Catatonia and Transcranial Magnetic Stimulation
To the editor: A painless and noninvasive stimulation of the brain has become possible by using transcranial magnetic stimulation (TMS). Most studies, but not all (1), have proven efficacy for TMS in treating depression. Fast repetitive TMS of the dorsolateral prefrontal cortex (2) and slow repetitive TMS of the opposite area (3) have been shown to improve depressive symptoms. Some studies have shown improvement of paranoid symptoms in schizophrenia patients (4). However, we know of only one study that has dealt with catatonia by using repetitive TMS (5). We report the case of a catatonic patient whose symptoms were relieved with TMS treatment.
Ms. A, an 18-year-old woman, was brought to the hospital in a catatonic state, according to DSM-IV criteria. She had no personal or family history of psychiatric disease. She was socially involved and was attending school regularly. Seven months before, she had experienced social withdrawal, a decline in school performance, panic attacks, and marked behavioral disturbances. Four days before hospitalization, she had developed acute catatonic syndrome.
When we examined Ms. A, her catatonic symptoms were found to involve mutism, waxy flexibility, negativism, rigidity, and catalepsy. Her symptoms were rated with the Bush Francis Catatonia Rating Scale (6) at baseline and every 3 days thereafter. After the failure of a short trial (3 days) of lorazepam, she was treated with fast repetitive TMS of the left dorsolateral prefrontal cortex for 2 weeks (10 sessions, 1600 stimuli/day, 10 Hz, 80% of the motor threshold).
Almost all of her catatonic symptoms had disappeared by the end of the TMS treatment, allowing a diagnosis of schizophrenia, according to the clinical picture (auditory hallucinations and delusions). The severity of the catatonic symptoms on the catatonia rating scale had dropped from 19 at baseline to 3 by days 12 and 15. Antipsychotic medication (amisulpride, 600 mg b.i.d.) was then initiated. Ms. A was discharged 4 weeks later.
The primary clinical picture seen in our patient is believed to be rare. To our knowledge, there has been only a single clinical instance of repetitive TMS working for catatonic patients (5). Our report corroborates previous findings of the efficacy of this technique in the treatment of catatonia, although the condition might have resolved spontaneously. TMS might offer a therapeutic alternative for the treatment of catatonia. However, further controlled studies are required to confirm the beneficial effect of TMS.
1. Loo C, Mitchell P, Sachdev P, McDarmont B, Parker G, Gandevia S: Double-blind controlled investigation of transcranial magnetic stimulation for the treatment of resistant major depression. Am J Psychiatry 1999; 156:946-948Link, Google Scholar
2. Pascual-Leone A, Catala MD, Pascual-Leone Pascual A: Lateralized effect of rapid-rate transcranial magnetic stimulation of the prefrontal cortex on mood. Neurology 1996; 46:499-502Crossref, Medline, Google Scholar
3. Klein E, Kreinin I, Chistyakov A, Koren D, Mecz L, Marmur S, Ben-Shachar D, Feinsod M: Therapeutic efficacy of right prefrontal slow repetitive transcranial magnetic stimulation in major depression: a double-blind controlled study. Arch Gen Psychiatry 1999; 56:315-320Crossref, Medline, Google Scholar
4. Hoffmann RE, Boutros NN, Hu S, Berman RM, Krystal JH, Charney DS: Transcranial magnetic stimulation and auditory hallucinations in schizophrenia (letter). Lancet 2000; 355:1073-1075Crossref, Medline, Google Scholar
5. Grisaru N, Chudakov B, Yaroslavsky Y, Belmaker RH: Catatonia treated with transcranial magnetic stimulation (letter). Am J Psychiatry 1998; 155:1630Link, Google Scholar
6. Bush G, Fink M, Petrides G, Dowling F, Francis A: Catatonia, I: rating scale and standardized examination. Acta Psychiatr Scand 1996; 93:129-136Crossref, Medline, Google Scholar
