catatonia was first described by kahlbaum in 1874 , as a brain disorder , which has cyclic , alternating and progressive course . over the years
, understanding about catatonia has increased and it is now well - known that besides the primary psychiatric disorders , catatonia is associated with many neurological and medical disorders .
catatonia in adolescents has been reported to be associated with affective , psychotic , autistic , developmental , drug induced and medical conditions .
further , as in adults , catatonia in children and adolescents also responds to benzodiazepines and electroconvulsive therapy ( ect ) .
however , the literature on the use of ect in adolescents with catatonia is limited . in this case report , we present a case of catatonic schizophrenia , treated with ect and review the literature on the use of ect in adolescent catatonia .
a 16-year - old single girl presented with an insidious onset illness of 3 year duration . for the initial 1 year , the symptoms were characterized by fearfulness , anxiety , derealization and poor academic performance . during the 2 and 3 years of symptomatic phase
, she developed additional symptoms of social withdrawal , poor initiative , irritability , muttering and gesturing in air , suspiciousness , delusions of reference and persecution and delusion of misidentification , poor self - care and stopped studying . about a month prior to presentation to our center , her speech output started reducing ,
she had perseveration and later became mute , had marked psychomotor retardation , ambitendency , active and passive negativism , posturing and refusal to eat .
she was taken to a psychiatrist for her symptoms and was given intravenous lorazepam up to 8 mg / day along with risperidone up to 4 mg / day , but did not show any improvement . following this ,
there was no history suggestive of other delusions , hallucinations in any other modality , made phenomenon , somatic passivity , delusional perception , depressive symptoms , manic symptoms , head injury , fits , loss of consciousness , fever , substance use and thyroid dysfunction .
patient was found to have immobility , posturing , withdrawal , gegenhalten , mutism , negativism , staring and drooling of saliva .
her bush - francis catatonia rating scale ( bfcrs ) score was 20 . in view of her symptomatology
, she was admitted to the in - patient unit of the hospital . on investigation ,
hemogram , liver function test , renal function test , serum electrolytes , thyroid function test , ultrasound abdomen , computerized tomography of brain , x - ray chest ( posterior anterior view ) and electrocardiogram did not reveal any abnormality .
on the basis of the history and mental status examination , a diagnosis of catatonic schizophrenia was considered .
she was initially treated with injection lorazepam 4 mg every 6 h for initial 24 h along with tablet olanzapine 7.5 mg / day but did not show any improvement . following this ,
her parents were educated about the electroconvulsive therapy procedure and the indications for the same in patient .
attempt was also made to take patient 's assent before initiating ects , but could not be done considering her condition .
she was administered nine ects ( details shown in table-1 ) over the period of 3 weeks and dose of olanzapine was increased to 15 mg / day . with this treatment , gradually she showed improvement in all her symptoms .
as her clinical condition improved , her assent was sought for subsequent ects . during this period ,
assessment for memory impairment was also undertaken following each ect , but patient did not have any subjective complaints or objective signs of memory impairment . by her ninth ect ,
her bfcrs score came down from 20 to 2 and following this , no more ects were given in view of a plateau of clinical response .
on mental status examination , she only had blunted affect with no other active psychopathology at the end of the course of ect .
it is recommended that catatonia should be managed with high doses of benzodiazepines ( i.e. , lorazepam or other benzodiazepines ) or ect , in addition to the treatment of underlying medical and psychiatric disorder with specific treatment .
however , the literature with regard to the use of ect in adolescents is limited . in a review of
the published literature from 1985 to 2009 , the authors located 31 reports , which described 59 cases of catatonia in children and adolescents treated with ect . majority of the patients described in the literature who were treated with ect were males ( 57% ) .
the age range of patients varied from 6 to 19 years with only three patients less than 11 years of age .
most of the cases were diagnosed with mood disorders ( 47.5% ) and this was followed by schizophrenia ( 27.1% ) , pervasive developmental disorder ( 13.5% ) , organic catatonia ( 5% ) , psychotic disorders other than schizophrenia ( 5% ) and one case ( 1.7% ) each of idiopathic catatonia and familial catatonia with seizures . in terms of response to ect , the data suggested that 45 patients ( 76.27% ) had a favorable response , 3 ( 5% ) cases had a partial response and in one case there was no response to ect .
the authors cautioned that while interpreting the efficacy data it is important to remember that there may a potential bias for reporting only those cases , which show improvement with ect . in another review , authors noted that bilateral ( bitemporal or bifrontal ) ect has better efficacy than the unilateral ect .
further , it is suggested that if a patient responds partially to lorazepam it should be used concurrently with ect for a better outcome in the acute management of catatonia .
we carried out a search in pubmed and could locate 10 reports of use of ect in adolescents with catatonia published after the review of consoli et al .
eight out of the 10 reports , described 11 cases in which ect was used in adolescents for treatment of catatonia in patients with varied clinical conditions [ table 2 ] .
one case series described the use of maintenance ect in three children with autism , in which ect had led to resolution of acute symptoms of catatonia . in the retrospective study from our center , which described the use of ect in adolescents , out of the 25 patients , 17 had catatonic symptoms and the response rate in patients with catatonia was 91.6% .
the present case adds to the limited data , which is available and shows that use of ect can be life - saving in adolescents with severe mental disorders .
case reports / case series of use of electroconvulsive therapy in adolescents published after consoli et al .
review from the above review , it can be concluded that ect is an effective treatment for management of catatonia in adolescents . in view of the same , rather than banning the use of ect in adolescents
, it would be better to leave the decision to use and not to use ect in adolescents in the hands of the clinicians .
 there is lot of skepticism about the use of electroconvulsive therapy ( ect ) in children and adolescents . 
 however , available literature suggests that use of ect can be at times life - saving in adolescents , especially those presenting with severe catatonia . 
 we treated a 16-year - old female who presented to us with catatonia with a course of nine ects , with which she showed marked improvement . 
 review of the literature suggests that ect should be considered as the second line treatment in the management of catatonia in adolescents . 
INTRODUCTION
CASE REPORT
DISCUSSION