Medication Summary
Medications that may be used in the treatment of patients suffering from catatonia include benzodiazepines, carbamazepine, zolpidem, tricyclic antidepressants (TCAs), muscle relaxants, amobarbital, reserpine, thyroid hormone, lithium carbonate, bromocriptine, and neuroleptics. [110]
Because neuroleptic malignant syndrome (NMS) may occur in patients with symptoms and signs of catatonia, prudent clinicians use neuroleptics, including atypical neuroleptics, with caution. Although success has been reported in cases of catatonia treated with a combination of lithium and a neuroleptic, the risk of adverse effects must be considered when this combination is given, even if an atypical neuroleptic is used.
Anxiolytics, Benzodiazepines
Class Summary
By binding to specific receptor sites, benzodiazepines appear to potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission and the action of other inhibitory transmitters.
Lorazepam (Ativan)
Lorazepam is a sedative hypnotic with a short onset of effects and a relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, it may depress all levels of the central nervous system (CNS), including the limbic and reticular formations. After a lorazepam dose is administered, the patient's blood pressure should be monitored. The dose is adjusted as necessary.
Clonazepam (Klonopin)
Clonazepam is a long-acting benzodiazepine that increases presynaptic GABA inhibition and reduces the monosynaptic and polysynaptic reflexes. It suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and the action of other inhibitory transmitters.
Midazolam
Midazolam is an alternative for the termination of refractory status epilepticus. Because it is water-soluble, it takes approximately 3 times longer than diazepam to reach peak electroencephalographic (EEG) effects. Therefore, the clinician must wait 2-3 minutes to evaluate midazolam's sedative effects fully. Midazolam has twice the affinity for benzodiazepine receptors that diazepam does. It may be administered intramuscularly (IM) if intravenous (IV) access cannot be obtained.
Anticonvulsants, Other
Class Summary
The use of certain anticonvulsants has proven helpful in some cases of catatonia.
Carbamazepine (Tegretol, Carbatrol, Epitol, Equetro)
Carbamazepine's mechanism of action may include modulation of voltage-dependent sodium channels.
Valproic acid (Depakote, Depakote ER)
Valproic acid may be helpful by increasing activity at GABA or modest antiglutaminergic effects.
Anticonvulsants, Barbiturates
Class Summary
The use of certain anticonvulsants has proven helpful in some cases of catatonia.
Amobarbital (Amytal)
Amobarbital is a sedative hypnotic with anticonvulsant properties that interfere with the transmission of impulses from the thalamus to the cortex.
Anxiolytics, Nonbenzodiazepine
Class Summary
The use of certain nonbenzodiazepine anxiolytics has been shown to be helpful in some cases of catatonia.
Zolpidem (Ambien, Edluar, ZolpiMist)
Zolpidem increases neural hyperpolarization by enhancing the activity of the inhibitory neurotransmitter GABA through selective agonist activity at the benzodiazepine-1 receptor.
Skeletal Muscle Relaxants
Class Summary
The use of certain skeletal muscle relaxants has been shown to be helpful in some cases of catatonia.
Dantrolene (Dantrium, Revonto, Ryanodex)
Dantrolene acts directly on skeletal muscle by interfering with the release of calcium ions from the sarcoplasmic reticulum.
Central Monoamine-Depleting Agents
Class Summary
The use of central monoamine-depleting agents has been shown in case reports to be helpful in some cases of catatonia.
Reserpine
Reserpine depletes norepinephrine and dopamine, and this depletion may result in reduced blood pressure and sedative effects.
Thyroid Products
Class Summary
The use of thyroid products has been shown in case reports to be helpful in some cases of catatonia.
Thyroid, Desiccated (Armour Thyroid, Nature Throid, Westhroid)
Thyroid hormone is involved in normal metabolism, gluconeogenesis, utilization and mobilization of glycogen, and stimulation of protein synthesis.
Antipsychotics, Other
Class Summary
The use of antipsychotic products has been shown in case reports to be helpful in some cases of catatonia.
Lithium carbonate (Lithobid)
A case report has described successful lithium treatment in a patient with long-standing periodic catatonia. Although success has been reported in cases of catatonia treated with a combination of lithium and a neuroleptic, the risk of adverse effects must be considered when this combination is given, even if the neuroleptic is an atypical one.
Antipsychotics, 2nd Generation
Class Summary
The use of second-generation antipsychotic products has been shown in case reports to be helpful in some cases of catatonia.
Olanzapine (Zyprexa)
The effects of olanzapine are mediated through combined antagonism of dopamine and serotonin type 2 receptor sites.
Clozapine (Clozaril, FazaClo)
Clozapine has been reported to improve catatonia in psychosis, perhaps via a greater pass-though of dopamine to the D2 receptor.
Ergot Derivatives
Class Summary
The use of ergot derivatives has been shown in case reports to be helpful in some cases of catatonia.
Bromocriptine (Parlodel, Cycloset)
Bromocriptine activates postsynaptic dopamine receptors in the tuberoinfundibular and nigrostriatal pathways. A case report on a patient with catatonia described successful treatment with bromocriptine.
Antidepressants, TCAs
Class Summary
The use of TCAs has been shown in case reports to be helpful in some cases of catatonia.
Amitriptyline hydrochloride
Amitriptyline is an analgesic indicated for certain chronic and neuropathic pain.
Clomipramine (Anafranil)
Clomipramine is a dibenzazepine compound belonging to the TCA family. It inhibits the membrane pump mechanism responsible for the uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons. Clomipramine affects serotonin uptake and affects norepinephrine uptake when converted into its metabolite, desmethylclomipramine. These actions are believed to be responsible for clomipramine's antidepressant activity.
Doxepin
Doxepin increases the concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by the presynaptic neuronal membrane. It inhibits histamine and acetylcholine activity and has proved useful in treatment of various forms of depression associated with chronic pain.
Nortriptyline (Pamelor)
Nortriptyline has demonstrated effectiveness in the treatment of chronic pain.
Desipramine (Norpramin)
Desipramine is the original TCA used for depression. It and similar agents appear to act by inhibiting reuptake of noradrenaline at synapses in central descending pain-modulating pathways located in the brainstem and spinal cord.
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Serotonin syndrome checklist.
Tables
Category |
Causes |
Neurologic conditions |
Neuroleptic malignant syndrome [28] Administration of agents that block postsynaptic dopamine receptors* Administration of sibutramine [29] (withdrawn from US market October 8, 2010) Withdrawal of lorazepam and other sedatives Akinetic-rigid syndrome Anti-NMDA receptor encephalitis [4] Arachnoid cyst in right parietal region Astrocytoma Atrophy of left amygdala [30] Autistic disorder [17, 10, 11, 31, 32, 33, 34, 35, 36, 12, 13] Basilar artery thrombosis Bilateral hemorrhagic lesions of temporal lobes Cerebellar catalepsy Cerebral hemorrhage Cerebral infarct Cerebrovascular disease Cortical venous thrombosis Central pontine myelinolysis Cortical basal ganglionic degeneration Dystonia Encephalitis (herpesvirus, Trypanosoma cruzi) Encephalopathy (Borrelia burgdorferi, HIV infection, Wernicke encephalopathy) Familial fatal insomnia [37] Fibromuscular dysplasia with dissection of basilar artery Frontal lobotomy Head injury Huntington disease Hydrocephalus Hypopituitarism secondary to postpartum hemorrhage Idiopathic recurring stupor Inherited neurometabolic disorders Locked-in syndrome Meningitis, tuberculous Meningoencephalitis Neurosyphilis Nonconvulsive status epilepticus Pervasive developmental disorders [10, 11, 35] Pallidoluysian atrophy Paraneoplastic encephalitis [40] Parkinsonism Postencephalitic parkinsonism Progressive multifocal leukoencephalopathy Progressive supranuclear palsy Schizencephaly Seizures (complex with partial symptomatology) Stiff-man syndrome Stroke Stupor Subarachnoid hemorrhage Subdural hematoma Substance intoxication (alcohol, disulfiram, organic fluorides, phencyclidine) Subthalamic mesencephalic tumor Surgical removal of cerebellar tumor Tay-Sachs disease Temporal lobe epilepsy Tuberous sclerosis Tumors (corpus callosum, glioma of third ventricle, supraventricular diffuse pinealoma) Vegetative state Von Economo (lethargic) encephalitis Wilson disease |
Psychiatric conditions |
Acute stress disorder Anorexia nervosa Autistic disorder [17] Brief reactive psychosis with catatonia Conversion disorder Hysteria Major depression, single episode with catatonic features Mood disorders Neuroleptic malignant syndrome [28] Posttraumatic stress disorder Schizophrenia Substance intoxication (3,4-methylenedioxymethamphetamine [“ecstasy”], alcohol, amphetamine, phencyclidine, substance withdrawal, hypnotic-sedative, lorazepam) |
Psychological factors |
Immigration Experiencing rejection of an expression of love Feelings of alienation in an unfamiliar country |
Medical conditions |
AIDS Acute intermittent porphyria Addison disease Bacterial septicemia Bronchorrhea Carcinoid tumors Diabetic ketoacidosis Encephalopathy (hepatic, HIV infection, Wernicke encephalopathy) Fever of unknown cause Heat stroke Hepatic failure Hereditary coproporphyria Homocystinuria Hypercalcemia Hyperparathyroidism Hyperthyroidism Hyponatremia Hypothermia Intestinal atony Malaria Neuroleptic malignant syndrome [28] Poisoning (carbon monoxide, tetraethyl lead) Renal failure Substance intoxication (alcohol, cyclosporine, disulfiram, organic fluorides, phencyclidine) Syndrome of inappropriate antidiuretic hormone (SIADH) Syphilis Systemic lupus erythematosus Thermal injury Thrombotic thrombocytopenic purpura Tuberculosis Typhoid fever Uremia Von Economo (lethargic) encephalitis |
Obstetric conditions |
Hypopituitarism secondary to postpartum hemorrhage |
*Administration of agents that block postsynaptic dopamine receptors is associated with the onset of catatonia in some individuals. |
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Medication
- Medication Summary
- Anxiolytics, Benzodiazepines
- Anticonvulsants, Other
- Anticonvulsants, Barbiturates
- Anxiolytics, Nonbenzodiazepine
- Skeletal Muscle Relaxants
- Central Monoamine-Depleting Agents
- Thyroid Products
- Antipsychotics, Other
- Antipsychotics, 2nd Generation
- Ergot Derivatives
- Antidepressants, TCAs
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- Tables
- References
