Case Presentation: A 64 year-old woman presented with two weeks of progressive refusal to eat, weakness, and somnolence. She had two weeks of abdominal pain that was worse with eating and diarrhea with significant weight loss and generalized weakness. She also endorsed worsening depression and suicidal ideation. Per the family, she was delusional and “losing her mind.”
She was cachectic and had a BMI of 15. She was minimally interactive and confused. She would not open her eyes or make eye contact, had a flat affect, and answered questions after long pauses and with a quiet, mumbling voice. She was unable to open her mouth past 3cm, and had dry mucus membranes. Her electrolytes, glucose, and renal and liver function tests were normal. Her urine and serum toxicology screens were negative, and CT head revealed no acute intracranial abnormality.
Her home psychiatric medications were held/tapered, and she was started on methylphenidate and lorazepam. She had a brief period of improvement in alertness, but the next day was somnolent again. She was continued on fluoxetine and lorezapam for the next 3 days, but without much improvement. She was able to eat with assistance, though consistently denied having an appetite. On day 7 of admission, she was restarted on a higher dose of methylphenidate. Over the next 24 hours, she improved significantly in both her alertness and ability to perform ADL’s. By 36 hours, she was putting on makeup, feeding herself, and getting up out of bed on her own. She noted that she could hear the members of her team, but “couldn’t get out” to them.
Discussion: Altered mental status is frequently encountered in the hospital, but catatonia is less frequently identified. It is important to note that although catatonia is often associated with underlying psychiatric disease, but it can also be secondary to a medical illness. Malignant catatonia is particularly dangerous. The triad of rigidity, altered mental status, and autonomic instability can clue a hospitalist into its diagnosis.
This patient had an acute and significant improvement in her symptoms with the addition of methylphenidate. Benzodiazepines and/or electroconvulsive therapy have also been effective in treating catatonia, but methylphenidate offers an additional option for the treatment of catatonia.
This case also highlights the need for narrative medicine. Through discussions with this patient and the medical team, she was able to relate how she felt during that period of more severe catatonia. She acknowledged that she was feeling depressed, and even pointed out that she heard the medical student’s voice and liked how he used her name. However, despite how hard she tried, she couldn’t get through this invisible barrier that kept her from interacting. Listening to this patient’s story allowed the provider to engage empathetically. Through ongoing conversations with patients, physicians can improve their delivery of care.
Conclusions: When encountering patients with altered mental status, physicians may not understand what the patient is experience. This case provides a patient perspective as she reflects on her experience of acute catatonia. Encouraging this documentation through physician and patient authorship may allow physicians a way to improve the hospital experience.