A 24-year-old male is admitted to our clinic presenting a behavioral trouble described by his parents as a disorganized speech, disorientation, and memory deficits during the last few days. His medical examination at the ECU does not reveal any organic abnormalities, with the exception of a mild leukocytosis (total WBC count: 13.380) without an infection outbreak.
His medical history includes a meningoencephalitis of unknown origins at the age of 3 weeks and a diagnosis of an attention deficit hyperactivity disorder (ADHD) at the age of 9, treated with methylphenidate (40 mg per day). He experienced difficulties at school; he is described as having always been slightly intellectually inferior to his peers, with a hyperactive behavior. At the age of 20, after he got his certificate of commercial apprenticeship, the methylphenidate was stopped, but had to be reintroduced because of a "strange, impulsive behavior, marked by aggressiveness and excessive anger, where it was difficult for him to express himself," according to his parents. He is not a smoker, nor does he use other psychotropic substances, and he is not known by the psychiatric services. He does not work, lives with his parents, and has a poor social life. He has never taken any antipsychotic treatment in his life.
Upon admission, we can observe a calm, distant, excessively cooperative patient with a nonspontaneous speech, with a prolonged latency in his answers and a poor production. Nonetheless, it is mostly comprehensible and coherent. The mood is labile, passing quickly from laughs to tears to anger, often inappropriate and out of context of the discussion. His thought process is characterized by poverty of production and a content marked by somatic delusions (that his organs do not work properly). He describes auditory hallucinations: different voices shouting at the same time or talking about him. The next day, he presents an episode of agitation and is withheld in therapeutic isolation.
After the first evaluation, given his clinical status, we stop the methylphenidate and introduce an antipsychotic treatment of olanzapine 20 mg/day, and given that after five days we do not get any positive evolution, we add amisulpride at 400 mg/day, as the psychotic symptoms and especially hallucinations are predominant in his clinical state. During the next few days, he develops rigidity, posturing, waxy flexibility, withdrawal from food and water, a repetitive speech, and automatic obedience. The Bush scale of catatonia score was 23, corresponding to a severe catatonia.
We diagnose a catatonic syndrome probably caused by a psychotic disease, and as a result, we discontinue all antipsychotic treatment. We reintroduce methylphenidate, as according to some studies it has a role in catatonia treatment and also lorazepam at 4 mg/day at the beginning, augmenting the dose until 10 mg/day, with a very poor response. We also schedule a brain MRI.
In the meantime, he is transferred to the ECU with an edema of the right leg with no pain or erythema and a body temperature of 37.8 C. A deep vein thrombosis and a right pneumonia are diagnosed, and he receives an antithrombotic and an antibiotic treatment. The brain MRI does not reveal any organic troubles. During his stay in the medical department, we gradually reduce the lorazepam treatment.
When he returns to the psychiatric department, after a thorough blood control and an ECG, we discontinue progressively lorazepam and introduce clozapine until the dose of 250 mg/day, following a classical titration, with a rapid and significant improvement of the catatonic symptoms after a few days. Soon, he eats and drinks normally, the motor disturbances disappear, and he is able to form spontaneous phrases from start to end. After two weeks, the CGI improvement scale (CGI-I) is at two; after three weeks, it lowers to 1 (very much improved). We also add mirtazapine (until 30 mg/day) to potentialize the effects of the clozapine. The regular blood tests and ECGs show a good tolerance to the treatment. He is discharged with a treatment of clozapine, mirtazapine, and methylphenidate at the usual doses.
One month after discharge from hospital, our patient returns to his usual state: he told us that the auditory hallucinations were present since his adolescence and that they consisted of several voices talking among them or talking about him, so we can confirm the presence of the first rank of criteria for schizophrenia. The Bush catatonia rating scale score is down to 3/69.