Electroconvulsive therapy management in benzodiazepine-resistant catatonic syndrome: A Case report

Catatonia is a rare but potentially lethal neuropsychiatric syndrome. Despite its historical association with schizophrenic disorders, it is more frequent in affective ones, and is currently considered an independent pathological entity. The basis of the treatment, regardless of the cause, is the use of benzodiazepines and electroconvulsive therapy (ECT), without a clear consensus on the combined treatment. Regarding ECT, the frequency and number of effective sessions has not been clearly established. Therefore, clinical evolution is the main factor to be considered in order to determinate the appropriate treatment regimen, although the daily application of ECT is preferred, at least for the first week. We report the case of a 41-year-old patient with paranoid schizophrenia, who presented with a benzodiazepine resistant catatonic syndrome. The clinical picture included stupor, mutism, negativism, severe stiffness, catalepsy, waxy flexibility and diaphoresis, with slight CPK increase but with no other extrapyramidal symptoms, fever more than 39 and hemodynamic instability, which allowed to exclude a neuroleptic malignant syndrome. A blood analysis, lumbar puncture, CT, EEG and viral serologies were performed with inconclusive results. The patient required ICU admission and ECT treatment and we used the Bush-Francis Catatonia Rating Scale to evaluate the evolution of symptoms. Six daily treatments with ECT led to an almost full recovery of the patient. Further case series regarding the clinical management of this syndrome are needed, in order to reach consensus on an effective ECT regimen.