle accident in 2017. The patient also presented with a potential anoxic brain injury with generalized spasticity, contractures, and severe cognitive defects. The patient’s past medical history was insignificant for psychiatric history or risk factors that could predispose the individual to develop psychiatric disorders. The patient also presents to the physical medicine and rehabilitation department of TIRR with a recent onset of catatonic features.

Upon admission, an Intrathecal Baclofen (ITB) pump was administered to the patient at a dosage of 131.68mcg/day. A Baclofen trial was performed on the patient, beginning with a 10% increase of the ITB. Regarding the Baclofen trial, the ITB pump was gradually increased approximately 5-10% weekly until achieving a maximal dosage of 1000mg. Gabapentin and Acetaminophen (Norco) treatment was simultaneously administered to the patient at the start of the Baclofen trial at an initial dosage of 300mg TID, with the subsequent discontinuation of Seroquel from the treatment regimen. Before the patient underwent therapy, the dosage of acetaminophen was changed from TID to BID. Due to the gradual increase in the Baclofen dosage over the course of the patient’s stay, a catheter tip aspiration was performed in order to examine the effectiveness of the ITB pump. The results of the catheter tip aspiration suggested that the ITB pump was providing an adequate amount of medication to the patient, and the patient’s lack of responsiveness to the medication could simply be due to an increased tolerance to the therapeutic dosage.

Following the procedure, the patient experienced significant autonomic abnormalities, most of which was a consistent decrease in heart rate. It should be noted however, that the patient was burned in his groin during bathing due to an iatrogenic cause. In order to relieve the associated pain, extra Acetaminophen was provided to the patient than what was normally administered to an average TBI or catatonic patient. Approximately 10 days after the ITB pump was placed in the patient, an Ativan (lorazepam) trial was performed. The patient’s catatonic features were assessed according to the Bush-Francis Catatonia Rating Scale (BFCRS), with daily evaluation of responses during rounds and therapy (Table 1). The patient demonstrated improvements in attention, arousal, concordance with therapy, and cognition after the application of lorazepam. Once lorazepam was removed from treatment, the patient displayed periodic bouts of emotional arousal, screaming, and was non-compliant with therapy. Lorazepam was once again administered to the patient 2-3 days following these observations, in which an improvement in symptoms was noted.

Discussion

To our knowledge, there are no studies that have examined the presence of catatonia secondary to Acetaminophen overdose. However, a case report published in the Journal of Clinical Psychiatry described the presentation of a catatonic patient with a serum acetaminophen level of 213μmol/L and suggested that acetaminophen toxicity could be associated with the presentation catatonic-like features [9]. Following treatment with N-acetylcysteine, catatonic signs resolved after 36-48 hours. The report is limited by the fact the patient’s history is significant for hepatitis C, polysubstance dependence including cocaine, methamphetamine, cannabis, and alcohol. These factors could have contributed to the observed mutism, hyperreflexia, and neurological symptoms seen in this patient.

Catatonia can be recognized by the presence of two or more “catatonic signs” [10]. Regarding Mr. K, while no definitive diagnosis of catatonia was confirmed, catatonia was heavily suggested due to the presence of most of the criteria that is needed for the classification of this condition. There is significant ambiguity surrounding the diagnostic criteria for catatonic schizophrenia which can consist up to 50 signs. The criteria used in the BFCRS for catatonic features presents concise and explicit descriptions of catatonic diagnostic criteria, and were used to assess the condition of our patient [11]. Some of the pertinent positive features seen in Mr. K that was consistent with the BFCRS criteria was mutism, staring, posturing/ catalepsy, stupor, autonomic abnormalities, and rigidity. Mutism was rated at a 0, which is characterized as an absence of speech. It was also observed that the patient had a fixed gazed with minimal scanning of the visual environment, along with poor maintenance of eye contact leading to a score of 1. The patient scored a 1 on the immobility/ stupor scale due to the brief interactions with the attending physician, along with immobility. The hypotension exhibited by the patient was the only abnormal autonomic parameter that was monitored, leading to a score of 1 in the BFCRS. The strongest features of this patient that provided us with the most confidence in the confirming the catatonic state of this patient was the abnormal posturing and contractures, as well as the sudden engagement in screaming and emotional impulsivity (Table 1).

  

    

      
Excitement 
    
  
  

    
0 = Absent
      
1 = Excessive motion
      
2= Constant motion, hyperkinetic without rest
      
3 = full-blown catatonic excitement
  
  

    

      
Immobility/Stupor 
    
  
  

    
0 = Absent 
      
1 = Sits still, may interact briefly
      
2 = No interaction 
      
3 = Stuporous, non-reactive to pain 
  
  

    

      
Mutism 
    
  
  

    
0 = Absent
      
1 = Verbally unresponsive 
      
2 = Speaks less than 20 words/5 minutes
      
3 = No speech
  
  

    

      
Staring 
    
  
  

    
0 = Absent
      
1 = Poor eye contact, repeatedly gazes less than 20 seconds between    shifting attention
      
2 = Gaze held longer than 20 seconds
      
3 = Fixed gaze, non-reactive
  
  

    

      
Posturing/Catalepsy 
    
  
  

    
0 = Absent
      
1 = <1 minute
      
2 = >1 minute, <15 minutes
      
3 = abnormal posture, maintained more than 15 minutes 
  
  

    

      
Grimacing 
    
  
  

    
0 = Absent
      
1 = <10 seconds
      
2 = <1 minute
      
3 = abnormal expression, maintained more than 1 minute
  
  

    

      
Exhopraxia/echolalia 
    
  
  

    
0 = Mimicking of examiner’s movements/speech
      
1 = Occasional
      
2 = Frequent
      
3 = Constant
  
  

    

      
Stereotypy 
    
  
  

    
0 = Absent
      
1 = Occasional
      
2 = Frequent
      
3 = Constant
  
  

    

      
Mannerisms 
    
  
  

    
0 = Absent
      
1 = Occasional
      
2 = Frequent
      
3 = Constant
  
  

    

      
Verbigeration 
    
  
  

    
0 = Absent
      
1 = Occasional
      
2 = Frequent
      
3 = Constant
  
  

    

      
Rigidity 
    
  
  

    
0 = Absent
      
1 = Mild resistance
      
2 = Moderate
      
3 = Severe, cannot be repostured
  
  

    

      
Negativism 
    
  
  

    
0 = Absent
      
1 = Mild resistance and/or occasionally contrary
      
2 = Modereate resistance and/or frequently contraty
      
3 = Severe resistance and/or continually contrary
  
  

    

      
Waxy    Flexibility 
    
  
  

    
0 = Absent
      
3 = Present
  
  

    

      
Withdrawal 
    
  
  

    
0 = Absent
      
1 = Minimal PO intake/interaction less than 1 day
      
2 = Minimal PO intake/interaction more than 1 day
      
3 = No PO intake/interaction for 1 day or more
  
  

    

      
Impulsivity 
    
  
  

    
0 = Absent
      
1 = Occasional
      
2 = Frequent 
      
3 = Constant or not redirectable
  
  

    

      
Automatic    Obedience 
    
  
  

    
0 = Absent
      
1 = Occasional 
      
2 = Frequent 
      
3 = Constant 
  
  

    

      
Mitgehen 
    
  
  

    
0 = Absent
      
3 = Present 
  
  

    

      
Gegenhalten
    
  
  

    
0 = Absent
      
3 = Present  
  
  

    

      
Ambitendency 
    
  
  

    
0 = Absent
      
3 = Present
  
  

    

      
Grasp    reflex 
    
  
  

    
0 = Absent
      
3 = Present 
  
  

    

      
Perseveration 
    
  
  

    
0 = Absent
      
3 = Present 
  
  

    

      
Combativeness 
    
  
  

    
0 = Absent
      
1 = Occasionally strikes out, low potential for injury
      
2 = Frequent strikes out, moderate potential for injury 
      
3 = Serious danger to others 
  
  

    

      
Autonomic    abnormality 
    
  
  

    
0 = Absent
      
1 = Abnormality of 1 parameter
      
2 = Abnormality of 2 parameters
      
3 = Abnormality of 3 or more parameters
  

Table 1: Bush-Francis Catatonia Rating Scale; Presence or Absence of items
1-14 are used for screening, the 0-3 scale for items 1-23 is used to rate severity.