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Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 62-64

Hyponatremia-associated catatonia in an elderly male: A case report and review of literature

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission24-Feb-2020
Date of Decision03-Apr-2020
Date of Acceptance31-May-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Dr. Aseem Mehra
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_6_20

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Catatonia is a condition characterized by abnormal behavior and reported to occur in various psychiatric as well as in medical illnesses. The association of hyponatremia and catatonia in the absence of confounding factors is a matter of debate. There are few case reports that found the association between hyponatremia and catatonia, but none of them reported in the absence of confounding factors. We report a case of an elderly male presented with catatonia in association with hyponatremia. Complete resolution of symptoms was associated with normalization of sodium and the use of a low dose of lorazepam. It is suggested that the evaluation of serum electrolyte levels should be an essential part of the evaluation of an older adult with catatonia.

Keywords: Catatonia, elderly, hyponatremia

How to cite this article:
Mehra A, Grover S. Hyponatremia-associated catatonia in an elderly male: A case report and review of literature. J Geriatr Ment Health 2020;7:62-4

How to cite this URL:
Mehra A, Grover S. Hyponatremia-associated catatonia in an elderly male: A case report and review of literature. J Geriatr Ment Health [serial online] 2020 [cited 2023 Jun 7];7:62-4. Available from:

  Introduction Top

Catatonia is a syndrome characterized by altered motor behavior changes accompanying many medical, psychiatric, and neurological conditions.[1] In the DSM-5, catatonia is classified depending on whether it is associated with a general medical condition or a medication-induced movement disorder, a primary psychiatric illness. At least three symptoms characterize catatonia out of the following symptoms: catalepsy, waxy flexibility, negativism, mannerism, stereotypy, echolalia, echopraxia, agitation, mutism, stupor, posturing, and grimacing.[2] Historically, catatonia is linked to schizophrenia, affective disorders, and other mental illnesses. However, the etiology of catatonia is numerous, ranging from medical to psychiatric illnesses. Electrolyte disturbance is one of the main etiologies for catatonia. Hyponatremia is the most common electrolyte disturbance reported in the literature, yet hyponatremia in the absence of medical or psychiatric illness and drug induced is an uncommon presentation of the catatonia. The index case highlights the association of hyponatremia and catatonia in the absence of medical or psychiatric illness. To the best of our knowledge, only seven reports of hyponatremia-induced catatonia exist in the literature.[3] Our case is unique in the sense that hyponatremia and catatonia occur in the absence of underlying any medical or psychiatric illness. This case too reports exemplifying that assessment of electrolyte disturbance (sodium/potassium/calcium) in the elderly population. The low dose of benzodiazepine and correction of sodium are sufficient to improve the condition.

  Case Report Top

Here, we report a novel case of a 65-year-old man, presented to the psychiatric outpatient clinic with the complaints of decreased psychomotor activity, not having food for the past 3–5 days, kept staring at one place, and remained in posture for few minutes to hours with poor self-care and minimal verbal output. As per the reliable informants, the patient was apparently maintaining well 7–10 days back. Following which, Family members observed odd behaviour like minimal response to external stimuli, would keep on looking at one place with a fix blank stare. The patient would be remaining in a fixed posture for a long time. One being asked, he would reply after a few minutes in a very short sentence “I am ok” before that he was a very talkative person. He would remain seated or lying in one place and would not show any interest in any activities. Thereafter, patient was brought to the psychiatry outpatient clinic. On examination, negativism was present. There was no evidence of neck rigidity, fever, autonomic disturbances, and diarrhea. There was no history of psychiatric illness. There was no history suggestive of cognitive decline, head injury, seizure disorder, substance use, diabetes, medication intake, hypertension, or any other medical conditions.

On examination, he exhibited signs of posturing, negativism, mutism, and grasp reflex. His blood pressure and pulse rate were within normal limits. Physical examination did not show any evidence of rigidity or gross nutrition deficiencies or any sign of dehydration. Neurological examination was not suggestive of any motor deficit. On investigation, his sodium level was found to be low (127 mmol/L). Other investigations, including hemogram, liver function test, renal function test, blood glucose level, and chest X-ray were within normal limit. His magnetic resonance imaging of the brain showed diffuse cerebral atrophy appropriate to the age. His arterial blood gas parameters and other electrolyte analysis did not reveal any abnormality. The patient was examined in detail by the specialists of medicine and neurology, respectively. No deficit was noted.

In terms of management, lorazepam test was done and showed improvement with 1 mg of lorazepam, following which he was started on tablet lorazepam 3 mg/day; increased intake of dietary salt along with monitoring of sodium level was advised. On multiple occasions, his sodium level varies from 126 to 134 mmol/L. By 5th day, his sodium level reached 137 mmol/L and after that remained from 136 to 141 mmol/L. Tablet lorazepam was tapered off over 3 weeks and stayed well after that. On follow-up, the informant and the patient never reported any symptoms, suggestive of primary psychiatric illness before the onset of catatonia.

  Discussion Top

Catatonia has been associated with hyponatremia in various clinical conditions. The index case also presented with catatonia in association with hyponatremia. However, in the present case, the patient developed hyponatremia in the absence of confounding factors, such as schizophrenia, medications induced, physical illness, and intake of a substance.[4],[5],[6] The existing literature reported a similar finding in the background of either the presence of psychiatric disorders such as psychotic illness or the presence of physical illness such as malignancy and hypothyroidism. In previous cases, the cause of hyponatremia could be elicitable. However, in the present case, the exact cause of hyponatremia could not be ascertained.

Hyponatremia is the most common electrolyte disturbance encountered in the emergency setting. It hampered the treatment process and is associated with poorer clinical outcome. Hyponatremia is often missed or managed suboptimally because of inadequate assessment, investigations, and lack of knowledge. Hyponatremia is not only associated with medical or psychiatric illness, but it can also be an independent manifestation in the elderly populations. As in the index case, hyponatremia occurred in the absence of any etiology.[7] Hyponatremia can manifest in an array of clinical symptoms, including affective disorder, anxiety, or catatonia and vice versa. There are only countable reports on the case representing the hyponatremia and catatonia. In one case series, hyponatremia was considered a sign of catatonia. Anglin et al.[8] considered that hyponatremia could cause the catatonia. However, in one case series, hyponatremia among the patients with psychotic illness reports as a physiological sign of illness, not an etiology. It can be concluded that catatonia occurred in the setting of various organics or the background of various psychiatric disorders, but identifying the exact cause is as much as important as the indication of the treatment. In the index case too, we found the association of hyponatremia and resolution of symptoms with correction of sodium and with a benzodiazepine. Similar findings also reflected in the previous studies that benzodiazepine is required along with the correction of sodium level.[9]

The index case also strengthens the evidence of association of hyponatremia and catatonia. As the index patient had no history of catatonia before hyponatremia. It also demonstrates that elderly patients with catatonia must be evaluated for hyponatremia as a probable cause. The serum electrolyte, especially serum sodium, must be evaluated. Further research is needed to understand the association of hyponatremia and catatonia; however, with the existing literature, the catatonia should be considered in the differential diagnosis while dealing with a case of hyponatremia. The index case also suggests that a low dose of lorazepam is a good treatment option for the patient with catatonia in the elderly. However, lorazepam should be considered after evaluating the blood gas analysis and other contraindications. Although the treatment of catatonia is essentially the same in all cases, a majority of patients respond to benzodiazepines and electroconvulsive therapy. But at the same time it is important to identify the underlying etiology for better outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Fink M, Shorter E, Taylor MA. Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature. Schizophr Bull 2010;36:314-20.  Back to cited text no. 1
American Psychiatric Association. Cautionary statement for forensic use of DSM-5. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. U.S.A. Published online 2014.  Back to cited text no. 2
Mehra A, Grover S. Catatonia associated with hypernatremia. Indian J Psychol Med 2019;41:293-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
Yeh YW, Kuo SC, Chen CY, Shiah IS, Chen YC, Huang SY. Mimicking catatonic symptoms: A head injury induced acute hyponatremia complicated by rhabdomyolysis in a patient with schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry 2009;33:731-2.  Back to cited text no. 4
Nizamie SH, Khanna R, Sharma LN. Catatonia and hyponatremia: A case report. Indian J Psychiatry 1991;33:118-22.  Back to cited text no. 5
[PUBMED]  [Full text]  
Maxwell DL, Polkey MI, Henry JA. Hyponatraemia and catatonic stupor after taking “ecstasy”. BMJ 1993;307:1399.  Back to cited text no. 6
Grover S, Somaiya M, Ghormode D. Venlafaxine-associated hyponatremia presenting with catatonia. J Neuropsychiatry Clin Neurosci 2013;25:E11-2.  Back to cited text no. 7
Anglin RE, Rosebush PI, Mazurek MF. The neuropsychiatric profile of Addison's disease: Revisiting a forgotten phenomenon. J Neuropsychiatry Clin Neurosci 2006;18:450-9.  Back to cited text no. 8
McGuire E, Yohanathan M, Lally L, McCarthy G. Hyponatraemia-associated catatonia. BMJ Case Rep 2017;2017:1-3.  Back to cited text no. 9

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