Catatonia: Another Reason to Get the COVID-19 Vaccine

My wife and I have been immunized against COVID-19 and we recognize that people can be hesitant about getting vaccinated. However, I’m remembering my last few months prior to my retirement a year ago working as a general hospital psychiatric consultant and I saw one or two cases of catatonia in the context of COVID-19 infections.

Catatonia is a complex, potentially lethal neuropsychiatric complication of many medical disorders including COVID-19. It can make a person mute and immobile, often making health care professionals mistake it for primary psychiatric illness (for example, catatonic schizophrenia). You can access a fascinating educational module on the National Neuroscience Curriculum Initiative (NNCI) website about catatonia and how it can be associated with COVID-19.

Catatonia can kill people, rendering them unable to move or eat, leading to blood clots and dehydration among a host of other complications. You’ve seen the news stories about blood clots being an extremely rare but deadly side effect of the Johnson & Johnson COVID-19 vaccine. The risk for blood clots is actually higher from COVID-19 infection itself compared with the very low risk from the vaccine.

I made a YouTube video about catatonia and other neuropsychiatric emergencies and that presentation continues to be viewed fairly often. You’ll want to crank up the volume.

I wrote a blog post about catatonia in the setting of delirium a couple of years ago and the information in it is still relevant below.

Catatonic patients may have a fever and muscular rigidity that leads to the release of an enzyme associated with muscle tissue breakdown called creatine kinase (CK). The level of CK can be elevated and detectable on a lab test.

Many patients will have a fast heart rate and fluctuating blood pressure. They may sweat profusely which can lead to a sort of greasy facial appearance. They may have a reduced eye blink rate or seem not to blink at all. They may display facial grimacing.

The patient may exhibit the “psychological pillow” (some call this the “pillow sign”). While lying in bed, the patient holds his head off the pillow with the neck flexed at what looks like an extremely uncomfortable angle. The position, like other odd, awkward postures can be held for hours.

Catatonia can be caused by both psychiatric and medical disorders. It tends to be more common in bipolar disorder than in schizophrenia even though catatonia has historically been associated with schizophrenia as a subtype. You can also see it in encephalitis, liver failure, and in some forms of epilepsy and other medical conditions—to which we can now add COVID-19 infection.

The patient may perseverate or repeat certain words no matter what questions you ask. He may simply echo what you say to him and that’s called “echolalia”.

Although catatonic stupor is what you usually see, less commonly you can see catatonic excitement, which is constant or intermittent purposeless motor activity.

The usual way to assess catatonic stupor in order to distinguish it from hypoactive delirium is to administer Lorazepam intravenously, usually 1 to 2 milligrams. A positive test for catatonic stupor is a quick and sometimes miraculous awakening as the patient returns to more normal animation. The reaction is usually not sustained and the treatment of choice is electroconvulsive therapy (ECT), which can be life-saving because the consequence of untreated catatonia can be death due to such causes as dehydration and pulmonary emboli.

Another less invasive test that doesn’t use medicine is the “telephone effect” described in the 1980s by a neurologist, C. Miller Fisher. It was used to temporarily reverse abulia or akinetic mutism, which in a subset of cases of stupor are probably the neurologist’s terms for catatonia. Sometimes the mute patient suffering from abulia can be tricked into talking by calling him on the telephone. It’s pretty impressive when a patient who is mute in person answers questions by simply calling him up on the telephone just outside his hospital room. 

So that, in my opinion, is yet another reason to get the COVID-19 vaccine.

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