Naohisa Tsujino, MD, PhD, Department of Psychiatry, Toho University School of Medicine, 6-11-1, Omori-Nishi, Ota-ku, Tokyo 143-8541, Japan. Email: email@example.com
The purpose of the present study was to investigate regional cerebral blood flow (rCBF) changes in a patient with very-late-onset schizophrenia-like psychosis (VLOS) with catatonia. A 64-year-old woman developed catatonia after experiencing persecutory delusions. The patient's rCBF was examined using single photon emission computed tomography (SPECT) with easy Z-score imaging system. Before treatment, hypoperfusion was observed in the striatum and the thalamus, whereas hyperperfusion was observed in the left lateral frontal cortex and the left temporal cortex. After treatment, the disproportions in rCBF disappeared, and hyperperfusion was observed in the motor cortex. Sequential SPECT findings suggest that rCBF abnormalities may be correlated with the symptomatology of catatonia in patients with VLOS.
CATATONIA IS A psychomotor syndrome that can be characterized by stupor, immobility, mutism, and echophenomena. Catatonia is observed in several psychiatric disorders such as mood disorders, schizophrenia, and organic brain diseases. Catatonia is also known to occur in patients with late-onset schizophrenia (LOS) and very-late-onset schizophrenia-like psychosis (VLOS).1 Clinical differentiation of the underlying causes of catatonia is frequently difficult, however, and the neuropsychological and pathophysiological mechanisms of catatonia remain unknown.
Recent advances in neuroimaging technology seem to be helpful in clarifying the mechanisms of catatonia. Functional brain imaging techniques, such as single photon emission computed tomography (SPECT), can demonstrate dynamic changes in neuroactivities during catatonia. We report a VLOS patient with catatonia who underwent sequential 99mTc-ethyl cysteinate dimer single photon emission computed tomography (99mTc-ECD SPECT) with the easy Z-score imaging system (eZIS). 2
The patient was a 64-year-old Japanese woman who was right-handed. She had no history of psychiatric episodes. She was not active, and her spontaneity had been declining since around the age of 63 years. At the age of 64 years she began to insist that someone was watching her, that she was stripped naked, and that someone with a handsaw was pursuing her. The patient subsequently complained of these delusional ideas and often remained in bed. She was referred to the Toho University Omori Medical Center in Tokyo after she developed catatonia (mutism, waxy flexibilities, immobility, and posturing). She was admitted to the psychiatric ward. She met both the recent consensus criteria for VLOS1 and the DSM-IV-TR criteria for schizophrenia.3 On electroencephalography the main background activity consisted of a 9-Hz bioccipital rhythm, and paroxysmal waves were not observed. No abnormal laboratory findings were obtained.
Pharmacotherapy with haloperidol (5 mg/day) given i.v. was initiated. Within 5 days the patient gradually recovered from the catatonia and began to take oral medicine. Aripiprazole (6 mg/day) and lorazepam (1 mg/day) were initiated on day 10 of hospital admission. After the dosage of aripiprazole was increased to 12 mg/day on day 19, her complaints were alleviated. The patient made satisfactory improvement and was discharged from hospital on day 65.
We assessed the patient's psychotic symptoms using the Positive and Negative Syndrome Scale (PANSS)4 and the Clinical Global Impression Scale (CGI).5 The PANSS and CGI scores were 77 and 7, respectively before treatment. After treatment, the PANSS and CGI scores were 41 and 3, and we considered that her psychotic symptom had improved.
At the time of initial presentation brain magnetic resonance imaging (MRI) showed mild frontal and parietal atrophy and septum pellucidum. 99mTc-ECD SPECT with eZIS was performed before and after treatment. Written informed consent for these procedures was obtained from the patient and her family.
Before treatment, hypoperfusion was observed in the bilateral striatum and the bilateral thalamus, whereas hyperperfusion was observed in the left lateral frontal cortex and the left temporal cortex. After treatment, the hypoperfusion in the bilateral striatum almost disappeared, while only a slight hypoperfusion was observed in the bilateral thalamus. The hyperperfusion in the left frontal and temporal cortex disappeared, while hyperperfusion was observed in the motor cortex (Fig. 1).
This report is the first in sequential SPECT with eZIS findings on VLOS with catatonia. To our knowledge, only a few studies have investigated rCBF using SPECT in patients with catatonia. The present results show an asymmetrical change in the rCBF in the frontal and temporal lobes of a patient with catatonia. Other studies have also demonstrated an asymmetry in rCBF in patients with catatonia.6–8 The locations of asymmetrical rCBF, however, were inconsistent among the studies. These inconsistent results may have arisen from differences in the techniques used or from differences in the clinical manifestations of catatonic types between the primary diseases. Further studies are needed to clarify the relationship between asymmetrical rCBF in the frontal and temporal lobes and catatonia.
Hyperperfusion in the left frontal and temporal cortex may be more closely related to psychotic symptoms, such as delusion, rather than catatonia. The present patient exhibited persecutory delusions prior to developing catatonia. The ‘lateralization defect’ hypothesis for schizophrenia has been reported in several studies.9 This hypothesis states that schizophrenia patients have an abnormal left hemisphere function. Catafau et al. reported that schizophrenia patients had significant interhemispheric differences in prefrontal and posterior temporal index values at rest (left hyperfrontality and left hypotemporality).9
Hypoperfusion in the striatum and the thalamus may be closely related to catatonic motor symptoms. Because both the striatum and the thalamus clearly participate in the regulation of voluntary movements, this hypothesis seems to be valid. In addition, hyperperfusion in the motor cortex after treatment is of particular interest. It is suggested that the removal of the suppression caused by the catatonic symptoms after treatment may have activated the motor area.
Although further studies are needed to clarify a more precise relationship, the present sequential SPECT findings suggest that rCBF abnormalities may be correlated with the symptomatology of catatonia in patients with VLOS.