A CASE PRESENTATION ON A

PATIENT BEING MANAGED FOR

CATATONIA
BY:
ADEYEMI H.S
RESIDENT, MENTAL HEALTH DEPARTMENT
OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX (OAUTHC), ILE-IFE
3RD APRIL, 2023
Case Summary
• MRs O.M is 29 year old woman, MTN Customer Care Representative, married who was
admitted 9weeks ago for 3weeks at Mental Health Department, Wesley Grid Hospital, Ilesha
and was transferred about 6weeks ago to Mental Health Department, IHU to have
electroconvulsive therapy done
• Her presentation at our hospital was on account of 3rd episodes of mental illness
characterized by 3months history of withdrawal to self and unusual behaviour (Reading bible
portions and pray before eating and use her drugs, and going about with bible) and a week
history of refusal to eat and take her bath, refusal to speak, staring into space, and motionless
posture
• In addition, we found that she had loss of interest in normal activities, lack of motivation and
apathy which was unlike her

• There is no persistent mood changes

• Unusual beliefs and perceptual disturbances could not be ascertained
Case Summary (Cont’d)
• All domains of functioning were severely affected:
• Involuntarily excused from workplace to attend to her health which lasted for 3months
before presentation
• Strained marital relationship

• She was initially placed on Tab chlorpromazine 100mg bd

• After 15days on admission, she was maintained on tab chlorpromazine 100mg nocte and
tab risperidone 2mg nocte

• The patient was transferred to Mental Health Department, IHU about 6weeks ago for
electroconvulsive therapy due to insignificant clinical improvement
Case Summary (Cont’d)
• First Episode:
• About 2years ago (March 2021), she had first episode of mental illness 2months to her
wedding characterized by excessive fasting and prayers, and poor sleep for 19days
• About 1month after her wedding(May 2021) she was gravid.
• The hyper-religiousity continued after her wedding till she had stillbirth (February
2022) at 36weeks GA
• Husband took her to Winners chapel for faith healing
• The mother also took her to CAC for faith healing from where they were advised for
hospital care
• The first episode lasted for 1year (March 2022) before she presented at a private
facility at Ilorin
Case Summary (Cont’d)
• First Episode:
• She was place on Tab chlorpromazine 100mg nocte, Tab risperidone
2mg nocte and tab Benzhexol 5mg mane
• She claimed to be adherent to her medication
• Level of functioning was said to improve as close to premorbid state
Case Summary (Cont’d)
• Psychosocial Issues Before and During First Episode:
• Wedding Preparation
• Excessive fasting and prayers
• Pregnancy
• Lack of support from husband (Not regular at home 1 month after
wedding, for 10months, June 2021 to April 2022)
• Financial constraints
Case Summary (Cont’d)
• Second Episode:
• About 7months ago (August 2022), she presented at WGH, Ilesha with
2nd episode of mental illness 6months after she had stillbirth
• Illness was characterized by social withdrawal (anhedonia, affective
blunting &avolition) and unusual behaviour (reading bible portions
and pray before eating or use her drugs, and going about with bible)
of 1month duration, poor sleep of 2weeks duration and involuntary
movement of the shoulder of 1 week duration
• Prior to the symptoms above she was not adherent to her medication
• Admission was declined based on financial ground
Case Summary (Cont’d)
• Second Episode:
• She was managed for psychotic disorder, ? Tic disorder on tab
chlorpromazine 100mg nocte
• Tab risperidone was discontinued
• Plan was to see after 1 week
• The patient did not return for clinic follow up
• She was also said to have stopped medication after 1 week of use
• Her recovery was partial
Case Summary (Cont’d)
• Psychosocial Issues before Second Episode:
• Stillbirth (6months)
• Lack of support from husband (Staying separate from husband at
Ibadan for 3months, btw May 2022 to August 2022)
• Financial constraints
Case Summary (Cont’d)
• She is the first of 3 children in a monogamous setting
• Father is a 60 year old retired Town planner, while mother is a 58 year
old civil servant(a typist at OSCOED)
• Relationship with members of the family is cordial
• Family history of mental illness was denied.
Case Summary (Cont’d)
• Graduated from Osun State University with 2nd class lower in
microbiology
• Worked with MTN office, Ilesha as customer care representative from
2017-2022 (4years)
• Transferred to MTN office, Ibadan about 10months ago
• Married to Mr Oladapo Victor, a 30year old man who now works as a
driver with his uncle
Case Summary (Cont’d)
• No history of use of psychoactive substances
• No conflict with the law
• Described as one who loves making friends, likes reading books, has a
good relationship with colleagues, optimistic, and cheerful
Case Summary (Cont’d)
Mental State Examination:

• Unkempt and poorly groomed

• Starring
• Selective mutism
• Posturing
• Negativism
• Suspicious
• Psychomotor retardation
• Dangerous to self
• Impaired judgment
• Partial insightful
Case Summary (Cont’d)
Physical Examination
• General physical examination: afebrile, not pale, anicteric, moderately dehydrated

• Weight: 21/2/23(51kg); 3/4/23 ( 48)kg

• Height: 1.52m
• BMI: 21/2/23 (22.2kg/m²), 3/4/23 ( 20.8kg/m²)

• Systemic Examination:
• CVS: PR: 70- 90bpm, BP: 100/60mmHg -120/80mmHg
• Chest: RR: 22cpm
• CNS – conscious
no signs of meningeal irritation
no cranial nerve deficit
normal tones and reflexes
normal gait
Other Systems - NAD
Diagnostic Formulation
Summary
• A 29 year old woman, MTN Customer Care Representative, married who was admitted
9weeks ago for 3weeks at Wesley Grid Hospital, Ilesha on account of 3rd episodes of
mental illness characterized by 3months history of withdrawal to self and unusual
behaviour and a week history of refusal to eat and have her bath, refusal to speak,
staring into space, and motionless posture

• She was transferred about 6weeks ago to Mental Health Department, IHU to have
electroconvulsive therapy done
• Was not adherent to medications prior to onset of current episode
• Involuntarily excused from workplace to attend to her health
• Relationship with husband strained
Diagnostic Formulation (Cont’d)
Items of Phenomenology:

• Unkempt and poorly groomed

• Staring
• Selective mutism
• Posturing
• Negativism
• Suspicious
• Psychomotor retardation
• Dangerous to self
• Impaired judgment
• Partial insightful
Diagnostic Formulation (Cont’d)
• Axis I: Diagnosis
-ICD 11: Schizophrenia multiple episodes currently symptomatic
-ICD11: Catatonia 2◦ schizophrenia
-ICD 10: Catatonic schizophrenia

• Axis II: Related Disability: Personal care (Severe), Occupation (Severe), Family (Severe) and Broader
social context (Severe)

• Axis III: Contextual Factors

i. Predisposing factor : Not identifiable
ii. Precipitating factor: Stressful events (marital disputes), compulsorily excused from workplace, Poor
adherence to treatment
iii. Perpetuating factor: Poor adherence to treatment and strained marital relationship
Diagnostic Formulation (Cont’d)

Management: • E/U/Cr result:

a. Investigations o Na – 135mmol/L
Biological: o K – 3.9mmol/L
• FBC + Diff Result: o Urea – 2.8mmol/L
o PCV - 40% o Creatinine – 63 umol/L
o WBC – 5500 per cmm3 o HCO3 – 23mmol/L
o neutrophils – 72%
o Lymphocytes – 28% • RBS – 4.5mmol/L
Diagnostic Formulation (Cont’d)
Psychological:
• PANSS:
o 21/3/23 (P=24/49, N=38/49, CS= -14, G=67/112, TS= 129/210)
o 3/4/23 (P=16/49, N=19/49, CS= -3, G=37/112, TS= 72/210)

• Bush Francis Catatonia Rating scale (BFCRS):

o 21/3/23: Screening Scale: 7/14 (Presence)
Severity Scale: 19/69 (Moderate)
o 3/4/23: Screening Scale: 3/14 (Presence)
Severity Scale: 5/69 (Mild)

Social:
• Effects on workplace and marriage and vice versa
Diagnostic Formulation (Cont’d)
Management:

b. Treatment
Biological:
• For inpatient care at MHW, IHU
• CT Tab chlorpromazine 100mg nocte
• CT Tab risperidone 2mg nocte
• Placed PRN medications
• Informed consent for ECT obtained from the father
• Anaesthetic review for commencement of ECT
Diagnostic Formulation (Cont’d)
Management:

b. Treatment
Psychological:
• Psychoeducation
• Psychodynamic formulation
Social:
• Aim to reduce the effects of the illness on workplace and marriage
Progress Reports (Cont’d)
First 16 Days on Admission in IHU:

• ECT was commenced the 2nd day of admission with good seizure quality and
duration
• Had 6 sessions of ECT
• The last shot was about 26days ago
• The seizure duration ranges from 20s – 48s
• Pre and post vital signs were stable during the procedures
• During sessions she was always persuaded to eat and for personal care
• She responded when engaged in discussion but does not initiate conversation
• Oral medications were continued during the sessions
Progress Reports (Cont’d)
1st to 4th Day Post ECT in IHU
• Started initiating conversation with nurses and other patients
• Taking her bath without persuasion
• She was coming to the nursing station to receive medications and for
vital signs
• Always received her food from dinning and her appetite also improved
Plan:
• CT tab chlorpromazine 100mg nocte and tab risperidone 2mg nocte
• Social workers to investigate her employment status and invite husband
Progress Reports (Cont’d)

5th to 12th Day Post ECT in IHU

• Interaction with others was good
• Persuade to bath and care for self
• Did not changed her ward uniform
• Started staring into space when engaged in conversation
• Blessed food with bible when she decided to eat
• Agitated to be discharged
Plan:
• ↑Tab risperidone 2mg bd
• CT tab chlorpromazine 100mg nocte
Progress Reports (Cont’d)
13th to 19th Day Post ECT in IHU
• Take her bath without persuasion but late into the day
• Did not change her ward uniform
• She responded when engaged but has stopped initiating conversation
• Always lie in bed, maintaining the same posture for less than an hour
and staring into space
• She always leaves her bed to receive food but eventually dumps it into
dustbin
• Sometimes, she ate the hospital food after blessing with the bible
Progress Reports (Cont’d)
13th to 19th Day Post ECT in IHU
• When she eats her personal food (golden mourn) she does not bless with bible
• Parents said her work is preserved and she is being paid half salary for the past
5months
• Her husband visited:
• She was very excited, staring resolved on that day, initiated conversation with
her husband and was expressive on the ward
• Her interaction with others improved
• She did not lie in bed nor maintain the same posture
• She also ate her lunch after a day of not eating hospital food
Progress Reports (Cont’d)

• Plan:

• Changed risperidone to risperdal

• ↑Tab Risperdal 2mg mane, 3mg nocte
• CT Tab Chlorpromazine 100mg nocte
• Reducing regimen of Diazepam:10mg bd x 3/7, 10mg nocte x2/7 and
5mg nocte
Progress Reports (Cont’d)
20th to 26th Day Post ECT in IHU

• Worsening of symptoms was observed when the husband left

• Take her bath without persuasion in the afternoon and evening
• Has not change her ward uniform
• Stopped initiating conversation
• Always lie in bed, maintaining the same posture for less than an hour and
staring into space
Progress Reports (Cont’d)
20th to 26th Days Post ECT in IHU

• Sometimes, she does not stare when engaged in conversation

• At other times, she stares during discussion
• Continue dumping hospital food inside dustbin
• Sometimes, she ate the hospital food after blessing with portions of
scriptures from the bible
Progress Reports (Cont’d)
• 20th to 26th Days Post ECT in IHU

• MSE:
• Staring into space (less severe)
• Posturing(less severe)
• Suspicious
• Dangerous to self
• Impaired judgment
• Partial insight
Progress Reports (Cont’d)
• PANSS:
o 21/3/23 (P=24/49, N=38/49, CS= -14, G=67/112, TS= 129/210)
o 3/4/23 (P=16/49, N=19/49, CS= -3, G=37/112, TS= 72/210)

• Bush Francis Catatonia Rating scale (BFCRS):

o 21/3/23: Screening Scale: 7/14 (Presence)
Severity Scale: 19/69 (Moderate)
o 3/4/23: Screening Scale: 3/14 (Presence)
Severity Scale: 5/69 (Mild)

• Plan:
• Tab Risperdal 2mg mane, 3mg nocte
• CT Tab Chlorpromazine 100mg nocte
• Family therapy
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