Abstract
In describing a 32-year-old man who developed an episode of ‘confusional psychosis’, Mendhekar and colleagues [1] characterize their patient as an example of cycloid psychosis. However, the presence of catatonic symptoms may have been overlooked.
The patient had an episodic psychotic disorder and ‘slowly improved with supportive care’ over several months. It is not stated what supportive care entailed. As well as hallucinations and delusions, the vignette suggests that the patient had speech and motor symptoms consistent with catatonia.
Catatonia is a syndrome characterized by motor signs (posturing, catalepsy, rigidity); psychosocial withdrawal (mutism, staring, negativism) or excitement (impulsiveness, combativeness, nudism); and bizarre repetitious behaviour (grimacing, stereotypies, mannerisms, echolalia, command automatism, echopraxia) [2].
It has recently been proposed that, in the absence of immobility, the presence of two other catatonic symptoms are required for a diagnosis of the catatonic syndrome [3]. The patient's catatonic symptoms, as described, were stereotyped movements, echolalia and perseverative speech.
Catatonia may be due to psychiatric, medical, neurological, and iatrogenic causes [2]. The presence of catatonic symptoms, irrespective of the underlying aetiology, has significant treatment implications. Seventy percent of patients respond to benzodiazepines and in the remainder, ECT should be seriously considered [4].
Mendhekar's patient had a recurrent, relapsing illness, being ill for several months and was likely to experience future relapses of a similar nature. To be ill with a severe mental illness several months each year is a major disruption to a person's life, as well as for carers. Specific treatment with benzodiazepines may reduce the severity of future relapses, in particular the speech and motor abnormalities. ECT may have also been helpful for both the catatonic symptoms and the hallucinations and delusions.
Catatonic symptoms are more common than many clinicians believe and are often overlooked in acute general adult psychiatry wards [5]. As a result, many patients miss out on the appropriate treatment. Fink and Taylor [3] believe that the most effective way to achieve a better treatment algorithm for patients with catatonia is to place catatonia into a distinct diagnostic category in psychiatric classification systems.