CASE Agitation and bizarre behavior
Ms. L, age 40, presents to the emergency department (ED) for altered mental status and bizarre behavior. Before arriving at the ED, she had experienced a severe headache and an episode of vomiting. At home she had been irritable and agitated, repetitively dressing and undressing, urinating outside the toilet, and opening and closing water faucets in the house. She also had stopped eating and drinking. Ms. L’s home medications consist of levothyroxine 100 mcg/d for hypothyroidism.
In the ED, Ms. L has severe psychomotor agitation. She is restless and displays purposeless repetitive movements with her hands. She is mostly mute, but does groan at times.
HISTORY Multiple trips to the ED
In addition to hypothyroidism, Ms. L has a history of migraines and asthma. Four days before presenting to the ED, she complained of a severe headache and generalized fatigue, with vomiting and nausea. Two days later, she presented to the ED at a different hospital and underwent a brain CT scan; the results were unremarkable. At that facility, a laboratory work-up—including complete blood count, urea, creatinine, C-reactive protein, electrolytes, magnesium, phosphorus, calcium, full liver function tests, amylase, lipase, bilirubin, thyroid function test, and beta-human chorionic gonadotropin—was normal except for low thyroid-stimulating hormone levels (0.016 mIU/L). Ms. L was diagnosed with a severe migraine attack and discharged home with instructions to follow up with her endocrinologist.
Ms. L has no previous psychiatric history. Her family’s psychiatric history includes depression with psychotic features (mother), depression (maternal aunt), and generalized anxiety disorder (mother’s maternal aunt).
The authors’ observations
Catatonia is a behavioral syndrome with heterogeneous signs and symptoms. According to DSM-5, the diagnosis is considered when a patient presents with ≥3 of the 12 signs outlined in Table 1.1 It usually occurs in the context of an underlying psychiatric disorder such as schizophrenia or depression, or a medical disorder such as CNS infection or encephalopathy due to metabolic causes.1 Ms. L exhibited mutism, negativism, mannerism, stereotypy, and agitation and thus met the criteria for a catatonia diagnosis.
EVALUATION Unexpected finding on physical exam
In the ED, Ms. L is hemodynamically stable. Her blood pressure is 140/80 mm Hg; heart rate is 103 beats per minute; oxygen saturation is 98%; respiratory rate is 14 breaths per minute; and temperature is 37.5° C. Results from a brain MRI and total body scan performed prior to admission are unremarkable.
Ms. L is admitted to the psychiatric ward under the care of neurology for a psychiatry consultation. For approximately 24 hours, she receives IV diazepam 5 mg every 8 hours (due to the unavailability of lorazepam) for management of her catatonic symptoms, and olanzapine 10 mg every 8 hours orally as needed for agitation. Collateral history rules out a current mood episode or onset of psychosis in the weeks before she came to the ED. Diazepam improves Ms. L’s psychomotor agitation, which allows the primary team an opportunity to examine her.
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