Abstract
We wish to report a patient with an extreme state of recurring, flaccid catatonia whose presentation was indistinguishable from coma.
Y. was a 24-year-old single male, living with his parents and enrolled in a Ph.D. program in computer science. Over 8 weeks he was admitted three times in an unresponsive state. In the days preceding each admission he had become more retarded. On each occasion he presented as if completely unconscious, flaccid, with no spontaneous movement and with no response to painful stimuli. He was not incontinent but was catheterised at each admission after failing to pass urine. A 4-month history of social withdrawal, loss of motivation, decreased activity and loss of spontaneity was elicited. He was not abusing substances and denied psychotic or affective symptoms. He did not satisfy even sub-threshold diagnostic criteria for either schizophrenia or major depression. Three years previously there had been an episode, lasting several months, of paranoid ideas, associated with mild marijuana abuse, that resolved spontaneously.
No abnormalities were detected on physical examination. Throughout each episode the Glasgow Coma Score ranged from 3 to 6. All investigations, including computerised tomography, electroencephalogram and magnetic resonance imaging were normal.
Three courses of two, two and four electroconvulsive therapies respectively were administered with good response. After the initial course he claimed to have full retrospective memory. With subsequent treatments, however, he remembered less on each occasion. There was minimal loosening of associations when observed after recovery from the acute phase and he had a weakly held belief that he may have been drugged.
Catatonia was diagnosed by three of the five consultant psychiatrists involved in his management. However, not only was muscle tone flaccid, at no stage did he exhibit any other signs of catatonia. Nor did he satisfy the requirement for apparent consciousness [1,2]. His low score on the Glasgow coma scale shows how well his behaviour matched that of the comatose patient. However, clinicians feel uncomfortable using the word ‘coma’ to describe functionally determined behaviour, even though it may be indistinguishable from coma of organic origin.
The failure of this type of presentation to correspond to standard descriptive psychopathological definitions highlights a gap in the current range of descriptive terminology. We suggest that the term ‘comatoid catatonia’ effectively conveys the essence of the clinical picture and communicates this patient's presentation when the use of existing descriptive terms [3] would have been misleading.