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A 14-year-old girl with major depressive disorder is psychiatrically hospitalized due to a lack of response to
outpatient interventions and total withdrawal from family, friends, and school. She is on fluoxetine and
quetiapine. During the initial evaluation, the girl does not speak or spontaneously move. Nursing reports that she
has also been mute on the unit and that they had to help her get into her scrubs. After the nurse raised the girl's
arms to help her get into the sleeves, the girl left her arms raised in that position for an extended time. What is
the mechanism of action of the first-line treatment for this condition?

AAnticholinergic effects
BDopamine and norepinephrine reuptake inhibition and release
CDopamine and serotonin receptor antagonism
DEnhancement of the inhibitory effects of gamma-aminobutyric acidCorrect Answer
ESelective serotonin reuptake inhibition

Correct Answer ( D )
Explanation:

The DSM-5 does not have a stand-alone diagnosis of catatonia. Instead, it is used as a specifier (catatonia
associated with another mental disorder), a catatonic disorder due to another medical condition, and unspecified
catatonia. Bipolar disorder, major depressive disorder, schizophrenia, and autism spectrum disorder are the most
common psychiatric disorders associated with the development of catatonia. A vast array of medical conditions
are associated with catatonia and tend to be similar to those implicated in delirium. At least three symptoms of
catatonia are required, such as stupor, mutism, agitation, posturing, or echolalia. Although the DSM-5 does not
make the distinction, clinical presentations are typically characterized as retarded, excited, or malignant. The
affected individual may vacillate between the retarded and excited types. In retarded catatonia, prolonged
immobility may lead to malnutrition, muscle wasting, bedsores, venous thrombosis, and pulmonary embolism.
Individuals with excited catatonia may require physical restraint in order to minimize dangers to themselves and
others posed by their excessive motor activity, impulsivity, and combativeness. Malignant catatonia is a life-
threatening syndrome that includes fever, autonomic instability, rigidity, and delirium. Early diagnosis and
prompt treatment are vital in reducing morbidity and mortality associated with catatonia. Hospitalization is
usually the safest setting for treatment. If the diagnosis is unclear, an intravenous lorazepam challenge will
demonstrate rapid improvement in most cases of catatonia. Benzodiazepines are also the recommended initial
intervention for the treatment of catatonia. Electroconvulsive therapy (ECT) is the treatment of choice for
malignant hyperthermia, but a benzodiazepine is used while awaiting consent and arranging for ECT.
Benzodiazepines cause an enhancement of the inhibitory effects of gamma-aminobutyric acid (GABA) by
binding to the benzodiazepine site on the GABA-A complex and are referred to as GABA positive allosteric
modulators. Other treatment measures include supportive care and avoiding or discontinuing dopamine blocking
agents due to the potential for worsening and an increased risk of neuroleptic malignant syndrome in the
presence of catatonia. There is an increased risk of mortality associated with malignant catatonia if ECT is not
initiated within 5 days of symptom onset.

Benztropine and trihexyphenidyl act through anticholinergic effects (A) to treat antipsychotic-induced
parkinsonism and acute dystonic reactions. Psychostimulant medications work through dopamine and
norepinephrine reuptake inhibition and release (B) and are sometimes used as adjuncts for treatment-resistant
depression. Dopamine and serotonin receptor antagonism (C) is most commonly associated with the
mechanism of action of some of the second-generation antipsychotic medications, such as olanzapine and
paliperidone. The mechanism of the first-line medications for major depressive disorder and many of the anxiety
disorders in children are antidepressants that work through selective serotonin reuptake inhibition (E), such as
fluoxetine and escitalopram.

Question: Why is flumazenil used prior to administering ECT in individuals being treated for catatonia with a
benzodiazepine?

Reveal Answer: To reverse the anticonvulsant properties of benzodiazepines.

Atypical Antipsychotics, Quetiapine

 Second-generation antipsychotic
Dual dopamine and serotonin antagonist
FDA-approved indications
Acute mania as monotherapy or adjunct to lithium or valproate (ages 10–17 years)
Acute schizophrenia (ages 13–17 years)
Common side effects: sedation, weight gain
Possible side effects: dyslipidemia, diabetes
Serious side effects
Diabetic ketoacidosis, rapid-onset hyperglycemia
Neuroleptic malignant syndrome: rare
Seizures: rare

References:
1. 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
American Psychiatric Publishing; 2013.
2. 2. Coffey MJ. Catatonia: treatment and prognosis. Post TW, ed. UpToDate. UpToDate Inc. Accessed
November 27, 2020.
3. 3. Williams DT. Delirium and catatonia. In: Martin A, Bloch MH, Volkmar FR, eds. Lewis’s Child and
Adolescent Psychiatry: A Comprehensive Textbook. 5th ed. Wolters Kluwer; 2018:(Ch) 5.11.

Reviewed February 2021

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Category: Schizophrenia Spectrum & Other Psychotic Disorders

Subcategory: Catatonia

Question: 118595

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 A. A 5%
B. B 2%
C. C 4%
D. D 89%
E. E 0%

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Normal Lab Values

25-hydroxyvitamin D, serum 25–80 ng/mL 62–200 nmol/L
Activated partial thromboplastin time (APTT) 25–35 seconds 25–35 seconds
Adrenocorticotropic hormone (ACTH) 9–52 pg/mL 2–11 pmol/L
Alanine aminotransferase (ALT) 0–35 U/L 0–0.58 µkat/L
Albumin 3.5–5.5 g/dL 35–55 g/L
Alkaline phosphatase 45–115 U/L (men), 30–100 U/L (women) 0.75–1.92 µkat/L (men), 0.50–1.67 µkat/L
(women)
Ammonia 40–80 µg/dL 23–47 µmol/L
Amylase 0–130 U/L
Anion Gap 8–16 mEq/L 8–16 mmol/L
Aspartate aminotransferase (AST) 0–35 units/L 0–0.58 µkat/L
Bands < 1 x 10,000/µL < 1 x 10,000/mm3
Bicarbonate 23–28 mEq/L 23–28 mmol/L
Bilirubin, direct/conjugated 0–0.3 mg/dL 0–5.1 µmol/L
Bilirubin, total 0.3–1.2 mg/dL 5.1–20.5 µmol/L
Blood urea nitrogen (BUN) 8–20 mg/dL 2.9–7.1 mmol/L
B-type natriuretic peptide (BNP) <100 pg/mL < 100 ng/L
Calcium (ionized, adult) 4.5–5.6 mg/dL 1.05–1.3 mmol/L
Calcium (total) 9–10.5 mg/dL 2–2.6 mmol/L
Ceruloplasmin 16–31 mg/dL (men), 19–39 mg/dL (women)
Chloride 98–106 mEq/L 98–106 mmol/L
Cholesterol (Total: Adult) 150–199 mg/dL 3.88–5.15 mmol/L
COHb (%) Non Smoker: < 2% Smoker: <9% Non Smoker: < 2% Smoker: <9%
Copper 63.7–140.12 µg/dL 12–22 µmol/L
Cortisol (bedtime) 3–13 µg/dL 83–359 nmol/L
Cortisol (free, urine) < 50 µg/24 h 138 nmol/24 h
Cortisol (morning) 10–20 µg/dL 275.88–551.76 nmol/L
C-peptide - serum 0.5–2.0 ng/mL 0.17–0.66 nmol/L
C-reactive protein (CRP) < 5 mg/L
Creatine kinase (CK) 30–170 U/L 0.50–2.84 µkat/L
Creatinekinase – MB fraction (CK-MB) 0–7 ng/mL 0–7 µg/L
Creatinine 0.7–1.3 mg/dL 61.9–115 µmol/L
CSF Cell count 0-5 cells/µL 0-5 × 10⁶ cells/L
CSF Glucose 40–80 mg/dL 2.2–4.4 mmol/L
CSF Opening pressure 7-20 cm of H20
CSF Protein 15–50 mg/dL 150–500 mg/L
D-dimer < 0.5 µg/mL < 500 ng/mL
Erythrocyte sedimentation rate (ESR) 0–15 mm/hr (men) 0–20 mm/hr (women)
Estradiol (female, day 1-10) 14–27 pg/mL 50–100 pmol/L
Estradiol (female, day 11-20) 14–54 pg/mL 50–200 pmol/L
Estradiol (female, day 21-30) 19–41 pg/mL 70–150 pmol/L
Estradiol (male) 10–30 pg/mL 37–110 pmol/L
Ferritin, serum 15–200 ng/mL 15–200 µg/L
Fibrinogen, plasma 150–350 mg/dL 1.5–3.5 g/L
Follicle-stimulating hormone (female, follicular/luteal phase) 5–20 mU/mL 5–20 U/L
Follicle stimulating hormone (female, midcycle) 30–50 mU/mL 30–50 U/L
Follicle stimulating hormone (female, postmenopausal) > 35 mU/mL > 35 U/L
Follicle stimulating hormone (male) 5–15 mU/mL 5–15 U/L
Free Thyroxine (T4), serum 0.9–2.4 ng/dL 12–31 nmol/L
Free Triiodothyronine (T3), serum 2.3 - 4.2 pg/mL 0.04-0.06 pmol/L
Gastrin 0–180 pg/mL 0–86.58 pmol/L
GGT level 0 to 30 IU/L
Glucose (fasting) 70–100 mg/dL 3.9–5.6 mmol/L
Glycosylated hemoglobin 4%–5.9% 4%–5.9%
Haptoglobin 50–150 mg/dL 500–1500 mg/L
HDL (Men) ≥ 40 mg/dL 1.0 mmol/dL
HDL (Women) ≥ 50 mg/dL 1.3 mmol/dL
Hematocrit (Hct) (Female) 36–47% 0.36–0.47
Hematocrit (Hct) (Male) 41–51% 0.41–0.51
Hemoglobin (Hgb) (Female) 12–16 g/dL 120–160 g/L
Hemoglobin (Hgb) (Male) 14–17 g/dL 140–170 g/L
Insulin - serum < 25 mU/L < 174 pmol/L
Iron 60–160 µg/dL 11–29 µmol/L
Lactate dehydrogenase (LDH) 60–100 units/L 1.00–1.67 µkat/L
Lactic acid 6–16 mg/dL 0.67–1.8 mmol/L
LDL < 100 mg/dL
Lipase < 95 U/L < 1.59 µkat/L
Luteinizing hormone (female, follicular/luteal phase) 5–22 mU/mL 5–22 units/L
Luteinizing hormone (female, midcycle) 30–250 mU/mL 30–250 units/L
Luteinizing hormone (female, postmenopausal) > 30 mU/mL > 30 units/L
Luteinizing hormone (male) 3–15 mU/mL 3–15 units/L
Lymphocytes 1,000–4,000/µL (20–40%) 1,000–4,000/mm3 (20–40%)
Magnesium 1.5–2.4 mg/dL 0.62–0.99 mmol/L
Mean corpuscular hemoglobin concentration (MCHC) 32–36 g/dL 320–360 g/L
Mean corpuscular hemoglobin (MCH) 28–32 pg 0.4–0.5 fmol/cell
Mean corpuscular volume (MCV) 80–100 fL/red cell
Metanephrines (urine) < 1.2 mg/24 hours < 6.1 mmol/24 hours
Monocytes 100–700/µL (2–8%) 100–700/mm3 (2–8%)
Neutrophils 2500–8000/µL (55–70%) 2500–8000/mm3 (55–70%)
Parathyroid hormone (PTH) 10–65 pg/mL 10–65 ng/L
PCO₂ 35–45 mm Hg 4.7–6 kPa
pH 7.35-7.45 7.35-7.45
Phosphorus 3–4.5 mg/dL 0.97–1.45 mmol/L
Platelets 150,000–350,000/µL 150–350 × 10⁹/L
PO₂ 80–100 mm Hg 10.6–13.3 kPa
Potassium 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Procalcitonin (adults and children > 72 hours old) < 0.15 ng/mL
Prolactin (Men) < 15 ng/mL < 15 µg/L
Prolactin (Nonpregnant women) < 20 ng/mL < 20 µg/L
Prolactin (Pregnant women) 36–372 ng/mL 36–372 µg/L
Protein C 65 to 135 IU dL-1
Prothrombin time (PT) 11–13 seconds 11–13 seconds
Pyruvate 300–900 µg/dL 34068.00–102204.00 µmol/L
Red blood cells (RBC) 4.7–6.1 x 10⁶/µL (men), 4.2–5.4 x 10⁶/µL (women)
Red cell distribution width (RDW) 11.6–14.6% 11.6–14.6%
Reticulocytes 0.5%–1.5% 0.5%–1.5%
Reverse Triiodothyronine (T3), serum 10–24 ng/dL 10–24 ng/dL
Sodium 136–145 mEq/L 136–145 mmol/L
Testosterone (adult male) 300–1200 ng/dL 10–42 nmol/L
Testosterone (female) 20–75 ng/dL 0.7–2.6 nmol/L
Thyroid-stimulating hormone (TSH) 0.5–5.0 µU/mL 0.5–5.0 mU/L
Total iron-binding capacity (TIBC) 250–460 µg/dL 45–82 µmol/L
Total Serum Protein 6.0–7.8 g/dL 60–78 g/L
Total Thyroxine (T4), serum 5–12 µg/dL 64–155 nmol/L
Total Triiodothyronine (T3), serum 70–195 ng/dL 1.1–3.0 nmol/L
Transferrin 200–360 mg/dL 24.60–44.28 µmol/L
Transferrin saturation 20–50% 20–50%
Triglycerides <150 mg/dL < 1.69 mmol/L
Troponin I 0–0.5 ng/mL 0–0.5 μg/L
Troponin T 0–0.10 ng/mL 0–0.10 µg/L
Tryptase < 11.5 ng/mL < 11.5 ng/mL
Urea 17–43 mg/dL 2.8–7.2 mmol/L
Uric acid, serum 2.5–8 mg/dL 0.15–0.47 mmol/L
White blood cells (WBCs) 4,000–10,000/µL 4.0–10.0 x 10⁹/L