Catatonia Secondary to Sudden Clozapine Withdrawal: A Case with Three Repeated Episodes and a Literature Review

Table 2

Details for 7 cases which were considered at least probable catatonic episodes secondary to clozapine withdrawal.

Authors	Catatonic symptoms	Treatment	Other catatonia episodes
Lee and Robertson [15]	Restless, impulsive aggressive, disoriented disturbed sleep, refusal to wear clothing, staring, periodic posturing mannerisms, irrelevant speech, and uncontrollable laughing	Oral lorazepam 8 mg/day did not work; Clozapine restarted 10 days after catatonia; Symptoms resolved in 3 weeks	No
Yeh et al. [16]	Stupor, mutism, waxy flexibility,; staring, posturing,; negativism, and nil oral intake	Trihexyphenidyl 2–4 mg/day; Clozapine restarted to 175 mg/day within 2 weeks; Catatonia resolved in 7 days	One future
Bastiampillai et al. [17]	Urine/feces incontinence,; mutism, mannerisms, stupor,; posturing fever, diaphoresis, and autonomic instability	IM lorazepam unknown dosages; Treated for 48 hours with no response; ECT response started in the 4th session; Major improvement in the 10th session	One past
Thanasan and Jambunathan [18]	Tremors in upper limbs,; unresponsive to call or commands,; febrile, flat affect, mute, and; cogwheel and general rigidity	Bromocriptine from 2.5 to 15 mg/day (33 days); Oral diazepam for 6 days; Improvement by day 12	No
Wadekar and Syed [19]	Fixed gaze, minimal withdrawal from pain, and Bush-Francis scale score 6/14	Lorazepam 1 mg IV with brief improvement; Lorazepam 3 mg/day on days 1 and 2; Restarted on clozapine 25 mg/day on day 2; On 200 mg/day of clozapine by day 5; Rapid improvement on day 4	No
Kumar et al. [20]	Nil oral intake, quiet, mutism, posturing, and waxy flexibility	Lorazepam for 2 days; ECT started on day 3 and improvement after 4 ECTs; Discharged on risperidone 4 mg/day	No
Wang et al. [21]	Excitement, mutism, posturing, staring, negativism, and echolalia^2	Inpatient admission with clozapine reinstitution	Four on clozapine withdrawal and five on lorazepam withdrawal^3

ECT: electroconvulsive therapy; IM: intramuscular; IV: intravenous.
Other catatonic episodes after clozapine withdrawal in the past or the future.
On four previous occasions in the immediate period following clozapine cessation, the patient developed florid psychotic symptoms in the form of persecutory, grandiose delusions, disorganized behavior, and auditory hallucinations. She displayed catatonic features (Bush-Francis scale of 20 indicating severe catatonia).
The patient initially had 4 episodes of catatonia after clozapine withdrawal. Then, she had 5 episodes of catatonia after lorazepam withdrawal, which were the focus of the article.