(120) Treatment Options for Catatonia in Cancer: Case Series and Literature Review

Abstract:

Background: Catatonia is a syndrome of neuropsychiatric symptoms, seen in mood and psychotic disorders, as well as medically complex individuals. Few studies have examined catatonia occurring in individuals with cancer, with case reports primarily focused on autoimmune encephalitis and paraneoplastic syndromes [1]. ]. To our knowledge, no clear cases of individuals developing catatonia without positive paraneoplastic causes or autoimmune markers have been reported. We present two individuals without prior psychiatric history who developed catatonia after cancer diagnosis. Our aim is to provide the consultation-liaison (CL) psychiatrist with management strategies in this population.

Case Presentation: Mr. G. is a 65 year old male who had catatonia after diagnosis of Stage II gastric adenocarcinoma. Workup was negative on neuroimaging and for paraneoplastic markers. His catatonia was unresponsive to benzodiazepines and later required ECT, with partial resolution of symptoms. He received chemotherapy for his cancer, which paradoxically led to worsening of catatonia. His catatonia resolved with benzodiazepines and augmentation using memantine and antidepressants.

Mr. S. is a 49 year old male who developed catatonia prior to diagnosis of Stage III testicular seminoma; workup negative for paraneoplastic markers. Initial treatment for catatonia included benzodiazepines, IVIG, plasmapharesis, and chemotherapy for his cancer, without symptom improvement. Symptoms persisted despite treatment with benzodiazepines and trials of antidepressants, memantine, antipsychotics, and mood-stabilizers. His catatonia improved after psychiatric hospitalization and initiation of ECT.


Results: We review existing data on catatonia in autoimmune encephalitis and apply these clinical cases to a growing body of literature. For catatonia from primary cancers, treatment focuses on tumor removal [2]. We identify alternative first-, second-, and third-line treatment options for catatonia in individuals with cancer. We also outline of potential drug interactions with chemotherapy. As CL psychiatrists have limited data on other treatment options, especially if symptoms persist after tumor removal [3], we will explore the role of ECT in treatment of catatonia in medically complex individuals and those undergoing cancer treatments.

Conclusion: This case series illustrates the complexity of treating catatonia in individuals with cancer. Studies suggest the use of benzodiazepines and ECT, but do not identify second-line treatments for refractory symptoms, as seen in the cases described in this series.

Significance: Identifying treatment options, including pharmacotherapy and ECT, for catatonia in individuals with cancer can help lead to improvement in symptoms and overall prognosis.


References:
1. Dalmau J, Graus F. Antibody-Mediated Encephalitis. N Engl J Med. 2018 Mar 1;378(9):840-851.
2. Coffey, M. Justin MD; Cooper, Joseph J. MD Electroconvulsive Therapy in Anti-N-Methyl-D-Aspartate Receptor Encephalitis, The Journal of ECT: December 2016: 32(4): 225-229
3. Leding C, et al. Complete cognitive recovery in a severe case of anti-N-methyl-d-aspartate receptor encephalitis treated with electroconvulsive therapy. BMJ Case Rep. 2020 Feb 6;13(2).