COVID-19 and Catatonia: A Case Series and Systematic Review of Existing Literature

Catatonia responsive to corticosteroids in a patient with an SCN2A variant

Variants in SCN2A are a known risk factor for developing autism spectrum disorder (ASD). Catatonia is a complex neuropsychiatric syndrome, which occurs at a higher rate in individuals with ASD. Catatonia has also been associated with COVID-19 infection, though the majority of these cases are associated with increased serum inflammatory markers. We present a case of a 15-year-old female with ASD and corticosteroid responsive stuporous catatonia to explore the relationship between SCN2A variants, ASD, COVID-19 exposure, and treatment refractory catatonia. Despite a lack of significantly elevated serum or CSF inflammatory markers, this patient showed significant improvement following initiation of corticosteroid therapy. This case presents a novel approach to the work-up and treatment of catatonia in individuals with SCN2A variants independent of elevated inflammatory markers.

Brain evolution and the meaning of catatonia - An update

Back in 2004, in a chapter titled "Brain Evolution and the Meaning of Catatonia", a case was made that the syndrome's core meaning is embedded in millions of years of vertebrate brain evolution. (Fricchione, 2004) In this update, advances over the last almost 20 years, in catatonia theory and research in particular, and pertinent neuropsychiatry in general, will be applied to this question of meaning. The approach will rely heavily on a number of thought leaders, including Nicos Tinbergen, Paul MacLean, John Bowlby, M. Marsel Mesulam, Bruce McEwen and Karl Friston. Their guidance will be supplemented with a selected survey of 21sty century neuropsychiatry, neurophysiology, molecular biology, neuroimaging and neurotherapeutics as applied to the catatonic syndrome. In an attempt to address the question of the meaning of the catatonic syndrome in human life, we will employ two conceptual networks representing the intersubjectivity of the quantitative conceptual network of physical terms and the subjectivity of the qualitative conceptual network of mental and spiritual terms. In the process, a common referent providing extensional identity may emerge (Goodman, 1991). The goal of this exercise is to enhance our attunement with the experience of patients suffering with catatonia. A deeper understanding of catatonia's origins in brain evolution and of the challenges of individual epigenetic development in the setting of environmental events coupled with appreciation of what has been described as the most painful mammalian condition, that of separation, has the potential to foster greater efforts on the part of clinicians to diagnose and treat patients who present with catatonia. In addition, in this ancient and extreme tactic, evolved to provide safety from extreme survival threat, one can speculate what is at the core of human fear and the challenge it presents to all of us. And when the biology, psychology and sociology of catatonia are examined, the nature of solutions to the challenge may emerge.

Neurological risks of COVID-19 in women: the complex immunology underpinning sex differences

The COVID-19 pandemic has uncovered many mysteries about SARS-CoV-2, including its potential to trigger abnormal autoimmune responses. Emerging evidence suggests women may face higher risks from COVID-induced autoimmunity manifesting as persistent neurological symptoms. Elucidating the mechanisms underlying this female susceptibility is now imperative. We synthesize key insights from existing studies on how COVID-19 infection can lead to immune tolerance loss, enabling autoreactive antibodies and lymphocyte production. These antibodies and lymphocytes infiltrate the central nervous system. Female sex hormones like estrogen and X-chromosome mediated effects likely contribute to dysregulated humoral immunity and cytokine profiles among women, increasing their predisposition. COVID-19 may also disrupt the delicate immunological balance of the female microbiome. These perturbations precipitate damage to neural damage through mechanisms like demyelination, neuroinflammation, and neurodegeneration - consistent with the observed neurological sequelae in women. An intentional focus on elucidating sex differences in COVID-19 pathogenesis is now needed to inform prognosis assessments and tailored interventions for female patients. From clinical monitoring to evaluating emerging immunomodulatory therapies, a nuanced women-centered approach considering the hormonal status and immunobiology will be vital to ensure equitable outcomes. Overall, deeper insights into the apparent female specificity of COVID-induced autoimmunity will accelerate the development of solutions mitigating associated neurological harm.

Surge of Midazolam Use in the Midst of Lorazepam Shortage

BACKGROUND

Lorazepam is a widely prescribed benzodiazepine that is used to manage anxiety, insomnia, and status epilepticus and is used for pre-anesthetic care as well as several off-label indications including aggression, alcohol withdrawal, panic disorder, chemotherapy-associated anticipatory nausea, and catatonia. Recent increases in demand, manufacturing changes, and quality control issues have resulted in a shortage of injectable and oral lorazepam, prompting clinicians to use alternatives. One such alternative is midazolam, a drug that has been used primarily in the intensive care unit and anesthesia settings.

PROCEDURES

This article examines the significant pharmacologic differences between lorazepam and midazolam. In addition, this article provides dosage guidelines based on the current scientific knowledge and recommendations for conversion equivalencies.

RESULTS

The clinical preference for lorazepam can be attributed to its simpler metabolism with no active metabolites, better suitability for patients with less severe hepatic and renal impairment, less risk of adverse reactions, fewer drug-drug interactions, and greater desirability for special populations. In periods of shortages, midazolam has been shown to be effective for a number of off-label uses. To manage conditions that have not been extensively studied, clinicians may opt to use conversion equivalencies, with the caveat that guidelines may vary greatly between institutions and online sources; therefore, it would be best to start low and titrate slowly.

CONCLUSIONS

Our goal is to aid clinicians in safely and effectively prescribing midazolam during the shortage of injectable lorazepam so that patients are provided the same effects and benefits.

First-Onset Psychosis After COVID-19 Infection: A Systematic Review of the Literature

BACKGROUND

The COVID-19 pandemic has been an inciting factor for a wide variety of neuropsychiatric symptoms, including first-episode psychosis (FEP).

OBJECTIVE

The aim of this systematic review was to summarize the current literature on COVID-19 associated postviral FEP.

METHODS

A systematic review was completed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 81 articles that met inclusion criteria.

RESULTS

Articles included case reports, case series, and cohort studies with postviral FEP occurring outside the setting of delirium, demonstrating a broad range of symptoms.

CONCLUSIONS

This systematic review shows that postviral FEP associated with COVID-19 follows a pattern similar to psychosis associated with other viral infections and is an important consideration when building a differential for FEP when delirium has been ruled out. Better understanding of postviral FEP associated with COVID-19 and other viral illnesses may help clarify aspects of underlying pathophysiology of psychotic symptoms broadly.

The diagnostic dilemma in a patient with neuroleptic malignant syndrome during the COVID-19 pandemic: A significant increase in acute phase reactants

Key Clinical Message

In some patients, neuroleptic malignant syndrome is accompanied significant high levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP).

Abstract

Neuroleptic malignant syndrome (NMS) is an idiosyncratic life-threatening adverse reaction and usually triggered in response to antipsychotic drugs. In addition, leukocytosis and increased muscle enzymes levels (especially creatine phosphokinase) are observed in NMS. In addition, a transient increase in different types of acute phase reactants in NMS has been mentioned. This article describes a woman treated with haloperidol, perphenazine, escitalopram, and alprazolam because she developed catatonic symptoms after psychological stress. She suffered from NMS symptoms and had elevated CRP and ESR levels, among other signs and symptoms. Given the COVID-19 pandemic and reports of co-occurrence of catatonia and NMS and COVID-19 and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), this patient was a diagnostic dilemma. After consultation with the consultation-liaison psychiatry units, she was managed adequately with electroconvulsive therapy and lorazepam.

Successful ECT in an adolescent with catatonia and psychosis due to COVID-19

This case report highlights the use of ECT in an adolescent patient with a COVID-19 infection, which is an area of limited data. The patient received a full course of bitemporal ECT, with a total of 15 treatments administered over four months. The patient responded robustly, with a complete return to her pre-infection baseline mental status, and response has remained durable for one-year post continuation phase ECT taper. Maintenance ECT considerations for catatonia should be determined on a case-by-case basis but was not needed for our patient, given the durability of the response to ECT.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

Catatonia Due to General Medical Conditions in Psychiatric Patients: Implications for Clinical Practice

Catatonic syndrome is frequently observed over the course of severe mental disorders and general medical conditions, but when catatonia occurs in psychiatric patients with co-morbid medical or neurologic conditions, diagnosis and management may be challenging. Several medical conditions may cause catatonia in psychiatric patients, but some, such as brain injury, infections, hyponatremia and critical illness, may be most relevant in this population. Alongside appropriate etiologic treatment, benzodiazepines and electroconvulsive therapy in refractory cases are effective and safe, and may resolve catatonic syndrome rapidly. When newly-onset psychotic symptoms in catatonic patients with established psychotic disorders occur, delirium should be suspected and appropriately managed. An extensive clinical and laboratory diagnostic workup to determine the underlying etiology of catatonic syndrome should be carried out. In cases of acute multi-morbidity, the exact cause of catatonic syndrome in psychiatric patients may be unclear. It is recommended to avoid antipsychotic drugs in acutely catatonic patients, because they may exacerbate the catatonic symptoms. The akinetic type of catatonia should be differentiated from hypoactive delirium, as treatments for these syndromes differ substantially. When a psychiatric patient presents with symptomatology of both catatonia and delirium, treatment is particularly challenging.

Demographic Features, Physical Examination Findings, and Medication Use in Hospitalized, Delirious Patients With and Without COVID-19 Infection: A Retrospective Study

BACKGROUND

Delirium is common in the setting of infection with severe acute respiratory syndrome coronavirus 2. Anecdotal evidence and case reports suggest that patients with delirium in the setting of Coronavirus 2019 (COVID-19) may exhibit specific features, including increased tone, abulia, and alogia.

OBJECTIVE

To determine whether differences exist in sociodemographic and medical characteristics, physical examination findings, and medication use in delirious patients with and without COVID-19 infection referred for psychiatric consultation.

METHODS

We undertook an exploratory, retrospective chart review of 486 patients seen by the psychiatry consultation service at a tertiary care hospital from March 10 to May 15, 2020. Delirious patients were diagnosed via clinical examination by a psychiatric consultant, and these patients were stratified by COVID-19 infection status. The strata were described and compared using bivariate analyses across sociodemographic, historical, objective, and treatment-related variables.

RESULTS

A total of 109 patients were diagnosed with delirium during the study period. Thirty-six were COVID-19+. Median age was 63 years and did not differ between groups. COVID-19+ patients with delirium were more likely to present from nursing facilities (39% vs 11%; Fisher's exact test; P = 0.001) and have a history of schizophrenia (11% vs 0%; Fisher's exact test; P = 0.011). Myoclonus (28% vs 4%; P = 0.002), hypertonia (36% vs 10%; P = 0.003), withdrawal (36% vs 15%; P = 0.011), akinesia (19% vs 6%; P = 0.034), abulia (19% vs 3%; P = 0.004), and alogia (25% vs 8%; P = 0.012) were more common in COVID-19+ patients. COVID-19+ delirious patients were significantly more likely to have received ketamine (28% vs 7%; P = 0.006), alpha-adrenergic agents besides dexmedetomidine (36% vs 14%; P = 0.014), and enteral antipsychotics (92% vs 66%; P = 0.007) at some point.

CONCLUSIONS

Patients with COVID-19 delirium referred for psychiatric consultation are more likely to reside in nursing facilities and have a history of schizophrenia than delirious patients without COVID-19. Patients with delirium in the setting of COVID-19 may exhibit features consistent with akinetic mutism. Psychiatrists must assess for such features, as they may influence management choices and the risk of side effects with agents commonly used in the setting of delirium.

Delayed onset catatonia after COVID-19

COVID-19 has many complications that are associated with this infection. Neuropsychiatric symptoms are common and can present with symptoms documented both during acute COVID-19 infection and developing after the resolution of respiratory symptoms. Patients have presented with a variety of symptoms such as anosmia, seizures, cognitive and attention deficits, new or progression of existing anxiety, depression, psychosis, and rarely catatonia. Although rare, catatonia and each of its subtypes have now been reported as complications of COVID-19 and therefore, should be considered known to occur in both during the acute and postinfectious states. Diagnosis of catatonia in the context of COVID-19 should be considered when work-up for more common medical causes of encephalopathy are negative. There have been cases documented in the literature of patients presenting to the hospital with catatonia during COVID-19 infection. However, we present a case of akinetic catatonia in setting of COVID-19 infection and premorbid serious mental illness that was diagnosed and treated on an outpatient basis with close collaboration between primary care and psychiatry.

Catatonia after COVID-19 infection: scoping review

AIMS AND METHOD

Catatonia has been increasingly described in cases of COVID-19; we therefore aimed to investigate the evidence for catatonia in patients with COVID-19. We searched PubMed, EMBASE, PsycINFO, BIN and CINAHL databases for articles published in English, from the initial descriptions of the COVID-19 pandemic to January 2022.

RESULTS

A total 204 studies were identified, 27 (13%) of which met the inclusion criteria. The evidence available was based on case reports. The articles included in this review identified a total of 42 patients, ranging from the ages of 12 to ≥70 years, with confirmed or possible catatonia during or after a COVID-19 infection.

CLINICAL IMPLICATIONS

This review provides valuable information to clinicians in medical practice for treating patients with COVID-19, and a foundation for further research for this uncommon syndrome of COVID-19.

The Use of Electroconvulsive Therapy in Neuropsychiatric Complications of Coronavirus Disease 2019: A Systematic Literature Review and Case Report

BACKGROUND

There is a significant prevalence of new onset neuropsychiatric symptoms (NPS), some severe and persistent, in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE

This study reports on the use of electroconvulsive therapy (ECT) to treat NPS associated with COVID-19.

METHODS

A review of the literature pertaining to the use of ECT in patients with COVID-19 and NPS was performed through PubMed, PsycINFO, and MEDLINE. Search terms included "Electroconvulsive Therapy" and "ECT," combined with "COVID-19" and "Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2)." In addition, we present a case in which ECT was used to achieve complete remission in a patient who developed new onset, treatment-resistant depression, psychosis, and catatonia, associated with COVID-19.

RESULTS

A total of 67 articles were reviewed with 3 selected for inclusion. These articles detailed 3 case reports of patients with new onset NPS (mania, psychosis and suicidality, and catatonia) that developed in the context of active COVID-19 and were treated successfully with ECT.

CONCLUSIONS

ECT, a broad-spectrum treatment that has been found to be effective in various NPS (independent of etiology), is shown in our case report and others, to be safe and effective for NPS associated with COVID-19. Although we identified only 3 other cases in the literature, we believe that the probable antiinflammatory mechanism of ECT, its safety and tolerability, and the faster time to symptom remission support the need for more research and increased clinician awareness about this life-saving procedure.

A case of catatonia in the aftermath of the COVID-19 pandemic: does autism spectrum matter?

BACKGROUND

There is growing concern about the psychopathological consequences of the COVID-19 pandemic. The prolonged stress due to the spreading fear of the contagion and to the enforced containment measures are deemed to trigger recurrences of preexisting mental disorders as well as the onset of new ones. From such perspective, clinical cases may be of primary ground to identify individual features and pandemic-related factors predisposing to the development of serious psychiatric symptoms.

CASE PRESENTATION

Mr. R. is a 64-year-old, married, unemployed man, whose premorbid personality was characterized by relevant autistic traits. The patient developed catatonia in the context of the COVID-19 pandemic. We aimed at discussing the role of both preexisting and precipitating factors.

CONCLUSIONS

Autism spectrum could represent a predisposing factor for severe psychopathological outcome and catatonia. Furthermore, the present clinical case highlights the role of COVID-19 pandemic in influencing physical and mental health.

New-Onset Catatonia and Delirium in a COVID-Positive Patient

Coronavirus disease (COVID-19) is a strain of coronavirus family, which was initially found in China in late 2019 and subsequently spread to rest of the world. COVID-19 has led to physical and mental health complications since its onset. In addition to the pandemic-associated social stresses, biological complications include direct viral encephalitis, autoimmune-mediated responses, medication side effects, hypoxic brain injury, and delirium, which can collectively cause varied presentations of neuropsychiatric symptoms. Neuropsychiatric complications have been reported in the acute stages of COVID-19 and post-infection period. Here we report our experience treating a patient who initially presented with a severe depressive episode and subsequently developed catatonia and delirium following hospital-acquired COVID-19 infection.

Clinical case of catatonic stupor developed as a result of acute respiratory disease COVID-19

The aim of this work is to demonstrate and analyze a clinical case of catatonic stupor as a consequence of the complex effect of the infectious process, namely systemic inflammation and direct neurotoxicity of the SARS-CoV-2 virus on the nervous system. A retrospective analysis of outpatient and inpatient medical records was performed. . Analysis of clinical case proves the possibility of catatonic syndrome due to acute respiratory disease COVID-19. 2. Given that catatonia is an urgent condition, it is necessary to be vigilant about its occurrence