Behaviour Changes with Autonomic Disturbances – Malignant Catatonia? a Case Report and Literature Review

Catatonia is a syndrome which has been reported in between 5-20% of acute psychiatric inpatients, but it often goes unrecognised. The recognition of catatonia is important as its features can overlap with those of delirium and psychosis, conditions which are treated with antipsychotics which can exacerbate catatonia. Malignant catatonia is a life-threatening subtype in which fever and autonomic disturbances can be present. This report describes a patient with an uncommon presentation of catatonia with some features of the malignant subtype. A 52-year-old lady presented with a 4 day history of change in behaviour which included refusal to speak, staring, restlessness, and disorganised behaviour. Signs demonstrated included mutism, stupor, negativism, and possible catalepsy and stereotypy. She had persistent fever with an elevated and labile blood pressure needing alpha-blockade with prazosin for management. An extensive workup did not yield any organic cause for her presentation. She was treated initially with lorazepam, and made a significant but temporary improvement. Psychotic features and anxiety later emerged, and olanzapine and escitalopram were added. 2 months after discharge, the patient had made a complete recovery. Olanzapine and prazosin were gradually discontinued. 6 months after discharge, she was being maintained on low doses of escitalopram and amlodipine with no recurrence of either hypertension or psychiatric symptoms. The clinical impression is that this patient suffered an episode of malignant catatonia, possibly due to a brief psychotic episode. The autonomic disturbances have resolved together with the catatonia and psychosis.