catatonic schizophrenia case study

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Introduction, case report, considerations.

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The Curious Case of a Catatonic Patient

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John H. Enterman, Dyllis van Dijk, The Curious Case of a Catatonic Patient, Schizophrenia Bulletin , Volume 37, Issue 2, March 2011, Pages 235–237, https://doi.org/10.1093/schbul/sbq110

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Catatonia is a syndrome characterized by the coexistence of psychiatric and motor symptoms. 1 It is associated with a wide range of psychiatric, medical, neurological, and drug-induced disorders. 2 The concept of catatonia was first described by the German psychiatrist Kahlbaum in 1874. 3 It is more frequently found among patients diagnosed with mania, depression, and neurotoxic syndromes than among those with schizophrenia. Yet, it is mainly classified as a form of schizophrenia. 4 The exact cause of catatonia has not been elucidated.

The syndrome of catatonia is defined by the objective presence of motor signs, over 40 of which have been described. These catatonic signs are listed in table 1 . There is no agreed threshold for the number or duration of symptoms that should be present to justify a diagnosis of catatonia. Research has suffered from this, and studies can rarely be compared with confidence. 7

Principal Features of Catatonia 5 , 6

There are consistent clinical reports that benzodiazepines are effective in acute catatonia syndromes, particularly stuporous conditions, but no placebo-controlled randomized studies have been published. 8 , 9 However, benzodiazepines are the drugs of choice for catatonia. 10 In most cases, lorazepam is administered parenterally or orally beginning with 3 mg/d and increasing rapidly to effective resolution. Dosages of 20–30 mg/d are occasionally necessary. 5 Patients who are unresponsive or insufficiently responsive to benzodiazepines need electroconvulsive therapy (ECT). 5 , 10

Patient A is a 28-year-old male of Mediterranean origin diagnosed with paranoid schizophrenia at the age of 23. He was hospitalized several times due to psychotic episodes characterized by religious delusions and auditory and visual hallucinations. He is living in an assisted living facility, where the medication is offered to the residents, but where they have to take it by themselves. He uses cannabis daily and does not use any other substances. Drug history mentions the use of risperidone and flupentixol decanoate, the latter since 2008 up to the present. At the end of 2008, he developed a progressive condition in which he showed less mimicry, staring, negativism, mutism, and immobility. There were no signs of autonomic dysregulation, such as increased body temperature or unstable blood pressure.

Because catatonia was assumed in April 2009, he was orally treated with lorazepam, starting at 2 mg a day. The lorazepam dose was increased based on the clinical state until 40 mg a day without any subjective or objective effects. He was admitted to the psychiatric ward to receive parenterally administered lorazepam up to 60 mg daily. After 2 days, there still was no measurable effect nor was there any effect on his consciousness. We resumed oral treatment with lorazepam 40 mgs daily and patient agreed to undergo ECT. During the lorazepam and ECT treatment, the patient continued to receive 30 mg of flupentixol decanoate every 2 weeks. After 3 ECT sessions (Mecta 5000, bilateral, 1 ms, 40 hz 2 s, 128 mC, 800 mA, [a relatively low, common, dosage]), the catatonic signs receded rapidly and patient refused to take the lorazepam, because “he was cured.” He soon afterward developed an acute catatonic state, in which he was found completely immobile next to his bed. He received lorazepam immediately and ECT the following days. After 2 more ECT sessions, the catatonic signs receded again. During the weeks afterward, patient received 40 mgs lorazepam daily, which was reduced and finally stopped on his demand.

A few months afterward, patient presented to the acute psychiatric service with signs of acute dystonia (cervical dystonia and dysphagia). He was treated with biperiden 2 mg and the dystonia almost immediately disappeared. Flupentixol decanoate dosage was lowered to 20 mgs every 2 weeks. Patient denied the use of any drugs except cannabis and urine examination confirmed this. After this episode, patient experienced several other episodes of dystonia, each time successfully treated with biperiden 2 mgs.

This case has many remarkable features. To begin with, the simple fact of a slowly progressive, during multiple months, catatonic state emerging elicited our curiosity. We could not relate it to a mood disorder nor to excessive cannabis use. Then again, the administration of doses of lorazepam up to 60 mg per day without any effects whatsoever seems remarkable, especially in the case of a young man not habituated to benzodiazepines. Of interest to those practicing ECT is the remarkable fact that the quality of the ECT did not suffer under the administration of high doses of benzodiazepines. We used the dosage titration method to determine the energy level needed for the ECT. We chose to temporarily halt the action of the lorazepam with the administration of 0.5 mg of flumazenil i.v. immediately prior to the ECT and achieved a therapeutically sufficient convulsion at a relatively low energy level. After 2 ECT sessions in this manner, we chose to try a treatment session without the use of flumazenil. This had no influence on the energy necessary for the ECT; on the contrary, we obtained a convulsion of the same length and electroencephalogram waveform as we did using the flumazenil, at precisely the same energy level. After the fifth treatment session, the patient did not return for further treatment sessions, in spite of his incomplete remission and in spite of his having been warned of the possibility of relapse. He was observed to be in worse condition in his home, but he himself seemed to be less distressed by his condition than his caregivers did, in spite of the many observations that catatonia is usually accompanied by anxiety. Because of the outpatient situation, there were limitations according to physical and blood examinations and the medication intake during the (acute) catatonic state of our patient. We have had our doubts of his acceptance of the benzodiazepines, but during his stay on the ward, the administration has been closely supervised by trained psychiatric nursing staff. Unfortunately, we did not determine a plasma level of benzodiazepines. Other laboratory results were unremarkable.

Should we consider other diagnoses than catatonia, and, if so, which? Perhaps a syndrome caused by cannabis consumption?

Does such a diagnosis explain the progression, over months, of the “catatonic-like” state?

How is the absence of an effect on the necessary ECT energy level by benzodiazepines to be explained?

How should we interpret the absence of distress?

Have we used the correct treatments or should we have had other considerations?

Submissions should be sent to the email address as listed in the author information. Any outcome will subsequently be published in this journal.

The Authors have declared that there are no conflicts of interest in relation to the subject of this study.

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

Brain Motor Region Diffusion Tensor Imaging in Patients with Catatonic Schizophrenia: A Case-Control Study

Affiliations.

• 1 Geha Mental Health Center, Petah Tikva, Israel.
• 2 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
• 3 Laboratory of Biological Psychiatry, Felsenstein Medical Research Center, Petah Tikva, Israel.
• 4 Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
• 5 Department of Diagnostic Imaging, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
• 6 Advanced Technology Center, Sheba Medical Center, Tel Hashomer, Israel.
• 7 Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel.
• PMID: 34672443

Background: Only a small proportion of schizophrenia patients present with catatonic symptoms. Imaging studies suggest that brain motor circuits are involved in the underlying pathology of catatonia. However, data about diffusivity dysregulation of these circuits in catatonic schizophrenia are scarce.

Objectives: To assess the involvement of brain motor circuits in schizophrenia patients with catatonia.

Methods: Diffusion tensor imaging (DTI) was used to measure white matter signals in selected brain regions linked to motor circuits. Relevant DTI data of seven catatonic schizophrenia patients were compared to those of seven non-catatonic schizophrenia patients, matched for sex, age, and education level.

Results: Significantly elevated fractional anisotropy values were found in the splenium of the corpus callosum, the right peduncle of the cerebellum, and the right internal capsule of the schizophrenia patients with catatonia compared to those without catatonia. This finding showed altered diffusivity in selected motor-related brain areas.

Conclusions: Catatonic schizophrenia is associated with dysregulation of the connectivity in specific motoric brain regions and corresponding circuits. Future DTI studies are needed to address the neural correlates of motor abnormalities in schizophrenia-related catatonia during the acute and remitted state of the illness to identify the specific pathophysiology of this disorder.

• Cerebellum / diagnostic imaging
• Cerebellum / physiopathology
• Connectome / methods
• Corpus Callosum / diagnostic imaging
• Corpus Callosum / physiopathology
• Correlation of Data
• Diagnostic and Statistical Manual of Mental Disorders
• Diffusion Tensor Imaging / methods*
• Internal Capsule / diagnostic imaging
• Internal Capsule / physiopathology
• Motor Cortex* / diagnostic imaging
• Motor Cortex* / physiopathology
• Psychiatric Status Rating Scales
• Schizophrenia, Catatonic* / diagnosis
• Schizophrenia, Catatonic* / physiopathology

• Case report
• Open access
• Published: 13 March 2018

A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy

• Yuanhan Bai 1 ,
• Xi Yang 1 ,
• Zhiqiang Zeng 1 &
• Haichen Yang 1  

BMC Psychiatry volume  18 , Article number:  67 ( 2018 ) Cite this article

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Ritualistic behaviors are common in obsessive compulsive disorder (OCD), while catatonic stupor occasionally occurs in psychotic or mood disorders. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms. The syndrome usually represents a specific diagnosis, as in the case of the 10th edition of the International Classification of Diseases (ICD-10) or the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, symptom-based diagnosis can result in misdiagnosis and hinder effective treatment. Few cases of ritualistic behaviors and catatonic stupor associated with schizoaffective disorder have been reported. Risperidone and modified electroconvulsive therapy (MECT) were effective in our case.

Case presentation

A 35-year-old man with schizoaffective disorder-depression was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled us to make the diagnosis of OCD. Sertraline add-on treatment exacerbated the psychotic symptoms, such as pressure of thoughts and delusion of control. In the presence of obvious psychotic symptoms and depression, schizoaffective disorder-depression was diagnosed according to ICD-10. Meanwhile, the patient unfortunately developed catatonic stupor and respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone were administered. As a result, we successfully cured the patient with the abovementioned treatment strategies. Eventually, the patient was diagnosed with schizoaffective disorder-depression with ritualistic behaviors and catatonia. Risperidone and MECT therapies were dramatically effective.

Making a differential diagnosis of mental disorders is a key step in treating disease. Sertraline was not recommended for treating schizoaffective disorder-depression according to our case because it could exacerbate positive symptoms. Controversy remains about whether antipsychotics should be administered for catatonic stupor. However, more case studies will be needed. Risperidone with MECT was beneficial for the patient in our case.

Peer Review reports

Diagnosis is the first step toward correctly curing disease. Unlike internal or surgical diseases, mental disorders are largely symptom-based diagnoses [ 1 , 2 ]. In the process of interviewing, syndromes are always associated with certain diagnoses according to the ICD-10 or DSM-5. Repetitive behaviors or ritualistic behaviors may be linked with OCD [ 3 ]. Immobility, mutism, negativism, and peculiar motor behavior represent catatonic stupor [ 1 , 2 ], which is a psychotic diagnosis because approximately 10–15% patients with catatonic stupor meet the criteria for schizophrenia [ 4 ]. Typical ritualistic behaviors and catatonic stupor may represent OCD and psychotic disorders, respectively. However, these patients are not “textbook” cases, which means that complex and complicated symptoms may lead to misdiagnosis. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms [ 5 ]. It is classified as “schizophrenia, schizotypal, and delusional disorders” by ICD-10 [ 1 ] and “schizophrenia spectrum and other psychotic disorders” by DSM-5 [ 2 ]. The complex symptomatology of schizoaffective disorder makes it highly likely that patients will be misdiagnosed.

Sertraline is a selective serotonin reuptake inhibitor [ 6 ] that is used to treat depression and OCD [ 7 ]. Previous studies have summarized the effective use of antidepressants in schizoaffective disorder [ 8 ]. However, the risk of exacerbation of positive symptoms of antidepressants should be considered [ 9 , 10 , 11 ]. A review of the treatments for catatonia has shown that MECT is effective, while antipsychotics remain controversial [ 12 ]. On the other hand, Huang et al. published other papers suggesting that the Lorazepam-Diazepam protocol can rapidly and safely relieve catatonia in schizophrenia, mood disorder, and organic lesions [ 13 , 14 , 15 ].

In this paper, we present the case of a patient who was initially suspected of having OCD but who actually suffered from schizoaffective disorder-depression with ritualistic behaviors and catatonic stupor. Sertraline exacerbated the psychotic symptoms. The ritualistic behaviors that were actually secondary to psychotic symptoms may have prevented us from making an accurate diagnosis. Finally, risperidone and MECT were effective strategies for this patient.

The patient was a 35-year-old male. He was apparently normal before the age of 27 years without any medical problems. He was intellectually normal and worked as a security guard. He was never married and had no children, often living with his older sister. He had been smoking for approximately 10 years or more, denying alcohol or other psychoactive substance abuse. He is the third child, with one older brother and one older sister. His father often became drunk and violent, going outside for no reason, and committed suicide many years ago. There were no detailed records for his father because he failed to see a doctor.

In 2009, the patient gradually became depressive; showed diminished pleasure, insomnia, and fatigue; and was unwilling to talk to others. Meanwhile, he developed delusions of persecution and reference, which made him believe that someone had insulted him and planned to kill him without evidence. Later, he came to the outpatient clinic of our hospital and was prescribed paroxetine 20 mg/d and sulpiride 0.2 g/d. He took these drugs irregularly, with minimal improvement in depressive symptoms and delusions. In August 2013, the patient was sent to the hospital for schizoaffective disorder-depression. During the following month, with quetiapine 600 mg/d and lithium carbonate sustained-release tablet 0.6 g/d, his depressive and positive symptoms improved. Taking these drugs, he almost enjoyed normal life and work. Unfortunately, he discontinued these medications in May 2017. Again, the patient gradually developed fear of the sound of water, a lack of any pleasure and negative ideas, and claimed that he could not trust anyone. Furthermore, the patient performed ritualistic behaviors, such as walking with a specific order. Once again, he was sent to our hospital by his older sister. At the time of admission, the patient presented depressive symptoms as well as ritualistic behaviors and distrust.

Upon admission, liver and kidney function, routine blood test, computed tomography (CT) of the head, and electrocardiograph (ECG) were normal. Depressive symptoms, delusions, and ritualistic behaviors were found upon psychiatric interview. By day 9 in the hospital, we followed outpatient therapeutic strategies with quetiapine 100 mg/d and lithium carbonate sustained-release tablet 0.6 g/d, observing that the depressive symptoms and distrust had moderately improved. However, the ritualistic behaviors gradually worsened. Before waking up, he would swing his arms up and down four times, did sit-ups four or five times, and sat at the edge of the bed for a few minutes, all of which took him approximately 8 min. These disturbed or interrupted behaviors made the patient anxious. Because of the predominant ritualistic behaviors, OCD was suspected first. Here, we wanted to reduce these behaviors by adding sertraline at a dose of 50 mg/d and titrating it to 100 mg/d.

Then, the symptoms further worsened, and the patient developed agitation, pressure of thoughts, and delusion of control. He felt that his ritualistic behaviors gradually became out of control, realizing that “unknown thoughts” and “a black shadow” affected his mind. Meanwhile, he felt sad, and there was nothing that brought him pleasure. Considering the clinical picture and depressive and psychotic symptoms with equal importance, the diagnosis of schizoaffective disorder-depression was eventually made according to the ICD-10. Sertraline 100 mg/d was immediately ceased. We planned to change the ineffective quetiapine to risperidone, which was more effective on positive symptoms according to our own clinical experiences when the patient developed catatonia. Mutism, posturing, nonverbal communication, hyper-myotonia of the limbs, and saliva collected in the mouth were observed. Redness and swelling of the pharynx and hyperthermia (38 °C) were present. Routine blood tests showed that the white blood cell (WBC) count was 12.85 × 10 9 /L (normal range 3.5–9.5 × 10 9 /L), and the neutrophil granulocyte (NEUT) count was 10.6 × 10 9 /L (normal range 1.8–6.3 × 10 9 /L). Chest computed tomography indicated a high-density streak like a shadow in the lower lobe of the left lung, which was clear at admission. After the case discussion, we decided to initiate risperidone at a dose of 1 mg/d and gradually titrate it to 4 mg/d to control the positive symptoms. A twice-daily intravenous injection of ceftriaxone 1 g in 250 mL 0.9% physiological saline was administered to treat the respiratory infection. Meanwhile, MECT was added three times a week to ameliorate the catatonia. MECT was administered with the SPECTRUM-5000Q device used in the bilateral mode. The treatment parameters included frequency (30 Hz), stimulus duration (2.5 s), electric charge (120 Mc), energy (21.1 J), and constant current (800 mA). Vital signs were stable; specifically, body temperature was not over 37.2 °C before starting MECT in this patient. Before and during the MECT, anesthesia was induced with etomidate 10 mg and muscle relaxation with succinylcholine 50 mg, while arterial oxygen saturation, heart rate, and electrocardiogram were continuously monitored. Each time, the patient experienced adequate generalized seizures measured with an electroencephalogram. The patient was ventilated with 100% oxygen until the resumption of spontaneous respiration.

On hospital day 23, inflammation of the pharynx disappeared, and normal WBC and NEUT counts suggested that the respiratory infection had been clinically cured. Ceftriaxone was ceased when we found negative blood bacterial culture results. We continued risperidone and MECT (a total of nine times) treatments. The patient gradually began to talk with doctors and other patients, joining some activities in the ward. The pressure of thoughts and delusion of control almost disappeared. Furthermore, it took him less and less time to perform the ritualistic behaviors. On hospital day 31, we stopped MECT and added lithium carbonate sustained-release tablets 0.6 g/d. Oral risperidone 4 mg/d was introduced, in which the blood concentration was 8.7 μg/L (normal range 2–60 μg/L). No obvious side effects were observed. Finally, we titrated the lithium carbonate sustained-release tablets to 0.9 g/d and maintained risperidone 4 mg/d. The patient remained normopyretic, and his psychotic and depressive symptoms were stable. We told the patient to review and check the blood lithium carbonate concentration 1 week later in the outpatient setting.

For the publication of this case report, written informed consent was obtained from the patient and his older sister.

Here, we describe a case of schizoaffective disorder-depression with ritualistic behaviors and catatonia. After admission, we suspected a diagnosis of OCD because of the dominance of ritualistic behaviors and depression, as the patient reported that the ritualistic behaviors must be performed or else he would feel sad. The ritualistic behaviors proved to be secondary to delusion of control. The patient’s insomnia, fatigue, and unwillingness to talk to others were not explained by the ritualistic behaviors. Ultimately, we made a diagnosis of schizoaffective disorder-depression. The symptom-based diagnostic criteria [ 1 , 2 ] as well as the multivariate symptoms made diagnosis and treatment difficult. Our case suggests that time, patience, and detailed observation are essential factors for making clinical decisions.

Selective Serotonin Reuptake Inhibitors (SSRIs) are beneficial for depression and OCD [ 6 ], among which sertraline is an effective therapeutic strategy [ 7 ]. In early studies and guidelines, psychiatrists were concerned about the risk of exacerbating psychosis when prescribing antidepressants to schizophrenic patients [ 9 , 10 , 11 ]. Rebecca Schennach et al. identified the exacerbation of positive symptoms in patients with antidepressant augmentation compared with patients without any antidepressants during the course of the study, and patients with antidepressant add-on treatment suffered from more severe psychopathological symptoms and greater psychosocial impairments at discharge [ 16 ]. However, a recent review does not support these points, as no studies found that add-on antidepressants worsened positive symptoms [ 17 ]. Although many studies have described the use of antidepressants in schizophrenia with depression, controversies remain about whether to administer antidepressants for schizophrenia spectrum disorders. We suggest that therapeutic strategies for schizoaffective disorder-depression might not include additional antidepressants, for sertraline may have exacerbated positive symptoms in our case.

Catatonia is a neuropsychiatric syndrome with psychomotor inhibition that occurs in approximately 8% of patients admitted for mental disorders, such as schizophrenia or mood disorders [ 18 ]. Schizophrenia and other psychotic spectrum disorders are more commonly presented as catatonia than mood disorders [ 19 ]. Catatonic stupor is a psychiatric emergency due to a broad range of complications [ 20 , 21 ]. Neuroleptic malignant syndrome (NMS) typically presents with fever, muscle rigidity, and altered mental status [ 22 ] and should be differentiated from catatonic stupor complicated by respiratory infection. In this case, the clear consciousness of the patient with psychomotor inhibition, redness and swelling of the pharynx, fever without muscle rigidity, increased WBC and NEUT counts, and a high-density streak of shadowing in the lower lobe of left lung in the chest X-ray at admission suggested a status of catatonic stupor complicated by respiratory infection. Therefore, our case describes schizoaffective disorder-depression with catatonic stupor complicated by respiratory infection. Controlling the infection and improving the catatonic stupor were important in treating this patient. Three treatment strategies were employed in this case. Supportive measures included high-level nursing care, intravenous fluids, and gastrointestinal support to reduce the risk of bedsores and deep vein thrombosis caused by immobility and to improve poor nutrition and dehydration. Antibiotic treatment was considered due to the redness and swelling of the pharynx, hyperthermia, increased WBC and NEUT counts, and abnormal chest X-ray. These symptoms successfully responded to the administration of 7 days of ceftriaxone. MECT was an effective strategy for improving catatonic stupor [ 23 , 24 ]. Although benzodiazepines proved to rapidly and effectively relieve catatonia, we did not prescribe these kinds of medications for the patient considering his poor nutrition, respiratory infection, and risk of respiratory inhibition. However, the role of antipsychotics in the treatment of catatonia is controversial. Several authors have suggested that antipsychotics may exacerbate the catatonic state and increase the risk of NMS [ 25 , 26 ]. Studies have found that second-generation antipsychotics (SGAs) have weak γ-aminobutyric acid (GABA)-agonist activity and 5-hydroxytryptamine 2 (5-HT 2 )-antagonism that could stimulate dopamine release in the prefrontal cortex and thus alleviate catatonic symptoms [ 20 ]. Several articles have suggested a beneficial effect of risperidone [ 27 , 28 ]. A case report identified MECT together with olanzapine, which resulted in improvement of catatonic stupor [ 29 ]. Given the results of the abovementioned studies, risperidone was cautiously administered at a low dose (2 mg/d). Once catatonic stupor improved and MECT came to a stop, risperidone would be titrated from 2 to 4 mg/d to target residual psychotic symptoms, such as the pressure of thoughts and delusion of control. Furthermore, lithium carbonate is also an effective strategy for patients with schizoaffective disorder, as it can reduce the rate of re-hospitalization [ 30 ].

Here, we describe a case of schizoaffective disorder-depression with secondary ritualistic behaviors complicated by catatonic stupor, which induces respiratory infection. Sertraline might not be recommended in patients with schizoaffective disorder to improve depression, which could have exacerbated the positive symptoms in our case. Supportive measures have an important role in the treatment of catatonic stupor. Once again, MECT has been shown to improve catatonic stupor. Although there is controversy over whether antipsychotics should be administered in the catatonic status, we considered risperidone to be beneficial in our case. Further studies should focus on the effectiveness and safety of antipsychotics associated with MECT in patients with catatonia.

Abbreviations

5-hydroxytryptamine 2

Computed tomography

5th edition of Diagnostic and Statistical Manual of Mental Disorders

Electrocardiograph

γ-aminobutyric acid

10th edition of International Classification of Diseases

• Modified electroconvulsive therapy

Neutrophil granulocyte

Neuroleptic malignant syndrome

Obsessive compulsive disorder

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Acknowledgements

We would like to thank the patient and his older sister for their collaboration.

This case report was partially supported by the Sanming Project of Medicine in Shenzhen (Grand No. SZSM201612006). The funding agency had no role in this case report; analysis or interpretation of data; or the preparation, review, or approval of the manuscript. We received no support from any pharmaceutical company or other industry.

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The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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YHB and XY were involved in the management of the patient. ZQZ and HCY were the primary clinicians involved in the assessment, management, and follow-up of the patient. The article was written by YHB. YHB, XY, ZQZ, and HCY provided final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.

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Bai, Y., Yang, X., Zeng, Z. et al. A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC Psychiatry 18 , 67 (2018). https://doi.org/10.1186/s12888-018-1655-5

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A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy

Yuanhan bai.

Department of Affective Disorder, Shenzhen Kangning Hospital, Cuizhu Road, Luohu District, Shenzhen, 518020 China

Zhiqiang Zeng

Haichen yang, associated data.

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Ritualistic behaviors are common in obsessive compulsive disorder (OCD), while catatonic stupor occasionally occurs in psychotic or mood disorders. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms. The syndrome usually represents a specific diagnosis, as in the case of the 10th edition of the International Classification of Diseases (ICD-10) or the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, symptom-based diagnosis can result in misdiagnosis and hinder effective treatment. Few cases of ritualistic behaviors and catatonic stupor associated with schizoaffective disorder have been reported. Risperidone and modified electroconvulsive therapy (MECT) were effective in our case.

Case presentation

A 35-year-old man with schizoaffective disorder-depression was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled us to make the diagnosis of OCD. Sertraline add-on treatment exacerbated the psychotic symptoms, such as pressure of thoughts and delusion of control. In the presence of obvious psychotic symptoms and depression, schizoaffective disorder-depression was diagnosed according to ICD-10. Meanwhile, the patient unfortunately developed catatonic stupor and respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone were administered. As a result, we successfully cured the patient with the abovementioned treatment strategies. Eventually, the patient was diagnosed with schizoaffective disorder-depression with ritualistic behaviors and catatonia. Risperidone and MECT therapies were dramatically effective.

Making a differential diagnosis of mental disorders is a key step in treating disease. Sertraline was not recommended for treating schizoaffective disorder-depression according to our case because it could exacerbate positive symptoms. Controversy remains about whether antipsychotics should be administered for catatonic stupor. However, more case studies will be needed. Risperidone with MECT was beneficial for the patient in our case.

Diagnosis is the first step toward correctly curing disease. Unlike internal or surgical diseases, mental disorders are largely symptom-based diagnoses [ 1 , 2 ]. In the process of interviewing, syndromes are always associated with certain diagnoses according to the ICD-10 or DSM-5. Repetitive behaviors or ritualistic behaviors may be linked with OCD [ 3 ]. Immobility, mutism, negativism, and peculiar motor behavior represent catatonic stupor [ 1 , 2 ], which is a psychotic diagnosis because approximately 10–15% patients with catatonic stupor meet the criteria for schizophrenia [ 4 ]. Typical ritualistic behaviors and catatonic stupor may represent OCD and psychotic disorders, respectively. However, these patients are not “textbook” cases, which means that complex and complicated symptoms may lead to misdiagnosis. Schizoaffective disorder is a specific mental disorder involving both psychotic and affective symptoms [ 5 ]. It is classified as “schizophrenia, schizotypal, and delusional disorders” by ICD-10 [ 1 ] and “schizophrenia spectrum and other psychotic disorders” by DSM-5 [ 2 ]. The complex symptomatology of schizoaffective disorder makes it highly likely that patients will be misdiagnosed.

Sertraline is a selective serotonin reuptake inhibitor [ 6 ] that is used to treat depression and OCD [ 7 ]. Previous studies have summarized the effective use of antidepressants in schizoaffective disorder [ 8 ]. However, the risk of exacerbation of positive symptoms of antidepressants should be considered [ 9 – 11 ]. A review of the treatments for catatonia has shown that MECT is effective, while antipsychotics remain controversial [ 12 ]. On the other hand, Huang et al. published other papers suggesting that the Lorazepam-Diazepam protocol can rapidly and safely relieve catatonia in schizophrenia, mood disorder, and organic lesions [ 13 – 15 ].

In this paper, we present the case of a patient who was initially suspected of having OCD but who actually suffered from schizoaffective disorder-depression with ritualistic behaviors and catatonic stupor. Sertraline exacerbated the psychotic symptoms. The ritualistic behaviors that were actually secondary to psychotic symptoms may have prevented us from making an accurate diagnosis. Finally, risperidone and MECT were effective strategies for this patient.

The patient was a 35-year-old male. He was apparently normal before the age of 27 years without any medical problems. He was intellectually normal and worked as a security guard. He was never married and had no children, often living with his older sister. He had been smoking for approximately 10 years or more, denying alcohol or other psychoactive substance abuse. He is the third child, with one older brother and one older sister. His father often became drunk and violent, going outside for no reason, and committed suicide many years ago. There were no detailed records for his father because he failed to see a doctor.

In 2009, the patient gradually became depressive; showed diminished pleasure, insomnia, and fatigue; and was unwilling to talk to others. Meanwhile, he developed delusions of persecution and reference, which made him believe that someone had insulted him and planned to kill him without evidence. Later, he came to the outpatient clinic of our hospital and was prescribed paroxetine 20 mg/d and sulpiride 0.2 g/d. He took these drugs irregularly, with minimal improvement in depressive symptoms and delusions. In August 2013, the patient was sent to the hospital for schizoaffective disorder-depression. During the following month, with quetiapine 600 mg/d and lithium carbonate sustained-release tablet 0.6 g/d, his depressive and positive symptoms improved. Taking these drugs, he almost enjoyed normal life and work. Unfortunately, he discontinued these medications in May 2017. Again, the patient gradually developed fear of the sound of water, a lack of any pleasure and negative ideas, and claimed that he could not trust anyone. Furthermore, the patient performed ritualistic behaviors, such as walking with a specific order. Once again, he was sent to our hospital by his older sister. At the time of admission, the patient presented depressive symptoms as well as ritualistic behaviors and distrust.

Upon admission, liver and kidney function, routine blood test, computed tomography (CT) of the head, and electrocardiograph (ECG) were normal. Depressive symptoms, delusions, and ritualistic behaviors were found upon psychiatric interview. By day 9 in the hospital, we followed outpatient therapeutic strategies with quetiapine 100 mg/d and lithium carbonate sustained-release tablet 0.6 g/d, observing that the depressive symptoms and distrust had moderately improved. However, the ritualistic behaviors gradually worsened. Before waking up, he would swing his arms up and down four times, did sit-ups four or five times, and sat at the edge of the bed for a few minutes, all of which took him approximately 8 min. These disturbed or interrupted behaviors made the patient anxious. Because of the predominant ritualistic behaviors, OCD was suspected first. Here, we wanted to reduce these behaviors by adding sertraline at a dose of 50 mg/d and titrating it to 100 mg/d.

Then, the symptoms further worsened, and the patient developed agitation, pressure of thoughts, and delusion of control. He felt that his ritualistic behaviors gradually became out of control, realizing that “unknown thoughts” and “a black shadow” affected his mind. Meanwhile, he felt sad, and there was nothing that brought him pleasure. Considering the clinical picture and depressive and psychotic symptoms with equal importance, the diagnosis of schizoaffective disorder-depression was eventually made according to the ICD-10. Sertraline 100 mg/d was immediately ceased. We planned to change the ineffective quetiapine to risperidone, which was more effective on positive symptoms according to our own clinical experiences when the patient developed catatonia. Mutism, posturing, nonverbal communication, hyper-myotonia of the limbs, and saliva collected in the mouth were observed. Redness and swelling of the pharynx and hyperthermia (38 °C) were present. Routine blood tests showed that the white blood cell (WBC) count was 12.85 × 10 9 /L (normal range 3.5–9.5 × 10 9 /L), and the neutrophil granulocyte (NEUT) count was 10.6 × 10 9 /L (normal range 1.8–6.3 × 10 9 /L). Chest computed tomography indicated a high-density streak like a shadow in the lower lobe of the left lung, which was clear at admission. After the case discussion, we decided to initiate risperidone at a dose of 1 mg/d and gradually titrate it to 4 mg/d to control the positive symptoms. A twice-daily intravenous injection of ceftriaxone 1 g in 250 mL 0.9% physiological saline was administered to treat the respiratory infection. Meanwhile, MECT was added three times a week to ameliorate the catatonia. MECT was administered with the SPECTRUM-5000Q device used in the bilateral mode. The treatment parameters included frequency (30 Hz), stimulus duration (2.5 s), electric charge (120 Mc), energy (21.1 J), and constant current (800 mA). Vital signs were stable; specifically, body temperature was not over 37.2 °C before starting MECT in this patient. Before and during the MECT, anesthesia was induced with etomidate 10 mg and muscle relaxation with succinylcholine 50 mg, while arterial oxygen saturation, heart rate, and electrocardiogram were continuously monitored. Each time, the patient experienced adequate generalized seizures measured with an electroencephalogram. The patient was ventilated with 100% oxygen until the resumption of spontaneous respiration.

On hospital day 23, inflammation of the pharynx disappeared, and normal WBC and NEUT counts suggested that the respiratory infection had been clinically cured. Ceftriaxone was ceased when we found negative blood bacterial culture results. We continued risperidone and MECT (a total of nine times) treatments. The patient gradually began to talk with doctors and other patients, joining some activities in the ward. The pressure of thoughts and delusion of control almost disappeared. Furthermore, it took him less and less time to perform the ritualistic behaviors. On hospital day 31, we stopped MECT and added lithium carbonate sustained-release tablets 0.6 g/d. Oral risperidone 4 mg/d was introduced, in which the blood concentration was 8.7 μg/L (normal range 2–60 μg/L). No obvious side effects were observed. Finally, we titrated the lithium carbonate sustained-release tablets to 0.9 g/d and maintained risperidone 4 mg/d. The patient remained normopyretic, and his psychotic and depressive symptoms were stable. We told the patient to review and check the blood lithium carbonate concentration 1 week later in the outpatient setting.

For the publication of this case report, written informed consent was obtained from the patient and his older sister.

Here, we describe a case of schizoaffective disorder-depression with ritualistic behaviors and catatonia. After admission, we suspected a diagnosis of OCD because of the dominance of ritualistic behaviors and depression, as the patient reported that the ritualistic behaviors must be performed or else he would feel sad. The ritualistic behaviors proved to be secondary to delusion of control. The patient’s insomnia, fatigue, and unwillingness to talk to others were not explained by the ritualistic behaviors. Ultimately, we made a diagnosis of schizoaffective disorder-depression. The symptom-based diagnostic criteria [ 1 , 2 ] as well as the multivariate symptoms made diagnosis and treatment difficult. Our case suggests that time, patience, and detailed observation are essential factors for making clinical decisions.

Selective Serotonin Reuptake Inhibitors (SSRIs) are beneficial for depression and OCD [ 6 ], among which sertraline is an effective therapeutic strategy [ 7 ]. In early studies and guidelines, psychiatrists were concerned about the risk of exacerbating psychosis when prescribing antidepressants to schizophrenic patients [ 9 – 11 ]. Rebecca Schennach et al. identified the exacerbation of positive symptoms in patients with antidepressant augmentation compared with patients without any antidepressants during the course of the study, and patients with antidepressant add-on treatment suffered from more severe psychopathological symptoms and greater psychosocial impairments at discharge [ 16 ]. However, a recent review does not support these points, as no studies found that add-on antidepressants worsened positive symptoms [ 17 ]. Although many studies have described the use of antidepressants in schizophrenia with depression, controversies remain about whether to administer antidepressants for schizophrenia spectrum disorders. We suggest that therapeutic strategies for schizoaffective disorder-depression might not include additional antidepressants, for sertraline may have exacerbated positive symptoms in our case.

Catatonia is a neuropsychiatric syndrome with psychomotor inhibition that occurs in approximately 8% of patients admitted for mental disorders, such as schizophrenia or mood disorders [ 18 ]. Schizophrenia and other psychotic spectrum disorders are more commonly presented as catatonia than mood disorders [ 19 ]. Catatonic stupor is a psychiatric emergency due to a broad range of complications [ 20 , 21 ]. Neuroleptic malignant syndrome (NMS) typically presents with fever, muscle rigidity, and altered mental status [ 22 ] and should be differentiated from catatonic stupor complicated by respiratory infection. In this case, the clear consciousness of the patient with psychomotor inhibition, redness and swelling of the pharynx, fever without muscle rigidity, increased WBC and NEUT counts, and a high-density streak of shadowing in the lower lobe of left lung in the chest X-ray at admission suggested a status of catatonic stupor complicated by respiratory infection. Therefore, our case describes schizoaffective disorder-depression with catatonic stupor complicated by respiratory infection. Controlling the infection and improving the catatonic stupor were important in treating this patient. Three treatment strategies were employed in this case. Supportive measures included high-level nursing care, intravenous fluids, and gastrointestinal support to reduce the risk of bedsores and deep vein thrombosis caused by immobility and to improve poor nutrition and dehydration. Antibiotic treatment was considered due to the redness and swelling of the pharynx, hyperthermia, increased WBC and NEUT counts, and abnormal chest X-ray. These symptoms successfully responded to the administration of 7 days of ceftriaxone. MECT was an effective strategy for improving catatonic stupor [ 23 , 24 ]. Although benzodiazepines proved to rapidly and effectively relieve catatonia, we did not prescribe these kinds of medications for the patient considering his poor nutrition, respiratory infection, and risk of respiratory inhibition. However, the role of antipsychotics in the treatment of catatonia is controversial. Several authors have suggested that antipsychotics may exacerbate the catatonic state and increase the risk of NMS [ 25 , 26 ]. Studies have found that second-generation antipsychotics (SGAs) have weak γ-aminobutyric acid (GABA)-agonist activity and 5-hydroxytryptamine 2 (5-HT 2 )-antagonism that could stimulate dopamine release in the prefrontal cortex and thus alleviate catatonic symptoms [ 20 ]. Several articles have suggested a beneficial effect of risperidone [ 27 , 28 ]. A case report identified MECT together with olanzapine, which resulted in improvement of catatonic stupor [ 29 ]. Given the results of the abovementioned studies, risperidone was cautiously administered at a low dose (2 mg/d). Once catatonic stupor improved and MECT came to a stop, risperidone would be titrated from 2 to 4 mg/d to target residual psychotic symptoms, such as the pressure of thoughts and delusion of control. Furthermore, lithium carbonate is also an effective strategy for patients with schizoaffective disorder, as it can reduce the rate of re-hospitalization [ 30 ].

Here, we describe a case of schizoaffective disorder-depression with secondary ritualistic behaviors complicated by catatonic stupor, which induces respiratory infection. Sertraline might not be recommended in patients with schizoaffective disorder to improve depression, which could have exacerbated the positive symptoms in our case. Supportive measures have an important role in the treatment of catatonic stupor. Once again, MECT has been shown to improve catatonic stupor. Although there is controversy over whether antipsychotics should be administered in the catatonic status, we considered risperidone to be beneficial in our case. Further studies should focus on the effectiveness and safety of antipsychotics associated with MECT in patients with catatonia.

Acknowledgements

We would like to thank the patient and his older sister for their collaboration.

This case report was partially supported by the Sanming Project of Medicine in Shenzhen (Grand No. SZSM201612006). The funding agency had no role in this case report; analysis or interpretation of data; or the preparation, review, or approval of the manuscript. We received no support from any pharmaceutical company or other industry.

Availability of data and materials

Abbreviations, authors’ contributions.

YHB and XY were involved in the management of the patient. ZQZ and HCY were the primary clinicians involved in the assessment, management, and follow-up of the patient. The article was written by YHB. YHB, XY, ZQZ, and HCY provided final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Competing interests.

We have no conflicts of interest to declare with respect to the manuscript, including no financial, consultant, political, personal, religious, ideological, academic, intellectual, or other relationships that could lead to a conflict of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Yuanhan Bai, Email: moc.361@nahnauyiab .

Xi Yang, Email: moc.621@elhcin .

Zhiqiang Zeng, Email: moc.qq@088740213 .

Haichen Yang, Email: moc.361@chyzs .