report

1. 1
Mental Health Follow-up/Progress Note
Patient Name: Catatonic Schizophrenia vs. Tardive Dystonia Facility: XXXX
Date(s): xx-xx-xx First seen: xx-xx-xx, Last seen: xx-xx-xx
I was asked to see her again because “she has been making suicidal statements such as “I should
just die””.
She continues to carry a diagnosis of Catatonic schizophrenia which is exceedingly rare now
days. Catatonic schizophrenia was common in the days before the advent of modern psychiatric
medications and during the time when psychiatric patients were warehoused in large psychiatric
institutions. The symptoms include the following: 1) a marked disturbance in motor function
called waxy flexibility which involves rigidity, stupor, posturing and echopraxia; patients may
hold awkward positions for long periods of time… 2) purposeless excitement with possible risk
of injury to self or others… patients may emerge from a catatonic state suddenly and, without
warning be quite violent… 3) speech disturbances such as echolalia or mutism. There may be a
need for medical care associated malnutrition, exhaustion, or hyperpyrexia. In the past, I
diagnosed her with schizoaffective schizophrenia.
Schizoaffective schizophrenia is the most benign form of schizophrenia. Schizoaffective
patients have a better prognosis than typical schizophrenic patients and a worse prognosis than
mood disorder patients. Schizoaffective patients are less likely to have a deteriorating course
than are schizophrenic patients. Antidepressant drugs should be used combined with
antipsychotic medications to control the signs and symptoms of the disorder. Also, the symptoms
of schizophrenia normally change with the passage of time; dramatic symptoms such as
delusions and hallucinations diminish in severity while negative symptoms such as withdrawal,
apathy and a flattening of affect persist. These negative symptoms of schizophrenia tend to
resemble symptoms of depression.
She was admitted to XXXX on Remeron 15mg qhs, Risperdal 4mg qhs, Lamictal 25mg qhs and
Fluvoxamine 25mg qhs. At one point following admission, her Risperdal was tapered to DC and
what emerged was a full-blown case of Tardive Dystonia, an uncommon complication of long-
term treatment with neuroleptic drugs. It is a variant of tardive dyskinesia and like tardive
dyskinesia the signs emerge as the neuroleptic medication is withdrawn. The risk of its
development increases with advancing age. Tardive Dystonia is a more severe and more
incapacitating condition than tardive dyskinesia. Patients with tardive dystonia show sustained
postures of the face, neck, arms and/or trunk. Patients may freeze up and become immobile and
mute. The dystonia may be focal, segmental or generalized. The dystonic contractures are often
exacerbated by emotion and distress and may appear only during certain motor acts. Risperdal
was restarted at 2mg qhs and Tardive Dystonia signs
were suppressed. As you can see, Tardive Dystonia can be mistaken for Catatonic
Schizophrenia.

2. 2
She is subject to frequent UTIs. Her last labs were in September of this year at which time she
had a high WBC, as well as, a positive UA. However, the UTIs do not usually produce a
delirium.
She currently takes Remeron 45mg qhs, (her Remeron was increased from 15mg qhs to 45mg
qhs because Remeron is activating in the higher doses and sedating in lower doses), Risperdal
2mg qhs, Lamictal 25mg qd and Fluvoxamine 50mg qhs, as well as, Tramadol 50mg tid and
Vicodin 5/325 q4hr prn.
On interview I found her in bed with her usual wide-eyed stare and mild bilateral arm tremors
but she was not showing dramatic signs of Tardive Dystonia. She said she was free of pain,
depression and anxiety. Her affect was flat. There were no delusions or hallucinations. She said
the suicide talk was “just on the weekend…I was upset…I didn’t mean it.”
Assessment; She is not actively suicidal. The suicide talk is passive. It is an indirect way of
expressing anger. (i.e. inducing guilt in and cause others to feel responsible for her depression).
In addition, her statements express a need for support from others. She did improve with the last
adjustment in psychiatric medication. She has Schizoaffective schizophrenia but she does not
suffer from Catatonic schizophrenia when her highly antidopaminergic antipsychotic meditation
drops below a certain dose level Tardive Dystonia emerges and clinicians working with her have
mistaken it for Catatonic schizophrenia.
Recommendations:
1. Would try increasing the Fluvoxamine to 100mg qhs.
2. Very gentile push to increase activities.
3. When she says “I should just die” try to get her to talk about the underlying feeling;
what is bothering her?
4. Keep things as calm and quiet as possible around her.
5. Do not directly contradict any of her irrational beliefs. Gently and indirectly assert
reality.
6. Reinforce rational, positive behavior with immediate praise.
7. Make your contacts with her frequent, brief and reassuring.
Drew Chenelly, Psy.D.
Clinical Neuropsychologist This document was created using voice recognition software.