1542 - “The Defense Does NOT Rest”: A Case Study of Excited Catatonia in a Lawyer Following an Anoxic Brain Injury

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

RM

Rachel R. Murray, MD

Resident Physician
Rutgers New Jersey Medical School / Kessler Institute for Rehabilitation
Bloomfield, New Jersey, United States

Co-Author(s)

Jennifer Russo, MD

Associate Program Director, Brain Injury Medicine Fellowship
Kessler Institute for Rehabilitation
Norwalk, Connecticut, United States

Case Diagnosis: Excited Catatonia

Case Description: A 72-year-old lawyer was admitted to acute inpatient rehabilitation due to an anoxic brain injury. Initially, nursing documentation noted that he was agitated and pulling at his tracheostomy tube. On physiatric assessment, his behavior was consistent with stereotypies involving meaningless hand movements to his neck and verbigeration consisting of contextually-inappropriate legal phrases. His initial Bush Francis Catatonia Rating Scale (BFCRS) score was 30. Due to a high suspicion for excited catatonia, he underwent a lorazepam trial and his BFCRS score decreased from 30 to 3. Subsequently, he was started on standing lorazepam three times a day. During his 5-week rehabilitation course, he progressed from requiring maximal assistance with bed mobility to ambulating independently with a rolling walker. He also demonstrated improvement in arousal, attention, communication, and command-following.

Discussions: Medical catatonia is associated with conditions such as encephalitis, brain injuries, metabolic disorders, and certain infections. There are three subtypes of catatonia: stuporous, excited, and malignant. Stuporous catatonia presents with immobility, mutism, and rigidity and is often misdiagnosed as a disorder of consciousness. Excited catatonia is associated with purposeless and excessive motor activity, which is frequently mislabeled as agitation. Despite increased activity, these patients have difficulty responding to environmental stimuli or commands appropriately. Treatment for catatonia includes administration of benzodiazepines, which are typically avoided in patients with brain injury, especially those displaying agitation, due to the side effect of cognitive impairment.

Conclusions: Given that stuporous and excited subtypes of catatonia are often mislabeled as disorders of consciousness and agitation respectively, it is necessary for providers to know the causes and signs of catatonia for proper diagnosis and treatment of this complex medical condition. Prompt and proper management of catatonia can lead to improved patient awareness and motivation resulting in better functional outcomes.