Letters

86 http://psy.psychiatryonline.org Psychosomatics 49:1, January-February 2008

On Catatonia, Seizures,and Bradycardia

TO THE EDITOR: The interestingreport of catatonia presentation

with bradycardia by Freudenreich etal.1 splendidly highlights the impor-tance of identification of catatonicsymptoms in clinical practice. How-ever, there are a few issues that needto be highlighted, particularly from thepoint of view of a psychiatrist pre-sented with a patient with catatonicsymptoms.

The first relates to the likelihoodof this presentation being a form of ep-ilepsy. The authors themselves brieflyconsider this possibility.

In the patient described, there is aprevious history of (unspecified) headinjury, bradycardia (40 bpm), GlasgowComa Scale score of 3, administrationof antipsychotics, and a history of asimilar episode in the past. As the au-thors describe, an EEG examinationwas not felt to be clinically indicated inthis case. We would wish to emphasizefurther, however, the importance gen-erally of the possibility of epilepsy inpresentations of catatonia with brady-cardia.

Almansori et al.2 report a case ofasymptomatic ictal bradycardia diag-nosed during video EEG telemetry, andthey stress that partial seizures (of tem-poral origin) can be associated withclinically significant tachycardia orbradycardia. Importantly, ictal brady-cardia and asystole has been implicatedas one of the causes of Sudden Unex-pected Death in Epileptic Patients (SU-DEP).3 Another study4 has indicatedthat ictal bradycardia can be explainedby influence of the central autonomicnetwork of the insular cortex and tem-

poral lobe, and there appears to be aplethora of reports on ictal bradycardia,mostly with temporal lobe seizures.2,4

Not only can catatonic features oc-cur in epilepsy, but a positive responseto benzodiazepines can be seen in bothepilepsy and catatonia. Suzuki et al.5

report on three patients in whom cata-tonic stupor persisted after resolutionof the epileptic seizures. They empha-size the importance of EEG examina-tion in patients with catatonic stupor,for early recognition of nonconvulsivestatus epilepticus, as well as epilepticseizures superimposed on catatonicstupor. The report5 also highlights theinformation that ECT is helpful for per-sistent catatonic stupor after resolutionof seizures.

Although it is important to considerthe possibility of catatonic symptoms inpatients presenting with stupor, the pres-ence of unusual episodic symptomatol-ogy with bradycardia should triggerinvestigations to rule out epilepsy. Cat-atonic symptoms can, and do, presentwith other general-medical conditions,including epilepsy.6

The second issue relates to the pos-sibility of bradycardia being secondaryto antipsychotic medication (olanza-pine as well as haloperidol). In the ab-sence of ECG data, it is not possible tocomment on whether the bradycardiareflected a prolonged QTc.

A prolonged QTc, as well as bra-dycardia, could be likely precursors oftorsades de pointes, which could wellbe fatal. Although, this does not ex-plain the appearance of catatonic symp-toms, it is possibly important to statethat any bradycardia of 40 bpm needsto be investigated, and an ECG exam-ination would be helpful.

We argue that although it is veryimportant to look for catatonic symp-toms, it is probably no less important

to rule out other, cardiac, causes of bra-dycardia as well as the possibility of aseizure phenomenon.

Niraj Ahuja, M.D., MRCPsychWallsend Community Mental Health

Team, Wallsend, U.K.and School of Neurology,Neurobiology, and PsychiatryUniversity of Newcastle-upon-Tyne, U.K.

Adrian J. Lloyd, MRCPsych, M.D.Wallsend Community Mental Health

Team, Wallsend, U.K.and School of Neurology,Neurobiology, and PsychiatryUniversity of Newcastle-upon-Tyne, U.K.

References

1. Freudenreich O, McEvoy JP, Goff DC, etal: Catatonic coma with profoundbradycardia. Psychosomatics 2007;48:74–78

2. Almansori M, Ijaz M, Ahmed SN:Cerebral arrhythmia influencing cardiacrhythm: a case of ictal bradycardia.Seizure 2006; 15:459–461

3. Leung H, Kwan P, Elger CE: Finding themissing link between ictalbradyarrhythmia, ictal asystole, andsudden unexpected death in epilepsy.Epilepsy Behav 2006; 9:19–30

4. Britton JW, Ghearing GR, Benarroch EE,et al: The ictal bradycardia syndrome:localization and lateralization. Epilepsia2006; 47:737–744

5. Suzuki K, Miura N, Awata S, et al:Epileptic seizures superimposed oncatatonic stupor. Epilepsia 2006; 47:793–798

6. Carroll BT, Anfinson TJ, Kennedy JC, etal: Catatonic disorder due to general-medical conditions. J NeuropsychiatryClin Neurosci 1994; 6:122–133

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