Cases That Test Your Skills

Depressed, delusional, and ‘dead’

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Mr. P. suddenly becomes mute, lethargic, and gravely disabled. He stands in the street and believes he is killing people around him. What causes his bizarre downturn? What treatment will help him?


 

References

History: Suddenly Speechless

Mr. P, age 52, is transferred to our behavioral health unit after 1 month of unsuccessful treatment at a psychiatric hospital. He is mute and disheveled with blunted affect.

Before his hospitalization, Mr. P—who is mildly retarded and has an IQ of 67—lived independently, managed his finances, held two part-time jobs, volunteered as an usher at church, and had a girlfriend. He has been medically stable with diagnoses of indolent stage-zero chronic lymphocytic leukemia (for which he took no medication), moderate obesity, and essential hypertension. For 2 years he has been taking reserpine, 0.25 mg/d, for hypertension, and weighs 200 lb at presentation (body mass index: 29 kg/m2). He has no history of mental illness.

Seven months ago, Mr. P began having trouble dressing and bathing. He also began eating considerably less—about one-third of his normal food intake—and lost 20 lbs over 6 months.

Mr. P also began standing in the street for hours at a time—calling out to passers-by that people were dying and he was causing their deaths—until family members persuaded him to return home. He was not hallucinating, but his brother—who is Mr. P’s legal guardian—said symptoms worsened after a family friend died. After Mr. P became mute, resistant to direction, and immobile, his brother got him admitted to the psychiatric hospital.

The attending physician stopped reserpine—which might cause depression—and started hydrochlorothiazide, 25 mg/d, to maintain normal blood pressure. A psychiatrist diagnosed major depressive disorder and psychosis not otherwise specified, and prescribed mirtazapine, 30 mg nightly, and quetiapine, 25 mg bid. The psychiatrist ruled out lethal catatonia, as vital signs remained stable. When Mr. P’s symptoms did not improve after 1 month, the psychiatrist recommended electroconvulsive therapy (ECT) and transferred him to our facility.

Physical examination and laboratory findings are normal except for lymphocytosis secondary to leukemia:

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The authors’ observations

Mr. P. has major depression with psychotic features. His staring, catalepsy, negativism, selective mutism, and posturing indicate catatonia, and his nihilistic delusions signal Cotard’s syndrome, a delusional depressive disorder.

Catatonia consists of changes in muscle tone and activity and is accompanied by echopraxia and echolalia. Many medical conditions or medications can cause catatonia (Table 1).1 Resultant immobility and stupor can lead to contractures, pressure ulcers, venous thrombosis, and pulmonary emboli. Refusal to eat or drink can cause malnutrition, dehydration, weight loss, and muscle wasting. Approximately 9% of psychiatric inpatients develop catatonia at some point.2

DSM-IV-TR3 describes catatonia criteria as specifiers in affective illness and requires two or more of the following features for diagnosis:

  • catalepsy or stupor
  • purposeless, excessive motor activity
  • negativism or mutism
  • peculiar voluntary behaviors, such as posturing, stereotypy, or mannerisms
  • echolalia or echopraxia (Table 2).
No consensus exists regarding which behaviors are pathognomonic or how long they must persist to meet criteria for catatonia.

Catatonia can occur during an excited or retarded state:

  • Excited catatonia—also called delirious mania or an oneiroid state—is marked by a dreamlike sensorium, rapid onset, confabulation, derealization, depersonalization, disorientation, and a mixture of catatonic features.4
  • Retarded catatonia can be diagnosed using DSM-IV-TR criteria for catatonia. In mild cases or early in presentation, symptoms resemble anergy and psychomotor slowing typical of depression.
Lethal catatonia—a rare, extreme, potentially life-threatening form—is clinically indistinguishable from neuroleptic malignant syndrome. Its cause is often toxic or iatrogenic.5 Hyperthermia, hypertension, tachycardia, fever, tachypnea, leukocytosis, and serum creatine phosphokinase >500 u/L indicate lethal catatonia.

Table 1

Recognized causes of catatonia

  • Affective disorders and schizophrenia
  • CNS injury or infection (such as encephalitis)
  • Lupus cerebritis
  • Medications (bupropion, disulfiram, fluoroquinolones, neuroleptics, steroids)
  • Metabolic imbalance
  • Porphyria
  • Seizure disorders
  • Substance abuse (cocaine, phencyclidine)
Table 2

Catatonia: Defining clinical characteristics

TermDefinition
AmbitendencyIndecision, hesitance, becoming stuck regarding stimuli
Analgesia to painful stimuliFailure to feel or withdraw from pain
CatalepsyPosturing, including facial expressions such as exaggerated lip puckering, with waxy flexibility and automatic obedience
EcholaliaRepeating words and phrases
EchopraxiaRepeating another person’s movements
ExcitementLoquacious confabulation and autonomic instability
MannerismsPurposeful eccentric movements, such as saluting
NegativismRigidity and resistance to commands
PerseverationContinuing a response long after it is appropriate
Prosectic speechDecreased production and volume of speech
Selective mutismAbsence of speech
StereotypyPersistently repeating gestures that do not appear goal-directed, such as head-banging, rocking, and twirling objects
VerbigerationRepeating a word, phrase, or sentence
In Cotard’s syndrome (Table 3), the patient might believe that he and others around him are dead, that his body is putrefying and missing internal organs and blood, or that the world no longer exists.6 Some patients also have delusions of negation and damnation.7

Cotard’s syndrome, first described in the late 1800s by French neurologist Jules Cotard, can accompany folie à deux7 or lycanthropy, the delusional belief that one has been transformed into a werewolf.8 In rare cases, patients believe that their bodies are abnormally enlarged.7 Cotard’s syndrome can exist alone or as part of a psychiatric illness with nihilistic delusions.7

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