Spice-InducedCatatoniaJoachimRaese,MD

KingwaiLui,DO,PGY-2DepartmentofPsychiatry

KaweahDeltaHealthCareDistrict

*  Catatonia*  Whatdowesee?*  Epidemiology*  Substypes*  Treatments

*  SyntheticCannabinoids*  Whyisitsodangerous?*  CaseStudy

*  Clinicalpresentations*  Epidemiology*  Minocyclineforneuroprotection

TopicsofDiscussion

Whatdowesee?WaxyflexibilityImmobilityRefusaltoeatordrinkEchopraxia/echolaliaDeadpanstaringNegativism

MutismImpulsivityRigidityExcitabilityDeserves1to1observation

*  9%-15%ofpatientsadmittedtotypicalacutecareservicemeetdiagnosticcriteriaforcatatonia1-3*  UnderlyingcausesofCatatonia*  AffectiveDisorder:46%*  Schizophrenia:20%*  SchizoaffectiveDisorder:6%*  Medical/neurologicalillnesses:16%*  Benzodiazepinewithdrawal:4%

EpidemiologyofCatatonia

1.  RosebushPI,HildebrandAM,FurlongBG,MazurekMF.Catatonicsyndromeinageneralpsychiatricin-patientpopulation:frequency,clinicalpresentationandresponsetolorazepam.JClinPsychiatry.1990;51:357–362.

2.  BushG,FinkM,PetridesG,DowlingF,FrancisA.Catatonia1.Ratingscaleandstandardizedexamination.ActaPsychiatrScand.1996;93:129–136.3.  LeeJW,SchwartzDL,HallmayerJ.Catatoniainapsychiatricintensivecarefacility:incidenceandresponsetobenzodiazepines.AnnClinPsychiatry.2000;12:89–96.4.  RosebushPI,MazurekMF.Catatonia:clinicalfeatures,differentialdiagnosisandtreatment.In:JesteDV,FriedmanJH,eds.CurrentClinicalNeurology:PsychiatryforNeurologists.

Totowa,NJ:HumanaPressInc;2006:81–92.5.  RosebushPI,MazurekMF.Catatoniaafterbenzodiazepinewithdrawal.JClinPsychopharmacol.1996;16:315–319.

*  RetardedCatatonia*  ExcitedCatatonia*  MalignantCatatonia*  Lifethreatening*  ConfusedwithNMS*  Indistinguishablein20%ofcases2

*  MisdiagnosisofdeliriumàAntipsychoticuseàWORSENScatatonia3

SubtypesofCatatonia1

1.  Fink,Max,andMichaelAlanTaylor."Thecatatoniasyndrome:forgottenbutnotgone."ArchivesofGeneralPsychiatry66.11(2009):1173-1177.2.  MannSC,CaroffSN,BleierHR,WelzWK,KlingMA,HayashidaM:Lethalcatatonia.AmJPsychiatry1986;143:1374–13813.  LeeJW.Neuroleptic-inducedcatatonia:clinicalpresentation,responsetobenzodiazepines,andrelationshiptoneurolepticmalignantsyndrome.JClin

Psychopharmacol(2010)30(1):3–10.

NMSvs.MalignantCatatonia

*  LorazepamChallengeTest*  1or2mgofLorazepamIVà5minutes,mayrepeat1

moretime*  IMrouteà15min*  POrouteà30min

Diagnosis

*  GABAAAgonists*  Benzodiazepines*  Remissionratesreportedtobeashighas70–80%1-7*  8to24mgperdayarecommonandaretoleratedwithout

ensuingsedation,especiallywheninstitutedusingdailyincrementaldosages8

*  Zolpidem*  7.5to40mgperdaywithoutnoticeableadverseeffects9,10

*  NMDAAntagonist11

*  Amantadine*  100–500mgTID

*  Memantine*  5–20mg/day

TreatmentsofCatatonia

1.  RosebushPI,MazurekMF.Catatoniaanditstreatment.SchizophrBull(2010)36(2):239–42.2.  LeeJW,SchwartzDL,HallmayerJ.Catatoniainapsychiatricintensivecarefacility:incidenceandresponsetobenzodiazepines.AnnClin

Psychiatry(2000)12(2):89–96.3.  RosebushPI,HildebrandAM,FurlongBG,MazurekMF.Catatonicsyndromeinageneralpsychiatricinpatientpopulation:frequency,clinical

presentation,andresponsetolorazepam.JClinPsychiatry(1990)51(9):357–62.83.4.  RosebushPI,HildebrandAM,MazurekMF.Thetreatmentofcatatonia:benzodiazepinesofECT?AmJPsychiatry(1992)149(9):1279–80.

84.5.  HawkinsJM,ArcherKJ,StrakowskiSM,KeckPE.Somatictreatmentofcatatonia.IntJPsychiatryMed(1995)25(4):345–69..6.  PayeeH,ChandrasekaranR,RajuGV.Catatonicsyndrome:treatmentresponsetoLorazepam.IndianJPsychiatry(1999)41(1):49–53.86.7.  HungYY,HuangTL.Lorazepamanddiazepamrapidlyrelievecatatonicfeaturesinmajordepression.CliNeuropharmacol(2006)29(3):144–

7.8.  DhosscheDM,WachtelLE,GoetzM,SienaertP.Catatoniainpsychiatricillnessess.In:FatemiH,ClaytonP,editors.TheMedicalBasisof

Psychiatry.NewYork:Springer(2014)9.  PeglowS,PremV,McDanielW.Treatmentofcatatoniawithzolpidem.JNeuropsychiatryClinNeurosci(2013)25(3):E13.10.  HlalH,KettaniN,BerhiliN,RammouzI,AalouaneR.Placeduzolpidemdansletraitementdescatatoniesrésistantesaux

benzodiazépines.Àproposd’uncas.PresseMed(2014)43(9):1018–20.11.  CarrollBT,GoforthHW,ThomasC,AhujaN,McDanielWW,KrausMF,etal.Reviewofadjunctiveglutamateantagonisttherapyinthe

treatmentofcatatonicsyndromes.JNeuropsychiatryClinNeurosci(2007)19(4):406–12

TreatmentsofCatatonia* ECT1

1.  Sienaert,Pascal,DirkM.Dhossche,DavyVancampfort,MarcDeHert,andGã¡borGazdag."AClinicalReviewoftheTreatmentofCatatonia."FrontiersinPsychiatryFront.Psychiatry5(2014):n.pag.Web.

SyntheticCannabinoid

*  "K2,""spice,""crazymonkey,""chillout,""spicediamond,""spicegold,"and"chillX"*  Potenciesrangingfrom2to800timesgreaterthandelta-9tetrahydrocannabinol1*  JWHsynthesizedbyDr.JohnW.Huffmanin19942

*  ClassIcontrolledsubstanceintheU.S2

1.  MusselmanME,HamptonJP."Notforhumanconsumption":areviewofemergingdesignerdrugs.Pharmacotherapy2014;34:745.2.  Huffman,J.W.,Dai,D.,Martin,B.R.,Compton,D.R.,1994.Design,synthesis,andpharmacologyofcannabimimeticindoles.Biomed.Chem.4,563–566.3.  DrugEnforcementAdministration,DepartmentofJustice.Schedulesofcontrolledsubstances:temporaryplacementoffoursyntheticcannabinoidsintoScheduleI.Final

order.FedRegist2014;79:7577.

SyntheticCannabinoid

*  Epidemiology*  FirstreportedinU.Sin20081*  Asmanyas11percentofhigh

schoolseniorsintheUnitedStatesreportedusingsyntheticcannabinoidsin2012.2

1.  UnderstandingtheSpicePhenomenon.EuropeanMonitoringCentreforDrugsandDrugAddiction.http://www.emcdda.europa.eu/attachements.cfm/att_80086_EN_Spice%20Thematic%20paper%20—%20final%20version.pdf(AccessedonJuly01,2014).

2.  MonitoringtheFutureSurvey,NationalInstituteonDrugAbuse.http://www.monitoringthefuture.org/data/data.html(AccessedonJuly01,2014).

CaseStudyGF,a22yr.oldHispanicmalewithhistoryofschizoaffective

disorder,bipolartype,generallywellcontrolledwiththerapeuticlevelsoflithiumandClozarilpresentedtoourEmergencyDepartmentinAugustof2014withsevereacutepsychosis.Patientadmittedtosmokingsyntheticcannabinoidpriortoadmission.Hewasunpredictable,violent,andsexuallyinappropriate.Heassaultedpeersandstaff.Onmultipleoccasionsheexposedhimselftofemalestaff.Herequiredcompleteassistancewithbasicneedssuchasshoweringandfeeding

ClinicalManifestations:Psychiatric

NeuroprotectiveTreatment* Minocycline*  Crossesbloodbrainbarrier*  Providesneuroprotectiontoexcitotoxicinsults

1.  Plane,JenniferM.,etal."Prospectsforminocyclineneuroprotection."Archivesofneurology67.12(2010):1442-1448.

Recommendations* GC-MS*  Urgencyfordiagnosis

* ECT*  Resistantcatatonia

Questions*  Contact:klui@kdhcd.org

*  Phone(559)624-5875