Case Presentation: 58 year old male with a history of hypertension and type 2 diabetes mellitus sought medical care for new onset generalized weakness, gait instability, bradykinesia and aphasia for a one week duration. On physical exam, he was non-verbal and experiencing decreased strength in his lower (1/5) and upper extremities (3/5). Review of systems revealed a loss of self-ambulation. A full neurological workup, including a CT head, lumbar puncture, MRI head and 24-hour Video EEG, was performed. A full infectious and toxicology workup was performed as well. Results were non-diagnostic. Further investigation into his social history revealed an increase in stress at work with prolonged periods of overtime over the past month. Ativan 1 mg was given with slight improvement in speech and strength. A diagnosis of catatonia secondary to severe anxiety was made. He was started on Ativan 1 mg twice daily. Within 4 days of his admission, he returned to a full functional baseline.
Discussion: Catatonia is a syndrome of motor dysregulation with features that include mutism, rigidity, inhibited movement, posturing and staring. Historically, catatonia has been associated with schizophrenic patients, but catatonia is not exclusively linked to schizophrenia and can be caused by a number of different psychiatric or even metabolic conditions. Catatonia is a clinical diagnosis and there is no diagnostic test or imaging specific to the condition. Lorazepam challenge has become the mainstay of diagnosis and treatment. If a patient responds well to an IV bolus of Lorazepam, then a course of three to six months of therapy, in addition to treating the underlying condition, can be a safe and effective treatment. In our patient, it took only two days of Lorazepam 1mg administered twice daily for him to completely return to his baseline. Continued outpatient follow-up with psychiatric treatment is paramount to symptom control.
Conclusions: This case highlights the importance of viewing a patient through both a psychosocial and behavioral-cultural lens. Upon initial presentation, the differential was broad. Yet, looking at the entire clinical picture of the patient allowed for successful diagnosis and treatment. Although catatonia may seem like a rare disease entity in a patient without any psychiatric illness, it can be the first sign of a severe underlying psychiatric or medical disorder.