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Ask the Mental Health Expert Archives 2001-2004

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Ativan Challenge

Q. We have a psychiatrist on staff who wants to do "Ativan Challenge" on catatonic patients as a diagnostic tool. He claims he has done this routinely in India. I have searched the Internet as has one of my staff nurses. I cannot find anything about giving Ativan IV push that is appropriate for diagnosing catatonia. This is a patient safety issue as well as a competency issue for my facility. Have you ever heard of this and, if so, could you point me in the direction of protocols and rationale for doing this?

A. Catatonia is a symptom--not a diagnosis. Therefore, the presence of catatonic symptoms requires a thorough medical, neurological, and psychiatric diagnosis--not simply a challenge test. As you know, catatonia may be due to virtually any underlying condition from bilateral subdural hematomas to (most commonly) affective disorders. Specifically, the differential diagnosis (JL Cummings, Clinical Neuropsychiatry) includes:

  • Basal ganglia disorders (including post-encephalitic parkinsonism)
  • Limbic system disorders (including viral encephalitis, temporal lobe infarction)
  • Diencephalic lesions (including traumatic hemorrhage, neoplasm)
  • Frontal lobe disorders (e.g., anterior cerebral artier aneurysm, traumatic contusion)
  • Epilepsy
  • Systemic and metabolic disturbances (e.g., DKA, hypercalcemia, hepatic encephalopathy)
  • Toxic agents (PCP, cocaine, neuroleptic malignant syndrome)

To be sure, oral or parenteral benzodiazepines are used in the acute treatment of various catatonic states, but a positive response does not provide you with a diagnosis. Your staff psychiatrist may have in mind something like the study done by Bush et al (Acta Psychiatr Scand 1996 Feb;93(2):137-43).

Twenty-eight patients with catatonia were treated systematically with parenteral and/or oral lorazepam for up to 5 days, and with ECT if lorazepam failed. Outcome was monitored quantitatively during the treatment phase with the Bush-Francis Catatonia Rating Scale (BFCRS). In 16 of 21 patients (76%) who received a complete trial of lorazepam (11 with initial intravenous challenge), catatonic signs resolved.

A positive response to an initial parenteral challenge predicted final lorazepam response, as did length of catatonic symptoms prior to treatment. Four patients failing lorazepam responded promptly to ECT. It was concluded that lorazepam and ECT are effective treatments for catatonia.

But again--this does not provide a diagnosis of the underlying cause of the catatonia. Lorazepam may help reverse, e.g., neuroleptic-induced catatonia (Fricchione et al, J Clin Psychopharmacol 1983 Dec;3(6):338-42), just as it may reverse functional catatonic states (Salam et al, Am J Psychiatry 1987 Aug;144(8):1082-3).

Furthermore, although IV lorazepam has generally proved safe in various medical settings, such as treatment of status epilepticus (Alldredge et al, N Engl J Med 2001 Aug 30;345(9):631-7), there are occasional reports of its causing respiratory or circulatory complications (ibid). In summary: while lorazepam (oral, IM, or IV) may be useful in treating catatonic symptoms, a positive response does not provide an etiological diagnosis, nor does it necessarily point toward definitive treatment.

February 2003

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