Unmasking the Enigma: A Case Report of Catatonia Unveiled As Munchausen by Proxy 2023 Takher and Cosme

Andy

Andy

Retired committee member
Abstract

Catatonia is a behavioral syndrome characterized by a variety of symptoms such as mutism, stupor, rigidity, negativism, and verbigeration. It can be caused by various psychiatric and general medical conditions. While the diagnosis in the pediatric population is relatively uncommon, emerging literature supports a higher prevalence of catatonia in children. We present a 12-year-old girl with a complex medical and psychosocial history, including a functional neurological disorder and concerns for child abuse and Munchausen syndrome by proxy imposed by her mother. The patient was initially admitted for medical management of vomiting and refusal to eat. Child psychiatry was consulted for further assessment and noted multiple catatonic symptoms with a Busch-Francis catatonia rating scale (BFCRS) score of 22. A subsequent 1 mg IV lorazepam challenge test showed improvement in the patient's symptoms with a repeat BFCRS score of 10. This case supports emerging literature suggesting a higher prevalence of catatonia in children and the importance of recognizing this syndrome and its wide array of underlying causes.

Open access, https://www.cureus.com/articles/173...-catatonia-unveiled-as-munchausen-by-proxy#!/
 
US based authors

The title is difficult to understand and probably misleading. As far as I can see, there is not in fact proof provided of the mother having been anything other than a concerned parent trying to get help for a child with a wide range of health issues.

The test is also similarly confused.
This case was particularly difficult to discern between true medical history and false impositions, but after thoroughly reviewing medical charts dating back to the patient’s birth, it was found that in addition to her history of medical child abuse, the patient has had positive group A Streptococcus results, a history of anxiety and OCD tendencies, and suspected autoimmune disfunction that apparently has responded to intravenous immunoglobulin (IVIG) in the past. Regardless, the patient had numerous risk factors and current symptomatology to warrant the investigation of catatonia through an LCT, which is not only diagnostic but also therapeutic. We witnessed a robust initial response to 1 mg ativan, with persistent relief while titrating up oral benzodiazepines throughout the hospital stay.
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The patient was evaluated by pediatric CPS and subsequently separated from her parents and taken into protective custody through CPS, with all further healthcare decisions requiring approval through the Department of Children and Family Services (DCFS). The patient was transitioned to oral lorazepam with DCFS approval, starting at 0.25 mg 4 times daily with eventual titration up to 1.25 mg 4 times daily, which was tolerated well and resulted in significant improvement in mood and cognitive ability.
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I don't really know what to conclude, other than there's a lot of tragedy here. I do often wonder about the scientific utility of individual case studies - so often they seem to serve purposes other than progressing medical knowledge.

We have seen people with a diagnosis of ME/CFS and some symptom overlap with this child reportedly responding to lorazepam/ativan.
 
From the first quote in post #2 - but I've changed the bolding :

This case was particularly difficult to discern between true medical history and false impositions, but after thoroughly reviewing medical charts dating back to the patient’s birth, it was found that in addition to her history of medical child abuse, the patient has had positive group A Streptococcus results, a history of anxiety and OCD tendencies, and suspected autoimmune disfunction that apparently has responded to intravenous immunoglobulin (IVIG) in the past.
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What is "medical child abuse"? Abuse carried out by medical professionals? Or abuse carried out by a family member which can be spotted by medical professionals?
 
Hutan said:
US based authors

The title is difficult to understand and probably misleading. As far as I can see, there is not in fact proof provided of the mother having been anything other than a concerned parent trying to get help for a child with a wide range of health issues.

The test is also similarly confused.




I don't really know what to conclude, other than there's a lot of tragedy here. I do often wonder about the scientific utility of individual case studies - so often they seem to serve purposes other than progressing medical knowledge.

We have seen people with a diagnosis of ME/CFS and some symptom overlap with this child reportedly responding to lorazepam/ativan.
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And PANS/PANDAS is one that every so often I see trying to be flagged as existing by those who I assume there often have experiences of it not being thought of enough as a differential diagnosis, the symptoms listed made me think of that initially too but it doesn't note it being ruled out.

Agree that without being confident the purpose has been for genuine inter/multidisciplinary geting to the bottom of from a patient's best interests perspective, rather than a description of the approach of one institution or specialism I can't be confident of conclusions either. If we could be confident that both were able to be present in the literature then the contrast would surely provide stark insight as to where different 'approaches' 'rub-up' against each other?
 
This is literally just the first result in a quick google for whether PANS?PANDAS respondds to ativan, so haven't analysed methods or bias etc
PANDAS with catatonia: a case report. Therapeutic response to lorazepam and plasmapheresis, Elia et al (2005)
https://pubmed.ncbi.nlm.nih.gov/16239863/

It is mentioned in the following paper as part of individualised approaches to consider (with antimicrobials, plasmapheresis and immunomodulators and psychotherapy also there among others):
Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I—Psychiatric and Behavioral Interventions, THienneman et al (2017)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610394/

https://www.panspandasuk.org/faq-s describes:

PANDAS is an acronym for Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections.

PANDAS is a subset of PANS. Similarly, it is a neuropsychiatric condition which is triggered by a misdirected immune response to a Group A Streptococcal (GAS) infection which disrupts a child’s normal neurologic activity. GAS infections can occur in many parts of the body, not just the throat and can result in the inflammation of a child’s brain. Symptoms can appear whilst the infection is still present or several months later.

PANDAS usually starts with an acute onset of obsessive-compulsive disorder and/or tics, particularly multiple, complex or unusual tics. PANDAS symptoms can then appear to wax and wane with the child experiencing flares periodically, following illness or periods of stress.

The child is usually between the ages of 3 and puberty when first symptoms occur and usually appear following a streptococcal infection such as Sinusitis, Ear infections or Scarlet Fever. In some cases children can carry the streptococcus bacteria without showing signs of illness.
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