Diagnosis and Management of Catatonia via Telepsychiatry: Case Series and Guide for Clinical Practice

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Catatonia is a complex neuropsychiatric syndrome characterized by motor and behavioral signs and may occur because of multiple medical, psychiatric, and neurological conditions.^1,2 Catatonia is diagnosed through a variety of validated rating scales, the most common of which is the Bush-Francis Catatonia Rating Scale (BFCRS), which is a 23-item scale that defines each catatonic sign, rates its severity, and provides a standardized schema for clinical examination.³ The assessment and diagnosis of catatonia generally requires a physical examination, as symptoms such as rigidity, waxy flexibility, mitgehen, gegenhalten, and grasp reflex require hands-on examination.³ Catatonia has a prevalence of 10% to 25% in acute psychiatric inpatients, but estimates show it can be present in up to 3% of acute neurology patients and 4% of patients in intensive care.² Other studies have found prevalences of up to 20% in patients with general medical conditions⁴ and up to 35% in intensive care patients.⁵

Catatonia is often underdiagnosed in the general hospital,^2,6 with retrospective studies showing up to 59% of cases not diagnosed during admission.¹ Consultation-liaison psychiatry (CL) is a subspecialty of psychiatry focused on the diagnosis and management of psychiatric disorders that are comorbid with general medical and surgical illness.⁷ As such, CL psychiatrists, given their expertise at the interface of medicine and psychiatry, are uniquely poised to diagnose and treat catatonia. A retrospective chart review study of patients deemed to meet criteria for catatonia showed a greater than 44 times odds of diagnosis of catatonia in the general hospital when CL psychiatry has been consulted during the admission vs when it was not.¹ However, access to consulting psychiatrists may often be limited in remote and rural areas.^8,9 The 2017 Merrit Hawkins report, which provides insights into physician supply and demand, highlights an uneven distribution of psychiatrists around the country.¹⁰ Approximately 80% of rural counties lack even a single psychiatrist.¹¹

Telepsychiatry may present a solution for these remote hospitals to effectively diagnose and treat catatonia.³ CL psychiatry services have developed telepsychiatry consultations to remote hospitals, which has shown satisfactory clinical outcomes and patient satisfaction.^8,9 The biggest challenge to the diagnosis and management of catatonia using a CL telepsychiatry modality is the inability of the consulting psychiatrist to perform a physical exam via telepsychiatry.

Our CL telepsychiatry service at the University of Pittsburgh Medical Center provides consultations to 6 nonurban or remote hospitals in Pennsylvania. In all of them, there is an on-the-ground clinician (nurse with psychiatric background or master’s level behavioral health clinician) to assist with telemedicine evaluations. These clinicians have been trained in performing the BFCRS and the appropriate physical exam maneuvers and assist the CL psychiatrists in being able to capture these symptoms and complement the telemedicine evaluation. In this case series, we outline 3 cases of catatonia that were diagnosed and managed by CL psychiatry via telemedicine. We will alsoprovide guidance based on our service’s experience to increase the odds of success when diagnosing and managing catatonia via CL telepsychiatry.

Case 1

“Ms Amy” is a 61-year-old woman with a psychiatric history of bipolar disorder maintained on vortioxetine and cariprazine, as well as catatonia requiring electroconvulsive therapy (ECT) in 2014, who presented to the hospital with increased weakness, falls, and decrease in oral intake over the last 2 weeks. The CL telepsychiatry team was consulted for change in mental status and refusal of care.

On telepsychiatry evaluation by the CL psychiatrist, with an in-person behavioral health (BH) clinician (trained to perform physical examination), Ms Amy demonstrated the following observable features of catatonia: mutism, immobility, staring, withdrawal, and automatic obedience. A physical exam by clinician with CL telepsychiatrist observing via telescreen, revealed oppositional paratonia (gegenhalten), for a total Bush-Francis score of 9.

Comprehensive metabolic panel, thyroid stimulating hormone, urinalysis, urine drug screen, chest x-ray, electroencephalogram (EEG), and brain magnetic resolution imaging (MRI) were unremarkable. She had minimal response to initiation of intravenous (IV) lorazepam at a total dose of 4 mg per day. Higher doses of lorazepam totaling 6, 8, and 10 mg per day did not show any additional improvement in serial BFCRS scores. Given her history of catatonia and lack of response to benzodiazepine therapy in setting of unrevealing medical workup, she was transferred to an inpatient psychiatric facility on hospital day 4 for further treatment, which included ECT. Chart review of inpatient psychiatric admission revealed that Ms Amy responded well to ECT treatments, with significant improvement in catatonic symptoms but not full resolution. Ms Amy was discharged home after 7 days with a plan for continued outpatient ECT treatment.

Case 2

“Mr Ben” is a 54-year-old male with a history of hyperlipidemia, gastroesophageal reflex disease, asthma, and no known psychiatric history who was admitted to the hospital for removal of hip prosthesis due to recurrent infections after a hip replacement. He began refusing medications, food, vitals, and other care starting on admission. MRI was significant for small left posteroinferior/parietal temporal junction stroke. EEG was notable for multifocal sharp waves but no seizures. CL telepsychiatry was consulted for change in mental status. On interview done with an in-person BH clinician, Mr Ben did not follow commands and stated "No," and "I don't want to do that" to most questions. He turned away from the camera and resisted attempts to move or engage him. As the BH clinician (master’s degree in social work) on service that day did not have training in doing physical exams for catatonia, the CL telepsychiatrist provided step-by-step instructions on how to perform each component of the exam. The BFCRS was completed based on the psychiatrist's own observations and the clinician's report from the physical exam. Signs of catatonia on exam including negativism/resistance, waxy flexibility, echopraxia, decreased spontaneity of speech, immobility, and relative mutism. Etiology of Mr Ben’s catatonia was unclear; however, a significant improvement in his BFCRS was noted when given IV lorazepam 2 mg as a 1-time dose. The CL telepsychiatry team recommended 1 mg of IV lorazepam 3 times daily as a standing dose; Mr Ben received a total of 18 mg over the next 6 days. Amantadine 100 mg orally twice a day was added as an adjunct treatment on hospital day 7 when plateauing of BFCRS scores were noted. Mr Ben’s BFCRS scores improved rapidly, and his mental status improved back to baseline with continued treatment over next 2 days. He was discharged from the hospital with close psychiatric and primary care follow up.

Case 3

“Ms Caroline” is a 23-year-old woman with a history of attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety, for which she was not in treatment, who was brought to the medical hospital by her parents due to a month-long history of social withdrawal, poor oral intake, and refusal to shower or change her clothes. CL telepsychiatry was consulted due to concern for depression. The BH clinician was on leave, so the hospital offered a floor nurse from the medical unit without any prior BH experience who would facilitate the patient assessment with the CL telepsychiatrist. While the patient and family interview were conducted easily over the telescreen by the psychiatrist, the physical exam was more challenging as the nurse did not have experience with performing BFCRS physical examination or telemedicine assessments. As such, more detailed instructions about camera position and lens angle, room lighting, microphone and speaker positioning were provided by the psychiatrist. While the assessment took longer to perform, a full assessment was ultimately obtained, including a catatonia physical exam. IV lorazepam 1 mg every 8 hours was started with noticeable improvement. Daily follow-up was done by the telepsychiatrist, and the same nurse assisted to allow consistency in serial physical exams for catatonia. Ms Caroline’s catatonic symptoms improved with continued lorazepam therapy and when she became more alert, she reported symptoms meeting criteria for a severe episode of major depressive disorder. Ms Caroline was thus transferred to an inpatient psychiatry unit on lorazepam 1 mg orally every 8 hours and sertraline 25 mg orally daily.

Discussion

The diagnosis of catatonia through CL telepsychiatry can represent a challenge given the inability to obtain a physical exam. Despite this, multiple signs and symptoms of catatonia can be readily examined through telemedicine. Prior studies report that the most common signs of catatonia in hospitalized patients are staring, immobility, stupor, mutism, and withdrawal.^2,3 Stereotypy, mannerisms, verbigeration, negativism, impulsivity, perseveration, and in some cases posturing/catalepsy can be observed through telemedicine evaluation.³ A prior publication documents a case of diagnosis and management of telepsychiatry and includes a good summary of the signs/symptoms that are observable via telemedicine and those that require hands-on assessment.³ Agitation, grimacing, echolalia, and echopraxia can also be readily seen through telemedicine but the literature reports that these signs are often missed or not attributed to catatonia.² Given increased familiarity with these symptoms, as well as with the medical etiologies of catatonia, CL psychiatry teams play a crucial role in diagnosis and treatment of catatonia in rural hospitals that utilize telehealth services.¹

Consistent with other reports in the literature, our cases highlight that patients are often consulted for nonspecific reasons such as depression, refusal of care, or altered mental status.¹ As such, it is important for psychiatrists consulting in the medical setting to be mindful of consult questions or phrases that could suggest catatonia. Similarly, it is essential for the CL psychiatrist to perform a thorough chart review for information that could suggest catatonia such as nursing documentation describing possible echolalia, stereotypy, mutism, and staring, as well as reviewing vitals for any signs of autonomic instability.

Telepsychiatry has the potential to provide early diagnosis and management of this complex condition, thus reducing the significant morbidity and mortality associated with it. Prior studies on clinician perceptions of telepsychiatry showed that most found its use challenging for patients with catatonia.¹² While the inability to perform a physical examination is certainly a limitation, there have been reports of catatonia diagnosed and managed successfully via telepsychiatry.³ This article expands on previous reports and provides suggestions to increase success in diagnosis and management of catatonia via telepsychiatry. We also discuss alternatives to obtaining a physical exam when it is required to complement the telepsychiatry evaluation. We encourage consulting psychiatrists to consider the following when diagnosing catatonia via telepsychiatry:

1. Training of the on-site clinician. Physical examination may not be routine for psychiatric clinicians or other providers assisting with the telemedicine consult. Training the on-site clinician to perform the BFCRS is essential. Certain signs such as gegenhalten, mitgehen, waxy flexibility, catalepsy, and grasp reflex require practice and observation to be done correctly. Since the psychiatrist is unable to physically examine the patient, this step is crucial. Ideally this should be done with any new hires on the service, but as noted in Case 3, the consulting psychiatrist should be prepared to provide this training in real time to the on-the-ground clinician if the situation calls for it. Working with the on-the-ground medical team may be necessary in some cases to ensure effective training for the clinicians assisting the telepsychiatrist.

2. Quality of the audiovisual connection. Having a high-quality connection with proper audio and high-resolution video is important to allow proper telemedicine examination. Poor video quality may make it difficult for physicians to appreciate signs such as grimacing or echopraxia. Poor audio connection may make it difficult for physicians to hear low volume sounds from patients. Visualization of the entire body is necessary to capture abnormal movements and postures. On-the-ground clinicians may need specific instructions to ensure good lighting and camera angles are achieved.

3. Using the primary team as a resource and primary team education. Primary teams may be able to assist in performing necessary physical exam maneuvers, with guidance from the psychiatrist. This also provides the opportunity for the psychiatrist to educate other providers on important and common signs of catatonia, such as agitation, grimacing, and echolalia.

4. Chart review. Careful review of laboratory results, toxicology, and MRI/EEG results is essential to distinguish symptoms of catatonia that may be overlapping with other conditions, such as delirium.

5. Using standardized scales. Catatonia can be diagnosed via BFCRS when 2 or more signs are present for greater than 24 hours.¹³ Using a standardized scale allows clear communication between providers and while it has its limitations due to symptom overlap with other conditions, this may still help reduce missed diagnoses.

Concluding Thoughts

While challenging, the diagnosis of catatonia through telepsychiatry is possible. To increase the odds of success, the CL psychiatrist must be aware of typical consult questions that suggest catatonia, such as refusal of care/withdrawal or depression. Most of the signs and symptoms of catatonia can be accurately captured via a good quality audiovisual connection. The assistance of on-site clinicians can help the telepsychiatrist capture physical exam findings that are not possible via telemedicine. Proper training of the on-site clinician in performing these maneuvers is essential.

Dr Shivanekar is an assistant professor of psychiatry at the University of Pittsburgh. Dr León-Barriera is an assistant professor of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania. Dr Gopalan is an associate professor of psychiatry and obstetrics, gynecology and reproductive sciences in the department of psychiatry at the University of Pittsburgh.

Acknowledgments: The authors thank Dr Neeta Shenai for her contributions to the conceptualization of this paper and for her helpful input on improving the manuscript.

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