Catatonia as the initial presentation of first-episode psychosis: a case report

Catatonia is a psychomotor syndrome characterized by abnormalities in movement, speech, behavior, and affect (1). Although historically associated with schizophrenia, recent literature highlights its transdiagnostic nature, particularly in mood disorders and medical conditions (2). In first-episode psychosis (FEP), catatonic symptoms may dominate the clinical presentation and obscure the underlying psychotic process, delaying diagnosis and treatment (3).

We present a 27-year-old single male with no previous psychiatric history who was involuntarily admitted due to refusal of food and treatment, severe social withdrawal, disorganized behavior, and progressive functional decline.

Collateral information from family members revealed progressive social isolation over the previous 6–7 years, with marked deterioration during the last year. During the preceding five months, the patient had stopped working, isolated himself in his room, avoided communication, and significantly reduced interpersonal interaction.

In the weeks before hospitalization, he developed prolonged staring, markedly reduced spontaneous speech, negativistic behavior, decreased sleep, poor oral intake, increased religious preoccupation, suspiciousness toward family members, persecutory beliefs involving poisoning and harm, apparent responses to internal stimuli, psychomotor retardation, and episodes of immobility.

Family members also described longstanding repetitive cleaning-related behaviors, excessive use of cleaning products, prolonged bathing rituals, repetitive touching behaviors, and stockpiling of cleaning supplies. Progressive occupational and social dysfunction was evident.

Mental status examination demonstrated markedly decreased psychomotor activity, poor eye contact, severe reduction in speech spontaneity, slowed thought processes, impaired goal-directed behavior, paranoid and persecutory delusions, possible auditory hallucinations, negativistic attitude toward examination and treatment, limited insight, and impaired judgment. Affect was constricted and mood dysphoric. Orientation and consciousness were largely preserved when cooperation could be established.

Physical and neurological examinations were unremarkable. Cranial magnetic resonance imaging (MRI), computed tomography (CT), electroencephalography (EEG), toxicology screening, and routine laboratory investigations showed no abnormalities.

Lorazepam administration resulted in partial but clinically meaningful improvement in psychomotor slowing and cooperation, supporting the diagnosis of catatonia (4). Olanzapine treatment was initiated, and electroconvulsive therapy (ECT) was planned because of persistent catatonic symptoms and impaired oral intake.

Following the first ECT session, the patient demonstrated improvement in speech output, sleep, food intake, emotional responsiveness, and psychomotor activity. Catatonic symptoms gradually diminished, although persecutory ideation persisted partially during the early treatment period.

This case illustrates several important clinical aspects of catatonia in FEP. First, catatonia may represent the predominant manifestation of an emerging psychotic disorder, overshadowing psychotic symptoms and complicating diagnostic assessment. Second, the case highlights the prolonged prodromal phase frequently observed in schizophrenia-spectrum disorders, characterized by progressive withdrawal, functional decline, and obsessive-compulsive-like symptoms preceding overt psychosis (5). Third, the patient’s response to lorazepam and ECT emphasizes the importance of early recognition and treatment of catatonia to reduce morbidity associated with dehydration, malnutrition, and severe functional impairment.

Catatonia may be the initial and most prominent manifestation of first-episode psychosis. Careful evaluation of psychomotor symptoms, longitudinal decline, and collateral history is essential for early diagnosis. Prompt treatment with benzodiazepines and ECT may lead to substantial clinical improvement and reduce complications associated with untreated catatonia

References

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3. Heckers S, Tandon R, Bustillo J, et al. Catatonia in the DSM—shall we move or not? Schizophr Bull. 2010;36(2):205–207.
4. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the treatment of catatonia. Front Psychiatry. 2014;5:181.
5. Fusar-Poli P, Borgwardt S, Bechdolf A, et al. The psychosis high-risk state: a comprehensive review. JAMA Psychiatry. 2013;70(1):107–120