Catatonia in Renal Failure and Major Depressive Disorder: A Case Series





Catatonia is an acutely evolving and severe medical emergency. It occurs in several medical and psychiatric disorders but is often missed or misdiagnosed. There are majorly three different categories; the retarded, excited and malignant types. The latter is the most severe due to the associated autonomic instability. Much is unknown about the pathophysiology, but dysfunction of cortico-cortical modulation and a "top-down modulation" of the basal ganglia resulting from a deficiency of GABA in the cerebral cortex, resulting in motor dysfunction and glutamate hyperactivity and dopamine hypoactivity at the D2 receptor have been proposed. Benzodiazepines, especially Lorazepam, are reportedly effective, but reports of other benzodiazepines, Zopiclone and trials of mood stabilisers are documented. Electroconvulsive therapy is the suggested next line of action in case benzodiazepine fail, while the use of antipsychotic in catatonia is inconclusive. We present a case series of catatonia in 1) acute on chronic renal failure, complicated with uraemic encephalopathy and 2) severe depressive disorder with psychotic features. Physicians are encouraged to have a high index of suspicion to forestall the lethal complications.


Edinoff AN, Kaufman SE, Hollier JW, Virgen CG, Karam CA, Malone GW, et al. Catatonia: Clinical Overview of the Diagnosis, Treatment, and Clinical Challenges. Neurol Int 2021;13:570-586.

Fink M. Catatonia: A Syndrome Appears, Disappears, and is Rediscovered. Can J Psychiatry 2009;54:437–445.

Kahlbaum KL. Die Katatonie oder das Spannungsirresein. 1874. Bernin: Verlag August Hirschwald; 1874.

Jaimes-Albornoz W, Serra-Mestres J. Prevalence and clinical correlations of catatonia in older adults referred to a liaison psychiatry service in a general hospital. Gen Hosp Psychiatry 2013;35:512-516.

Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatr 2016;6:391-398. http://dx.doi. org/10.5498/wjp.v6.i4.391.

Sienaert P, Dhossche DM, Vancampfort D, Hert MD, Gazdag G. A clinical review of the treatment of catatonia. Frontiers Psychiatry 2014; 5.

Northoff G. What catatonia can tell us about “top-down modulation”: a neuropsychiatric hypothesis. Behav Brain Sci 2002; 25: 555-604.

Takaoka K, Takata T. Catatonia in childhood and adolescence. Psychiatry Clin Neurosci 2003;57:129-137.

Reddick B, Stem TA. Catatonia, neuroleptic malignant syndrome, and serotonin syndrome. In: Stem TA, Herman JB, Eds. Massachusetts General Hospital Psychiatry Update & Board preparation, 2nd Ed. New York, NY: McGraw-Hill; 2004:217-224.

Fekete R. Renal failure in dementia with Lewy bodies presenting as catatonia. Case Rep Neurol. 2013;5:10-13.

Levenson JL, Pandurangi AK: Prognosis and complications. In catatonia: from psychopathology to neurobiology Edited by: Caroff SN, Mann SC, Francis A, Fricchione GL. Washington, DC: American Psychiatric Publishing. 2004. p. 161-172.

Tandon R, Heckers S, Bustillo J, Barch DM, Gaebel W, Gur RE, et al. Catatonia in DSM-5. Schizophr Res 2013;150:26–30.

Fink M. Rediscovering catatonia: The biography of a treatable syndrome. Acta Psychiatr Scand 2013;127:1–47.

Medda P, Toni C, Luchini F, Giorgi Mariani M, Mauri M, Perugi G. Catatonia in 26 patients with bipolar disorder: clinical features and response to electroconvulsive therapy. Bipolar Disord 2015;17:892-901.

Morrison JR. Catatonia. Retarded and excited types. Arch Gen Psychiatry 1973;28:39-41. archpsyc.1973.01750310023005.

Bhati MT, Datto CJ, O’Reardon JP. Clinical Manifestations, Diagnosis, and Empirical Treatments for Catatonia. Psychiatry Edgmont Townsh. 2007;4:46–52.

Fink M., Taylor M.A. The Catatonia Syndrome: Forgotten but Not Gone. Arch. Gen Psychiatry 2009;66:1173.

Northoff G, Wenke J, Pflug B. Increase of serum creatine phosphokinase in catatonia: An investigation in 32 acute catatonic patients. Psychol Med 1996;26:547–553.

Ghaffarinejad A.R., Sadeghi M.M., Estilaee F., Zokaee Z. Periodic catatonia. Challenging diagnosis for psychiatrists. Neurosci Riyadh Saudi Arab 2012;17:156–158.

Hawkins JM, Archer KJ, Strakowski SM, Keck PE. Somatic treatment of catatonia. Int J Psychiatry Med 1995;25:345-369.

Oldham M.A. The Probability That Catatonia in the Hospital has a Medical Cause and the Relative Proportions of Its Causes: A Systematic Review. Psychosomatics 2018;59:333–340.

Rogers JA, Pollak T, Blackman G, David A. Catatonia and the immune system: A review. Lancet Psychiatry 2019;6:620–630.

Rosebush PI, MacQueen GM, Clarke JT, Callahan JW, Strasberg PM, Mazurek MF. Late-onset Tay–Sachs disease presenting as catatonic schizophrenia: diagnostic and treatment issues. J Clin Psychiatry 1995; 56:347–353.

Lander M, Bastiampillai T, Sareen J. Review of withdrawal catatonia: What does this reveal about clozapine? Transl Psychiatry 2018;8:139.

Ungvari GS, Caroff SN, Gerevich J. The Catatonia Conundrum: Evidence of Psychomotor Phenomena as a Symptom Dimension in Psychotic Disorders. Schizophrenia Bulletin 2010;36:231-238.

Jabs BE, Pfuhlmann B, Bartsch AJ, Cetkovich-Bakmas MG, Stöber G. Cycloid psychoses-from clinical concepts to biological foundations. J Neural Transm 2002;109:907–919.

Peralta V, Campos MS, de Jalon EG, Cuesta MJ. DSM-IV catatonia signs and criteria in first-episode, drug-naive, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophr Res 2010;118:168–175.

Muneer A. Aripiprazole in the treatment of refractory mood disorders: A case series. Clin Psychopharmacol Neurosci 2014;12:157–159.

Van Den Eede F, Van Hecke J, Van Dalfsen A, Van den Bossche B, Cosyns P, Sabbe BG. The use of atypical antipsychotics in the treatment of catatonia. Eur Psychiatry 2005;20:422–429.

Yoshimura B, Hirota T, Takaki M, Kishi Y. Is quetiapine suitable for treatment of acute schizophrenia with catatonic stupor? A case series of 39 patients. Neuropsychiatr Dis Treat 2013;9:1565-1571.

Cieslak K, Feingold J, Antonius D, Walsh-Messinger J, Dracxler R, Rosedale M, et al. Low vitamin D levels predict clinical features of schizophrenia. Schizophr Res 2014;159:543–545.

Caroff SN, Hurford I, Bleier HR, Gorton GE, Campbell EC. Recurrent Idiopathic Catatonia: Implications beyond the Diagnostic and Statistical Manual of Mental Disorders 5th Edition. Clin Psychopharmacol Neurosci 2015;13:218-221.

Girish K, Gill NS. Electroconvulsive therapy in lorazepam non-responsive catatonia. Indian J Psychiatry 2003;45:21–25.

Stompe T, Ortwein-Swoboda G, Ritter K, Schanda H, Friedmann A. Are we witnessing the disappearance of catatonic schizophrenia? Compr Psychiatry 2002;43:167–174.

Mimica N, Folnegovic-Smalc V, Folnegovic Z. Catatonic schizophrenia in Croatia. Eur Arch Psychiatry Clin Neurosci 2001;251:117–I20.

Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardised examination. Acta Psychiatr Scandi 1996;93:129–136.

Dhossche DM, Watchel LE. Catatonia in psychiatric illnesses. In: Fatemi SH, Clayton PJ, Editors. The Medical Basis of Psychiatry. Totowa, NJ: Humana Press 2008.

Zisselman MH, Jaffe RL. ECT in the treatment of a patient with catatonia: consent and complications. Am J Psychiatry 2010;167:127-132.

Grover S, Ghosh A, Ghormode D. Do patients of Delirium have catatonic features? An exploratory study. Psychiatry Clin Neurosci 2014;68:644-651.






Case Report