help/advice w/ a patient

[madison88]

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Hi everyone. Just wanted to see if anyone had any advice on a difficult patient I am taking care of. I am a pgy-1 finishing my psych inpatient months.
I have a 40 something y/o female, past dx of Bipolar II, presented to the hospital a few weeks ago w/ worsening depression, isolation, difficulty w/ memory, worsening confusion. On admissions, pt is very delayed in speech and response, poor eye contact, perseveration in speech, unusual repeated neck movements up and down, w/ possible thought disorder. Pt also observed to have very delayed movements in terms of eating, walking, picking up objects, writing, etc. Per family, pt had a similar episode 4-5 years ago but family does not remember what was done in terms of treatment.
Pt treated w/ topamax, lexapro, and geodon(slowly tapered and stopped in Jan/feb this year) by outpt psychiatrist. Per outpt psychiatrist, pt is a pleasant lady who functions pretty well when at her baseline.
CT head-normal, RPR, ANA, Folate, B12 all wnl. EEG-pending.
Currently pt on risperdal 3 qhs along w/ home meds. Originally I dx her w/ MDD, severe w/ catatonic features/psychotic features. Trial of low dose benzo's showed no real response. Pt slowly improving but still with signficant delays in speech and movements, continued perserveration, and unusual hand and neck movements. Not really sure if antipsychotic is really changing things or if just being in hospital has helped!
Family meeting w/ husband did not come up w/ any acute stressors or changes in her life recently that may attribute to her behavior.
Just wondering if I am missing anything. My attending is also not sure what is going on. If anyone had any advice or could refer me to any literature, that would be great!

Madison88

 

[Doc Samson]

If you suspect catatonia, would taper/stop the risperdal since catatonia is thought to be a hypodopaminergic state (that's how the benzos work, via release of endogenous dopamine) and the dopamine antagonism of the medication could be worsening the catatonia. How much benzo have you tried? In our neck of the woods the standard trial is Ativan 2 mg IV. Did you see any loosening of the catatonic symptoms? Next step (if you really think this is catatonia) is ECT.

 

[Anasazi23]

Sounds to me more like a variation of a tardive movement - possibly with a concomitant catatonic component.

 

[Doc Samson]

Sounds to me more like a variation of a tardive movement - possibly with a concomitant catatonic component.

Not sure I agree with TD here, but either way, you'd want to taper/stop the neuroleptic.

 

[Anasazi23]

Yes, tardive in the classical sense is probably the wrong word, though this description is often a missed early stage tardive movement that doesn't fit the classical picture. I've seen at least 4-5 cases in which this description was an initial presentation. In two of those cases, the patient had a history of tic disorder that had resolved to some degree. It didn't sound like a withdrawal dyskinesia, but is likely related to the neuroleptic on board. More likely some sort of involuntary motor movement related to the neuroleptic. Purposeless repetitive movements or stereotypies are often a sign of degenerated or advanced stage psychosis. I think the bottom line is that it's difficult to say without seeing the movement for ourselves.

Either way, I'd probably taper the neuroleptic, as DS says.

 

[MBK2003]

If you suspect catatonia, would taper/stop the risperdal since catatonia is thought to be a hypodopaminergic state (that's how the benzos work, via release of endogenous dopamine) and the dopamine antagonism of the medication could be worsening the catatonia. How much benzo have you tried? In our neck of the woods the standard trial is Ativan 2 mg IV. Did you see any loosening of the catatonic symptoms? Next step (if you really think this is catatonia) is ECT.

I agree that there is a strong suspicion for malignant/lethal catatonia here. In addition to stopping the neuroleptic, I'd check a catatonia rating scale score (I use the Bush-Francis one) and consider calling the NMSIS hotline for professional consultation.

MBK2003

 

[PsychMD2100]

If you suspect catatonia, would taper/stop the risperdal since catatonia is thought to be a hypodopaminergic state (that's how the benzos work, via release of endogenous dopamine) and the dopamine antagonism of the medication could be worsening the catatonia. How much benzo have you tried? In our neck of the woods the standard trial is Ativan 2 mg IV. Did you see any loosening of the catatonic symptoms? Next step (if you really think this is catatonia) is ECT.

Doc Samson,

I always thought of benzos working by binding to the GABA-Chloride channel complex, thereby resulting in inhibition.

Is it true that benzos have dopaminergic activity? I'm asking not to challenge but rather to learn more about this pharmacologic pathway.

 

[Doc Samson]

Doc Samson,

I always thought of benzos working by binding to the GABA-Chloride channel complex, thereby resulting in inhibition.

Is it true that benzos have dopaminergic activity? I'm asking not to challenge but rather to learn more about this pharmacologic pathway.

My neurophysiology might be a little rusty here, but as I remember it benzos treat catatonia by modulating the dopamine/GABA connections in the mesostriatal/mesolimbic systems and the hypothalamus. There's a great book published by APPI dedicated to catatonia - just can't find my copy right now.

 

[Doc Samson]

Here's a blurb from a recent article by one of my supervisors that captures it nicely:

The beauty of benzodiazepine treatment in catatonia is that it does not only inhibit corticostriatal tracts and decrease NMDA activity in the dorsal striatum through GABAA activation in the medial orbitofrontal, anterior cingulate, and prefrontal cortices, but it can also disinhibit dopamine cell activity in the basal ganglia via GABAA activation, with subsequent reduction of GABAB inhibition of dopamine cell bodies.

Freudenreich O, McEvoy JP, Goff DC, Fricchione GL
Catatonic coma with profound bradycardia.
Psychosomatics. 2007 Jan-Feb;48(1):74-8.

 

[PsychMD2100]

Thanks Doc Samson!

I appreciate you taking the time to cite a source. That's something I'll have to keep in mind the next time I prescribe benzos.

 

[Doc Samson]

No problem.

It'd be great if the OP could give us all an update on the patient... enquiring minds want to know!

 

[Dramkinola]

what do y'all think of stopping the topamax also, in addition to stopping the Risperdal and adding more benzo's?
Bipolar II can be subjective at times, and maybe a little hypomania at this point may turn things around a little...