Letters

On Catatonia, Seizures,
and Bradycardia

EDITOR: The interesting

report of catatonia presentation
with bradycardia by Freudenreich et
al.1 splendidly highlights the importance of identification of catatonic
symptoms in clinical practice. However, there are a few issues that need
to be highlighted, particularly from the
point of view of a psychiatrist presented with a patient with catatonic
symptoms.
The first relates to the likelihood
of this presentation being a form of epilepsy. The authors themselves briefly
consider this possibility.
In the patient described, there is a
previous history of (unspecified) head
injury, bradycardia (40 bpm), Glasgow
Coma Scale score of 3, administration
of antipsychotics, and a history of a
similar episode in the past. As the authors describe, an EEG examination
was not felt to be clinically indicated in
this case. We would wish to emphasize
further, however, the importance generally of the possibility of epilepsy in
presentations of catatonia with bradycardia.
Almansori et al.2 report a case of
asymptomatic ictal bradycardia diagnosed during video EEG telemetry, and
they stress that partial seizures (of temporal origin) can be associated with
clinically significant tachycardia or
bradycardia. Importantly, ictal bradycardia and asystole has been implicated
as one of the causes of Sudden Unexpected Death in Epileptic Patients (SUDEP).3 Another study4 has indicated
that ictal bradycardia can be explained
by influence of the central autonomic
network of the insular cortex and temO THE

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poral lobe, and there appears to be a

plethora of reports on ictal bradycardia,
mostly with temporal lobe seizures.2,4
Not only can catatonic features occur in epilepsy, but a positive response
to benzodiazepines can be seen in both
epilepsy and catatonia. Suzuki et al.5
report on three patients in whom catatonic stupor persisted after resolution
of the epileptic seizures. They emphasize the importance of EEG examination in patients with catatonic stupor,
for early recognition of nonconvulsive
status epilepticus, as well as epileptic
seizures superimposed on catatonic
stupor. The report5 also highlights the
information that ECT is helpful for persistent catatonic stupor after resolution
of seizures.
Although it is important to consider
the possibility of catatonic symptoms in
patients presenting with stupor, the presence of unusual episodic symptomatology with bradycardia should trigger
investigations to rule out epilepsy. Catatonic symptoms can, and do, present
with other general-medical conditions,
including epilepsy.6
The second issue relates to the possibility of bradycardia being secondary
to antipsychotic medication (olanzapine as well as haloperidol). In the absence of ECG data, it is not possible to
comment on whether the bradycardia
reflected a prolonged QTc.
A prolonged QTc, as well as bradycardia, could be likely precursors of
torsades de pointes, which could well
be fatal. Although, this does not explain the appearance of catatonic symptoms, it is possibly important to state
that any bradycardia of 40 bpm needs
to be investigated, and an ECG examination would be helpful.
We argue that although it is very
important to look for catatonic symptoms, it is probably no less important

to rule out other, cardiac, causes of bradycardia as well as the possibility of a

seizure phenomenon.
Niraj Ahuja, M.D., MRCPsych
Wallsend Community Mental Health
Team, Wallsend, U.K.
and School of Neurology,
Neurobiology, and Psychiatry
University of Newcastle-uponTyne, U.K.
Adrian J. Lloyd, MRCPsych, M.D.
Wallsend Community Mental Health
Team, Wallsend, U.K.
and School of Neurology,
Neurobiology, and Psychiatry
University of Newcastle-uponTyne, U.K.

References

1. Freudenreich O, McEvoy JP, Goff DC, et

al: Catatonic coma with profound
bradycardia. Psychosomatics 2007;
48:7478
2. Almansori M, Ijaz M, Ahmed SN:
Cerebral arrhythmia influencing cardiac
rhythm: a case of ictal bradycardia.
Seizure 2006; 15:459461
3. Leung H, Kwan P, Elger CE: Finding the
missing link between ictal
bradyarrhythmia, ictal asystole, and
sudden unexpected death in epilepsy.
Epilepsy Behav 2006; 9:1930
4. Britton JW, Ghearing GR, Benarroch EE,
et al: The ictal bradycardia syndrome:
localization and lateralization. Epilepsia
2006; 47:737744
5. Suzuki K, Miura N, Awata S, et al:
Epileptic seizures superimposed on
catatonic stupor. Epilepsia 2006; 47:793
798
6. Carroll BT, Anfinson TJ, Kennedy JC, et
al: Catatonic disorder due to generalmedical conditions. J Neuropsychiatry
Clin Neurosci 1994; 6:122133

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EDITOR: In patients with

severe mental illness, there is often

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Psychosomatics 49:1, January-February 2008