When the Bush-Francis and Lorazepam Just Aren't Enough: Engaging the Tension of Catatonia in Neurodevelopmental and Neurological Conditions

Several neurodevelopmental and neurological conditions should be on the differential as potential causes of catatonia. In fact, these conditions account for roughly two thirds of secondary catatonia. Despite this link between catatonia and neurological conditions, identifying catatonia in these conditions can be challenging due to the overlap of clinical features, especially motor findings. For instance, spasticity, tics, dystonia or other extrapyramidal symptoms are common in several neurological conditions. Whereas the Bush-Francis Catatonia Rating Scale recommends not scoring pre-existing neurological findings toward a diagnosis of catatonia, it is not always clear what features are pre-existing and which ones should qualify. Also, lorazepam is often sub-optimally effective in these populations.

Sponsored by the neuropsychiatry SIG, this session will explore catatonia in neurodevelopmental and neurological conditions across the lifespan. Presenters will provide an overview of a topic followed by clinical case presentations to illustrate key principles. To promote clinical application for attendees, Dr. Oldham will co-facilitate audience participation during case presentations. At the end of each case, Dr. Oldham will present pertinent statements from the British Association of Psychopharmacology Catatonia Guidelines [in press at Journal of Psychopharmacology at the time of this submission].

Introduction (10 min): Dr. Soin will introduce the session and discuss the challenges of diagnosing catatonia in neurodevelopmental and neurological disorders.

Neurodevelopmental conditions (Dr. Brahmbhatt)

Didactic (10 min): She will review the unique considerations for evaluating catatonia in children with neurodevelopmental disorders, with a focus on autism-spectrum disorders.

Facilitated case presentation (15 min): She will present a case of excited catatonia in a teenage boy with autism. She will highlight the importance of establishing a clear baseline for sensory motor symptoms and specifically mannerisms common to autism. Key discussion points will include the importance of having a high degree of suspicion and understanding the limitations of standard clinical criteria and rating scales in diagnosing catatonia in those with autism.

Acquired conditions (Dr. Kalra)

Didactic (10 min): She will focus on catatonia associated with anti-NMDAR encephalitis, stroke, non-convulsive seizure, and traumatic brain injury and review specific clinical signs that may aid in recognizing catatonia in the context of these conditions.

Facilitated case presentation (15 min): She will present a case of severe traumatic brain injury with delayed diagnosis of catatonia, highlighting common neurological manifestations in both conditions. Neurotransmitter dysfunction will be reviewed as a rationale for treatment. Key discussion points will include the limited generalizability of current catatonia treatment approaches to catatonia in acquired neurological conditions and the importance of keeping catatonia on the differential for these conditions.

Neurodegenerative and related conditions: (Dr. Sivaraman)

Didactic (10 min): She will review the symptomatic overlap of catatonia in neurodegenerative disorders, focusing on dementia, delirium, and Parkinson disease.
Facilitated case presentation (15 min): She will present two geriatric cases with catatonia in the context of delirium, one superimposed on a neurodegenerative disorder and the other with non-progressive neurological disorder, with different response to catatonia-specific treatments. Discussion will focus on open questions regarding tailored treatment to this population based on underlying etiopathology.