SCHIZOPHRENIA, A VETERAN DIAGNOSIS WITH FEATURES OF CATATONIA

Updated: Jan 12

It feels like it was just yesterday I received a phone call from a colleague, about a patient who would not respond to any form of call by anyone right after his wedding ceremony. This patient would proceed to blankly stare at any person when a question was thrown at him. As a medical doctor faced with this instance, this can be distressing! I am going to use a patient seen in a consulting room on a Monday morning to explain to you the features of Catatonic Schizophrenia, how to accurately make a diagnosis and refer appropriately to a psychiatrist for expert management. As a relative to an individual who presents with symptoms which would be mentioned later in the blog post, there is no need to fret! Just report to the clinic to visualize a resolution to these symptoms as the magic wand in the form of a pen is being waved.

Did you know an average person moans for 34 minutes on a Monday, compared to the 22 minutes on other days? Did you also know Mondays are commonly considered “suicide days”, being the day of the week where the most people take their own lives. Also, the reason why the cardiologists in my hospital work on a Monday, is because “Heart attack day” takes place on Mondays; when there is a marked increase in the incidence of heart attacks. This incidence could rise to as much as 20%. Fascinating isn’t it?

A middle aged woman walks in hesitantly, led by her husband holding her hands. As they sit, you notice the shuffling, unhurried gait of this woman. She maintains her gaze at a fixed spot in the Consulting Room and keeps looking at that spot, as if she had visualized a static, imaginary angel on the wall. That was my story on an active Monday morning.

The man complained her wife had been periodically losing awareness of her environment, and herself intermittently during conversations. This symptom usually intensified anytime he had had a heated argument with her of varied topics. Right after the well-spaced occasional arguments, she would complain of unremitting headaches which were localized to either the front of her head, or the back of her head. These headaches surprisingly, were associated with pain in both eyes every time, and would not cower to over-the-counter pain killers.

The first task as a physician is to rule out the possibility of a migraine by asking further questions; which include the nature of the headache, how episodic it is, the duration of an episode and its associated symptoms. It is important to identify the aura that heralds the symptom of the headache before you proceed to work on the next symptom being voiced out by the patient.

Hours into the onset of the symptom, she begins to talk to herself; muttering under her breath as she makes inappropriate gestures in succession. She could remain in this state until she was nudged by her husband, for which there would be a temporary break in the choreography of her symptoms of gesticulation. To make matters worse, she would respond to an imaginary voice calling out her name for three times in broad daylight irrespective of her location and laugh inappropriately even in the absence of a full-fledge discourse.

For the past 2 years, these symptoms spontaneously resolve after a few days of onset for which no intervention was sought. However the most distressing of the symptoms still remained!

Humans are more than just conscious—we are also self-aware. Scientists differ on the difference between consciousness and self-awareness, but one common explanation that lingers is: Consciousness is the awareness of one's body and one's environment and self-awareness is the recognition of that consciousness—not only understanding that one exists, but further understanding that one is aware of one's existence.

It is a written rule “Human infants are conscious!” They perceive and respond to people and things around them—but they are not yet self-aware. In their first years of life, infants develop a sense of self, learn to recognize themselves in the mirror and distinguish their own point of view from other people's perspectives. Was this woman conscious? Was she self – aware?

This woman lost her self awareness and could sit still for hours without budging or moving. She could not recognize the need to either have her lunch or take her bath. A nudge at her would jolt her into brief seconds of awareness and send her right back into unconsciousness.

This symptom could rule in the possibility of a seizure; because a seizure is diagnosed clinically. However there were no extraneous symptoms of: abrupt movement of the hands and legs, tongue-biting, eye-rolling, foaming at the mouth and sudden falls to the ground. Just blank staring!

Surprisingly enough, she could regain awareness after as long as a month of oblivion, but…she could not put a name to the intimate friends and acquaintances who paid casual visits to her; including her husband. To cap it all off, she had to be assisted with activities of daily living such as bathing, cooking and how to use a phone. This sounds like work! Remember “For Better, For Worse

A Mental State Exam could not reveal much information except her emotionless, blank stare at a spot in the consulting room and her refusal to respond to any question posed at her. Also, I noticed she had clasped her fingers throughout the interview with little to no movement at her neck. A typical oneiroid dream-like state!

I employed the use of a Bush Francis Rating Scale, a tool predominantly used in the assessment of catatonia; for which had a score of 17. A quite significant score!

Next, I made an Impression of CATATONIC SCHIZOPHRENIA based on the bizarreness of her symptoms, the duration of her illness and the associated catatonic symptoms, as evidenced by the score on the rating scale. However I had not ruled out the possibility these symptoms could be caused by a seizure; for which I requested for an electroencephalogram (EEG).

An EEG records the electrical activity of your brain via electrodes affixed to your scalp. The results of an EEG show changes in brain activity that may be useful in diagnosing brain conditions, especially epilepsy and other seizure disorders.

I then started her on antipsychotics and other medications to help relax her tensed muscles; scheduling her for a 2 week review at the end.

Catatonia refers to a set of symptoms that might develop in some patients with schizophrenia. It can include periods where the individual moves very little and does not respond to instructions. At the other end of the extreme, the individual can demonstrate motor activity that is considered “excessive” and “peculiar,” such as echolalia (mimicking sounds) or Echopraxia (mimicking movements). This is called catatonic excitement.

Catatonia is a behavioural syndrome marked by an inability to move normally. This state could be associated with schizophrenia and other mental illnesses. It usually involves symptoms such as staying still, fast or strange movements, lack of speech and other unusual behaviour.

Catatonic states are now more likely to be found in types of mental illness other than schizophrenia, such as neurodevelopmental conditions that affect children during the development of their nervous system, psychotic bipolar disorder, and depressive disorders. Individuals with catatonia may flip between decreased and excessive motor activity.

It is important to identify these symptoms of Catatonia for appropriate investigation into its cause and effective management of the cause. Catatonic schizophrenia is now much rarer than it used to be thanks to improved treatments.

With modern treatments, patients with catatonic schizophrenia can manage their symptoms easier, making the likelihood of leading a happier and healthier life much greater.

Let’s make the world better, with a better you in it.



Thanks for reading

Eliezer

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