Abstract
Catatonia is manifested by any of the following features: motoric immobility or excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia, or echopraxia [1]. Catatonia may be associated with affective disorders, schizophrenia, and a variety of neurological and general medical conditions [2], including benzodiazepine withdrawal [3,4]. We report a case of catatonia associated with acute temazepam withdrawal, the first such case to be reported to our knowledge.
A 73 year old woman with no prior history of psychiatric illness was admitted to a general hospital with an infective exacerbation of her chronic obstructive pulmonary disease. On the fourth day of her admission she was discovered to be in an acute catatonic state: mute and immobile in her bed, lying in the posture of an entombed soldier with her arms crossed over her chest and her eyes squeezed shut. There was no deterioration in her physical parameters. The patient also experienced periods of extreme agitation, walking with a stooped posture and a shuffling gait, and remained mostly mute with occasional incomprehensible speech or echolalia.
On reviewing potential causes of her catatonic symptoms, it was noted that she had been taking temazepam regularly at 40 mg a day for the last 40 years, and that her dose had been reduced to 20 mg on admission. It had not been administered 24 hours before the deterioration and the patient had subsequently refused all oral medications. As there were no other likely causes of her deterioration, a preliminary diagnosis of catatonia due to benzodiazepine withdrawal was made. An initial dose of 2.5 mg of midazolam was given intramuscularly as the patient continued to refuse oral medication. This resulted in a rapid improvement and the oral temazepam was re-initiated, with a full recovery to her premorbid coherent state. She did not experience any return of the symptoms.
We believe this patient had a rare adverse reaction of catatonia related to the sudden suspension of her usual benzodiazepine medication. The patient had multiple risk factors for severe benzodiazepine withdrawal: prolonged, high dose usage of a short acting benzodiazepine [5], as well as being elderly and medically unwell. Interestingly, benzodiazepines are commonly used in the management of catatonia [2].
Benzodiazepines are commonly prescribed in Australia, particularly in the elderly and those with a chronic medical condition [6]. Many of these patients do not appear to have an anxiety or affective disorder. With the increasing documentation of the adverse effects of the long term use of benzodiazepines in the elderly, extreme care needs to be taken in the use of these medications and how they may be withdrawn when considered unnecessary [5]. In general, gradual reduction of the patient's dose is recommended in an ambulatory setting, with the agreement of both the patient and their treating doctor [5], with psychological support for emergent symptoms of insomnia and anxiety.