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Drs. Fink and Taylor Reply

To The Editor: Catatonia is a syndrome defined by two or more persistent clinical signs cited in catatonia rating scales (1, 2). It is commonly identified in patients with depressive illness, manic-depression, and psychotic disorder. It is frequently seen in patients with seizure disorder, frontal circuitry brain disease, and in toxic metabolic states (1). Dr. Balhara objects to the suggestion that the rapid relief of catatonia by the intravenous administration of lorazepam or amobarbital verifies the diagnosis in subjects who meet the clinical criteria. He recognizes that catatonic features are not specific to a single condition and cites elective mutism as an example of a condition that does not meet the criteria for catatonia and yet responds to amobarbital assisted interviews.

In 1930, barbiturates were replaced by benzodiazepines for reasons of safety. In recent trials among patients who meet rating scale criteria for catatonia, more than 80% of patients had a rapid reduction in symptoms with an intravenous lorazepam challenge (1, 2). Such a response to lorazepam typically results in a lorazepam treatment trial, followed by electroconvulsive therapy if substantial relief is not maintained. Adhering to this algorithm achieves remission of catatonia in almost all patients.

Dr. Balhara notes that conversion disorders like mutism "are associated with features that do resemble catatonia and do respond to amobarbital assisted interview" as a negation of the lorazepam challenge test as verification of the diagnosis. In his example, however, the patient with elective mutism and "associated features [of catatonia]" would meet the diagnostic criteria for catatonia, and the relief afforded by amobarbital would verify the diagnosis and encourage the prescription of effective treatments of the syndrome.

References

1. Fink M, Taylor MA: Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cambridge, UK, Cambridge University Press, 2003
2. Bush G, Fink M, Petrides G, Dowling F, Francis A: Catatonia, II: treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand 1996; 93:137–143[Medline]

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