To the Editor: The following are reports on three male youths who were diagnosed with catatonia while residing in an intensive mental health unit within a juvenile correctional facility.
Abe, a 14-year-old African American youth who was diagnosed previously with both schizophrenia and bipolar disorder with psychotic features, was admitted because of paranoid delusions that his food was being poisoned and subsequent inadequate food intake, with a 10-lb weight loss over a 4-week interval. He demonstrated repeated inappropriate touching and maintenance of assumed positions for up to 10 minutes at a time. He was extremely combative at times but immobile at others. He exhibited mutism, stereotypy, mannerisms, negativism, and staring. His Bush-Francis Catatonia Rating Scale score was 26. (1) Abe was treated with lorazepam, 2 mg/day, and his catatonic signs and food intake improved dramatically over the following 5 days. He was treated with quetiapine and lithium for the next 18 months, with partial remission of his mood and psychotic symptoms until he became noncompliant. Abe’s catatonic signs reemerged, and he again responded favorably to lorazepam, 2 mg/day. For the past year, he has been receiving treatment with clozapine and lithium and remains in full remission of catatonic, mood, and psychotic symptoms, with dramatic improvement in social, interpersonal, and educational functioning.
Mr. B, an 18-year-old Caucasian man with a history of cannabis abuse and declining social, vocational, and interpersonal involvement (but no previous diagnoses of mood or psychotic disorder), was admitted because he was talking to himself, had lack of motivation, and was laughing inappropriately. He exhibited profound mutism, intermittent excitement, posturing, staring, mannerisms, stereotypy, perseveration, autonomic abnormality (elevated blood pressure), automatic obedience, and impulsivity. His Bush-Francis Catatonia Rating Scale score was 24. His catatonic signs responded well to lorazepam, 3 mg/day. Manic symptoms subsequently emerged, and Mr. B was diagnosed and treated for bipolar disorder.
Carl, a 17-year-old Caucasian youth who was previously diagnosed with schizoaffective disorder, was admitted because of declining self-care, response to internal stimuli, and bizarre delusions. He displayed facial grimacing that resolved completely when risperidone, 5 mg/day, was discontinued. His Bush-Francis Catatonia Rating Scale score was 18, and his catatonic signs included immobility, mutism, excitement, posturing, staring, mannerisms, echolalia, stereotypy, negativism, gegenhalten, ambitendency, impulsivity, and combativeness. These signs resolved with lorazepam treatment, 3 mg/day.
All youths had negative serum toxicology screens upon admission to the facility and, in the case of Mr. B, for 6 months before admission, as verified through court-ordered monitoring. The youths received medical and neurological evaluations, including hematological, metabolic, toxicological, and CSF analysis, EEGs, and neuroimaging. All results were normal or lacked positive findings. Prenatal and developmental histories were unremarkable, although Abe and Carl had extensive family histories of mental illness.
There have been several case series and reports of catatonia occurring in the child and adolescent population (2). Although substantial psychiatric morbidity has been identified among youths in the juvenile justice system (3), I am unaware of previous case reports of catatonia occurring among youths detained within the juvenile justice system. Presumably, the etiology and risk factors leading to catatonia in adolescents and young adults in juvenile justice and community settings is similar, regardless of criminal history. However, the identification of this syndrome in male juvenile offenders is especially important, given the paucity of resources for adolescents and the increasing recognition of the prevalence and severity of mental illnesses among juvenile offenders (4). Incarcerated juveniles may exhibit unusual behavioral phenomena, making detection of psychiatric disorders in need of treatment extremely difficult (5).
Considerable functional improvement was evident in all three cases after treatment of catatonia, similar to documented case reports. Also, more youths are entering the criminal justice system than ever before. With more diverse clinical treatment settings and declining resources, greater awareness of the catatonia syndrome, with its well-defined features and response to treatment (6), may aid in its recognition and management.