Schizophrenia Research 263 (2024) 257–264

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

Catatonia during pregnancy and the postpartum period

Levente Csihi a, Gabor S. Ungvari b, c, Stanley N. Caroff d, e, Stephan C. Mann f, Gábor Gazdag a, g, *
a
Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest, Hungary
b
Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, Australia
c
Section of Psychiatry, University of Notre Dame, Fremantle, Australia
d
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, USA
e
University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
f
Central Montgomery Behavioral Health, Norristown, PA, USA
g
Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Budapest, Hungary

A R T I C L E I N F O A B S T R A C T

Keywords: While the psychopathology of mental disorders during pregnancy and the postpartum period is a growing area of
Catatonia research, the prevalence and significance of catatonic symptoms has been relatively neglected. To address this
Pregnancy gap in knowledge, a systematic review of articles on catatonia occurring during pregnancy and the postpartum
Postpartum
period was conducted. PubMed, Excerpta Medica, (later EMBASE) databases were queried for articles published
Perinatal
in English from their inception in 1966 and 1946, respectively to May 31. 2022 using the terms “catatonia”, AND
Benzodiazepines
Electroconvulsive therapy “perinatal”, “puerperal”, “postpartum”, “antepartum” “lactation” “pregnancy” or “pregnancy-related”, supple­
mented by a manual search of references. This review failed to identify any well-designed, prospective, or
controlled studies addressing the subject of catatonia during pregnancy or the postpartum period; only one
retrospective chart review, a single small case series, and twenty single case reports were found. The limited
literature suggests that the clinical presentation and treatment response during pregnancy and after childbirth
are similar to catatonia observed in other contexts. Catatonic signs and symptoms could affect physical and
mental health, markedly compromising a mother's ability to take care of and bond with her infant. Further
studies are needed to advance understanding of the role of catatonia in the pathogenesis, diagnosis and treatment
of perinatal mental disorders.

1. Introduction with dramatic onset usually within a few days or weeks following
childbirth. There is no consensus regarding the time of onset, which has
Given dramatic hormonal and body image changes, obstetric com­ varied between 2 weeks and 1 year after delivery across studies (Jones
plications, sleep deprivation, and psychosocial stresses, women face and Smith, 2009). The majority of PP episodes have been associated
profound emotional and mental challenges during pregnancy and with bipolar illness, schizophreniform disorder, or psychotic depression
childbirth. >50 % of women exhibit transient episodes of emotional (Sit et al., 2006). The risk of infanticide related to PP is about 4 %
lability after childbirth (“postnatal blues”), but these symptoms usually (Lisette and Crystal, 2018). Women with a pre-existing psychiatric dis­
disappear in a few days without specific intervention. However, some order are at higher risk for psychosis, suicidality and psychiatric hos­
women may develop more serious clinically significant episodes that pitalization during pregnancy and postpartum. Conversely, recurrence
require treatment. Approximately 1 in 13 women develop a major rates in subsequent pregnancies for women who recover from PP are up
depressive episode during pregnancy (Lisette and Crystal, 2018). During to 50 % or more and about 50 % of women have further non-puerperal
the first 6 months after delivery, 10–15 % of mothers experience episodes (Robertson et al., 2005).
depressive symptoms, but only 2–4 % of them receive treatment. Catatonia is a neuropsychiatric disorder with psychomotor, behav­
The term “puerperal”, “postpartum” or “lactation” psychosis [here­ ioral, affective, and vegetative symptoms emerging in a variety of psy­
after: PP] refers to a severe mental illness characterized by delusions, chiatric, neurological, and general medical conditions. The prevalence
multimodal hallucinations, confusional periods, and agitation, often of catatonia is reported to be 7–17 % in acutely ill psychiatric inpatients

* Corresponding author at: Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Köves út 1, Budapest 1204, Hungary.
E-mail address: [email protected] (G. Gazdag).

https://doi.org/10.1016/j.schres.2022.08.003
Received 6 June 2022; Received in revised form 9 August 2022; Accepted 10 August 2022
Available online 5 September 2022
0920-9964/© 2022 Elsevier B.V. All rights reserved.
L. Csihi et al. Schizophrenia Research 263 (2024) 257–264

with the highest rates occurring in mood disorders (Lee et al., 2000; complications of ECT in pregnancy include uterine contractions, pre­
Chalasani et al., 2005; Takács et al., 2019). Catatonia has 3 main clinical mature labor, vaginal bleeding, miscarriage, abdominal pain, pre­
subtypes: “stuporous” with mutism, inhibited movement, negativism eclampsia, and placental abruption. Similarly rare fetal complications
and staring; “excited” with excessive and purposeless motor activity, are arrhythmia, stillbirth, fetal malformations, respiratory distress, and
restlessness, impulsivity and combativeness and; “malignant”, a life- bilirubinemia (Ward et al., 2018).
threatening state with fever, autonomic instability, delirium and rigid­ Although the fundamental hormonal changes in the pre- and post­
ity. These subtypes are on a spectrum and can change forth and back to partum periods are well-known, there have been no studies to determine
each other (Fink and Taylor, 2009; Burrow et al., 2022). whether these endocrine or other physiologic changes are involved in
Despite the upsurge of interest in catatonia over the past few de­ the development of peri- or postpartum catatonia. We sought to examine
cades, catatonia emerging during pregnancy or in the postpartum period the available evidence to determine whether there are any significant
has received little attention. Catatonic signs and symptoms such as differences in the symptom profile, response to treatment or outcomes of
immobility, stupor, mutism, and excessive motor activity along with catatonia occurring in the pre- or postpartum period compared with
resultant medical complications including dehydration, nutritional de­ current consensus knowledge on catatonia. The availability of effective
ficiencies, pneumonia, thrombosis, skin ulceration, and contractures, treatment underscores the need for greater awareness and additional
may compromise the mother's ability to take care of and bond with her research on catatonia during pregnancy and the postpartum period.
infant. More severe complications occurring if catatonia progresses to its
malignant form include rhabdomyolysis, renal failure, myocardial 2. Methods
infarction, metabolic acidosis, disseminated intravascular coagulation,
and death (Hirjak et al., 2019)(Table 1). A systematic search of the English-language literature according to
On the other hand, specific treatment of catatonia is highly effective. PRISMA guidelines was performed in the PubMed and Excerpta Medica,
Benzodiazepines (hereafter BZD), in doses up to 20 mg of lorazepam per (later EMBASE) databases from their inception in 1966 and 1946,
day (Sienaert et al., 2014), successfully alleviate or reverse >70 % of respectively to May 31, 2022. The following search terms were used:
catatonic symptoms (Weder et al., 2008). Numerous studies, review “catatonia”, “perinatal”, “puerperal”, “postpartum”, “antepartum”
papers and meta-analyses discuss the use of BZDs as anxiolytics during “lactation”, “pregnancy”, and “pregnancy-related”. A manual search
pregnancy, and BZDs as first-line treatment for catatonia arising in other was also conducted by scrutinizing the reference lists of the relevant
condition (Ungvari et al., 1994; Fink and Taylor, 2006; Lee et al., 2000). publications. Only those cases were included in this systematic review
Although BZDs are clearly effective in the treatment of catatonia and where the author clearly described catatonia, or where catatonia was
have relatively few side effects ordinarily, BZDs used during pregnancy reliably diagnosed with a rating scale or a structured interview. Cases
in combination with antidepressants can increase the risk of congenital where catatonic signs and symptoms were merely mentioned without
malformations, particularly cardiovascular malformation or oral cleft diagnostic considerations were excluded (Fig. 1).
deformities, although this risk is negligible with BZD monotherapy
(Grigoriadis et al., 2019; Bais et al., 2020). Following antenatal use of 3. Results
BZDs, an increased risk for spontaneous abortion, preterm birth, low
birth weight, small gestational age and low Apgar scores at 5 min were The literature search yielded only one retrospective chart review, a
reported (Kallen et al., 2013; Grigoriadis et al., 2020). After birth, BZDs small observational case series, and 20 case reports, but no prospective
can cause floppy infant syndrome, hypotonia, thermal dysregulation, studies or controlled trials. In the retrospective chart review (Nahar
poor feeding, and neonatal toxicity or withdrawal syndrome. Before et al., 2017), data were extracted from the files of 200 women with PP
commencing BZD treatment for catatonia or other conditions in a admitted to an inpatient mother-baby unit in India from November 2011
pregnant woman, all these risks should be weighed against the benefits to July 2015. Forty patients (20 %) displayed symptoms of catatonia.
of the treatment. The mean score on the Bush-Francis Catatonia Rating Scale (BFCRS) was
Electroconvulsive therapy (ECT), as a second line treatment for 14.97 ± 3.2 (mean ± SD; range: 8 to 22); the most frequent symptoms
catatonia, is often effective in patients who do not respond to a BZD after were mutism (100 %), followed by withdrawal (90 %), and negativism
48 to 72 h (Babu et al., 2013; Espinola-Nadurille et al., 2007). ECT is the (82.5 %). Women with catatonia had significantly higher rates of onset
preferred treatment in malignant catatonia. The effectiveness and safety of psychosis within the first four weeks of the postpartum period (50 %
of ECT in pregnancy has been reported with adverse effects similar to the vs 31.5 %, Chi-square test, P = 0.022), a longer duration of untreated
risks of ECT in other conditions. Possible, but rare maternal psychosis on admission (79.46 ± 159.88 vs 56.12 ± 47.26, t-test, P =
0.002), and were more likely to receive a diagnosis of acute and tran­
Table 1 sient psychotic disorder rather than bipolar disorder compared to their
Complications catatonia can cause for pregnancy. non-catatonic counterparts. Brain imaging data available in 31 of the 40
During pregnancy Postpartum
catatonic mothers were normal. An adequate trial of lorazepam (3–6
mg/day) was used in 36 cases resulting in complete resolution of cata­
Hospitalization can disturb both psychological and All complications that
tonic symptoms (BFCRS score = 0) in 18 (50 %), partial response (BFCRS
material preparations for the arrival of the child can occur during
pregnancy, and: ≥1) in 9 (25 %), while 9 (25 %) showed no response after three days of
Hypoactive form Excited form Malignant form of Harm to the newborn lorazepam treatment. Two of the four women who did not receive an
of catatonia of catatonia catatonia adequate lorazepam trial continued to be very restless and agitated
Dehydration Dangerous Rhabdomyolysis Infanticide following parenteral lorazepam, and had to be administered olanzapine
situations
Nutritional Self-harm Renal failure Compromise the
10 mg. One woman of the four was administered ECT due to severe
deficiencies mother's ability to take psychomotor retardation, and one woman was discharged by her family
(both mother care of and bond with against medical advice. Older age, a greater number of days of persisting
and fetus) her infant catatonia observed before treatment initiation and a longer duration of
Pneumonia Suicidality Myocardial
untreated psychotic symptoms emerged as factors associated with
infarction
Thrombosis Metabolic acidosis poorer response to lorazepam. Time of onset of PP following delivery,
Skin ulceration Disseminated and the BFCRS score did not differ significantly between the lorazepam
intravascular responsive and non-responsive groups. ECT was given as a second-line
coagulation treatment to 18 women with catatonia who showed a partial or no
Contractures Death
remission with lorazepam, while one woman received ECT as first-line

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L. Csihi et al. Schizophrenia Research 263 (2024) 257–264

Identification of studies

Records identified from*:

Pubmed (n =72 )

Identification
Embase (n=184)
(Catatonia, and postpartum, Manual search and other
perinatal, antenatal sources (n = 19)
puerperal, lactation,
pregnancy or pregnancy-
related)

Records screened
(n = 275) Records excluded
non-English (n =32 )
non-human research (n=6)
duplicates (n=18)
Screening

Reports assessed for eligibility Reports excluded:

(n = 219) no valuable details: (n=11)
not clearly diagnosed (n = 10)
catatonic but not pregnant (n =23
)
out of topic of interest (n = 153)

Studies included in our review

Included

(n =22 )
Cases in the included titles (n
=64 )

Fig. 1. PRISMA flow chart.

treatment due to severe psychomotor retardation. The remission rate of tomography revealed no prominent lesions. The fourth patient was 29
catatonic symptoms following ECT was 100 %. The number of ECT years old diagnosed with psychotic disorder due to a general medical
sessions required to achieve full response ranged between 3 and 12 (6.36 condition (pneumonia, sepsis, adult respiratory distress syndrome), who
± 2.08). Following recovery from catatonia, the women were treated presented a week after giving birth to her first child. Her psychosis was
with antipsychotics, antidepressants or mood stabilizers depending on characterized by stuporous catatonic features, auditory and visual hal­
the primary underlying diagnosis. lucinations, insomnia, and disorientation. She died on the fourth day of
The small case series on postpartum catatonia was reported from her hospitalization without receiving lorazepam. The authors consid­
Taiwan (Lai and Huang, 2004) The study sample was recruited from 636 ered whether the use of lorazepam might have prevented a lethal
women who received psychiatric consultations at the emergency room outcome. Three of the patients had complete remission of catatonic
at Chang Gung Memorial Hospital, a multi-specialty, tertiary-care center symptoms after receiving an intramuscular injection of lorazepam (the
between January 1, 2001, and December 31, 2001. Fifteen of these 636 dose was not stated) within 30–60 min.
women were noted to have postpartum mental illness and 4 of the 15 Twenty patients were reported in single case reports; their age
exhibited catatonic features including stupor, mutism, immobility, and/ ranged from 18 to 42 years and eight had a positive history of mental
or negativism. Diagnostic and Statistical Manual-IV (DSM-IV) diagnoses illness (Table 2). Seven patients each were diagnosed with schizophrenia
and the assessment of catatonia were made by two psychiatrists without spectrum disorders, five with mood disorders, five with medical condi­
using standardized instruments. The first patient was a 25-year-old tions (atypical posterior reversible encephalopathy, anti-NMDA en­
primiparous woman diagnosed with major depressive disorder, who cephalitis, Hashimoto encephalopathy, Graves' disease with organic
became ill 10 days after delivery. In addition to her mood and catatonic psychosis and infective endocarditis), one with postpartum psychosis
symptoms, she presented with déjà vu, derealization, anterograde with catatonia, and in two cases catatonia was mentioned, but was not
amnesia, disorientation, and confusion. The second patient was 33- unequivocally diagnosed. Twelve cases of catatonia arose during preg­
years-old, also with major depressive disorder commencing two weeks nancy and seven during the postpartum period while in one case, the
after her second childbirth. The clinical picture was dominated by relationship between pregnancy and onset of catatonic symptoms was
depressed mood, stuporous catatonia, fatigue, retardation, disorienta­ not reported. ECT was used in 13 cases. In twelve cases ECT caused no
tion, and confusion. The third patient was 38 years old, diagnosed with harm to the mother or to the child, in one case a macerated fetus was
catatonic schizophrenia just 3 days after the birth of her fifth child. The delivered with weight of 3459 g. In this case, however, ECT was com­
principal symptoms included the above-mentioned catatonic features, bined with insulin coma treatment. The details of ECT are shown in
persecutory delusions, auditory hallucination, and confusion. Her elec­ Table 2. Several cases lacked details regarding technical aspects of ECT,
troencephalogram was borderline normal, but a brain computed underscoring the need for more procedural details in future studies. Ten

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Table 2
Case reports of patients with pre- or postpartum psychiatric disorders presenting with catatonia.
Authors/ Age Psychiatric history Underlying medical Onset of Main clinical Method of Treatment Outcome of
year of (yrs) or psychiatric symptoms symptoms diagnosing current episode
publication condition(s) relative to catatonia
delivery

Gralnick, 33 Persecutory Persecutory 1st month Persecutory Clinical ECT (6 sessions)a, insulin Recovered, but the
1946 delusions, auditory delusions, mutism, of delusions, extreme treatment (18 sessions), symptoms
hallucinations, catatonic symptoms pregnancy perplexity, confusion, ECT (18 sessions)b returned after 3
mutism, refusal to (diagnosis not mutism, resistance weeks;
eat (diagnosis not reported) (negativism) macerated foetus
reported) with weight of
3459 g
Laird, 1955 19 Unknown Catatonic type of 6th month Aimlessly wandering, Clinical ECT (7 sessions)b Recovered
schizophrenic of near mutism, (symptom free)
reaction pregnancy incoherently
mumbling,
purposeless,
manneristic
grimacing, refusal to
eat
Yellowlees 22 Negative Schizoaffective 29 weeks of Withdrawal, mutism, Clinical Amitriptyline (100 mg at Recovered
and Page, psychosis gestation reluctance to eat and night), fluphenazine (symptom free)
1990 drink decanoate (25 mg/3
weeks), ECT (9 sessions)c
Bach-y-Rita 22 Negative Affective disorder Shortly Fear/anxiety, Clinical Lithium, perphenazine, Recovered
and De after delusions, bizarre lorazepam, (doses are (symptom free)
Ranieri, delivery behaviour affective unknown) ECTb
1992 fluctuations,
agitation,
aggressiveness,
refusal of food/drink
Polster and 29 Chronic paranoid Chronic paranoid 23 weeks of Psychomotor Clinical Risperidone (6 mg/day Minimal
Wisner, schizophrenia schizophrenia with gestation slowing, poverty of po.), loxapine (150 mg/ improvement:
1999 depressive speech, profound day), nortriptyline (50 Depressive and
symptoms thought-blocking mg/day), lorazepam (3 psychotic
mg/day), ECT (12 symptoms failed to
sessions)d improve; transient
but significant
bradycardia and
hypoxemia
Kitabayashi 19 Negative Severe 13th day Stupor, mutism, Clinical Diazepam (10 mg/day Recovered
et al., hypertension, after refusal of food/drink iv.), haloperidol (15 mg/ (symptom free)
2007. atypical reversible delivery day iv.), midazolam (5 mg
posterior iv. Only once), etizolam
encephalopathy (3 mg/day po.), ethyl-
loflazepate (4 mg/day
po.)
Espinola- 22 Unknown Schizophreniform 21 weeks of Agitation/ Clinical Lorazepam and clozapine Recovered
Nadurille disorder gestation withdrawal, mutism, (doses are unknown) ECT (symptom free)
et al., negativism, (10 sessions)e
2007. disorganized speech,
hallucinations
Gervasoni 32 Recurrent major Major depression 2 weeks Depressive thought/ Clinical Sertraline (50 mg/day), Recovered
and Aubry, depressive disorder after guilt, psychomotor venlafaxine (max. 300 (symptom free)
2008. delivery retardation, stupor, mg/day), alprazolam (0,5
mutism, negativism, mg/day), amisulpride
delusions (200 mg/ day), quetiapine
(600 mg/ day), lorazepam
(three 20-min perfusions
of lorazepam 4 mg in 250
ccs of saline solution per
day)
Malhotra 22 Unknown Unknown Not Not reported Clinical ECT (3 sessions)b Not reported
et al., reported
2008.
McCarthy 32 Unknown Anti-nmda 8 weeks of Agitation, visual and Clinical methylprednisolone Recovered
et al., encephalitis gestation auditory (1000 mg iv for 5 days, (symptom free)
2012 hallucinations, then slow oral taper),
delusions, azathioprine, olanzapine
negativism, (doses are unknown)
stereotypic
movements, waxy
flexibility, loquacity,
perseveration,
fluctuating vigilance,
fever, tachycardia
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L. Csihi et al. Schizophrenia Research 263 (2024) 257–264

Table 2 (continued )
Authors/ Age Psychiatric history Underlying medical Onset of Main clinical Method of Treatment Outcome of
year of (yrs) or psychiatric symptoms symptoms diagnosing current episode
publication condition(s) relative to catatonia
delivery

Strain et al., 18 Negative Postpartum 5 months Auditory and visual BFCRS Lorazepam (max. 3 mg in Recovered
2012. psychosis and after hallucinations, (score is every 4 h iv.), olanzapine, (symptom free)
catatonia delivery psychomotor unknown) citalopram, (doses are
retardation/ unknown), ect (6
excitement, waxy sessions)b
flexibility, mutism,
negativism,
posturing, Mitgehen,
anxiety
Durand 42 Progressive Schizophrenia with 27 weeks of Psychomotor BFCRS Haloperidol (max. 20 mg/ Recovered
et al., mutism, brief catatonia gestation retardation, mutism, (score of day po.), lorazepam (max. (symptom free)
2013. periods of posturing, 22) 8 mg/day im.)
prominent negativism, staring,
psychomotor grimacing
retardation
Dahale et al., 22 Negative Graves' disease with 3 days after fear, auditory Clinical Lorazepam 2 mg 3 times Recovered
2014. organic psychosis delivery hallucinations, per day iv. Then after 3 (symptom free)
laughing to herself, days per os. Propranolol
reduced social 40 mg twice per day,
interactions, carbimazole 30 mg,
impaired mother- olanzapine 10 mg per os
infant interactions,
decline in sleep and
food intake,
immobility, mutism,
passive negativism,
posturing, anxieaty,
muttering to herself,
incontinence, moist,
cold skin,
exophtalmus,
tachycardia,
tachypnea, diffuse
thyroid swelling
Gonzales 23 Negative Major depression 24 weeks of Confusion, agitation/ BFCRS Haloperidol (5 mg twice Partial remission:
et al., gestation withdrawal, staring, (score of daily), sertraline (up to notable
2014. negativism odd 21) 200 mg daily), ECT (10 improvement of
39 weeks of behaviour sessions)f affect, appetite,
gestation and personal
isolation, negativism, sertraline (200 mg daily), hygiene, speech
mutism, very poor haloperidol (2,5 mg twice improved from
personal hygiene and daily), nearly mute to
appetite lorazepam (1 mg by impoverished, and
mouth twice daily) negativism
ECT (12 sessions)b resolved.
mirtazapine (15 mg at
bedtime) recovered
(symptom free)
Aghukwa 24 Schizophrenia Schizophrenia, 33 weeks of Visual hallucinations, Clinical Lorazepam (10 mg/day), Recovered
and Takai, catatonic type catatonic type gestation posturing, refusal of diazepam (20 mg/day), (symptom free)
2015. food and drink, ECT (10 sessions)g,
negativism, poor haloperidol (5 mg/day)
personal hygiene,
insomnia
Pinna et al., 28 Bipolar disorder (2 Psychotic manic 14 weeks of Perplexity, CRS (score haloperidol (7.5 mg/day), Recovered
2015. previous mood state gestation Irritability, between 20 lorazepam (6 mg/day), (symptom free)
episodes) aggressive behaviour, and 30) ECT (9 sessions)h
intolerance
To noise,
verbigerations, motor
excitement, and
persecutory
Delusions.
Lalanne 27 Negative Catatonia, 5 month Fluctuating Clinical Risperidone 2 mg/day, Free of any
et al., Hashimoto after psychomotor cyamemazine 30 mg/day psychiatric
2016 encephalopathy delivery agitation, anxiety, then lorazepam 12,5 mg/ symptoms
emotional lability, day then oral
impulsivity, prednisolone 60 mg/day
incoherent speech,
persecutory
delusions, auditory
hallucinations,
disorientation in
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L. Csihi et al. Schizophrenia Research 263 (2024) 257–264

Table 2 (continued )
Authors/ Age Psychiatric history Underlying medical Onset of Main clinical Method of Treatment Outcome of
year of (yrs) or psychiatric symptoms symptoms diagnosing current episode
publication condition(s) relative to catatonia
delivery

space and time,

euthyreoid, but
elevated titres of anti-
thyroglobulin and
anti-thyroperoxidase
Grover et al., 28 Undifferentiated Undifferentiated 17 weeks Not reported BFCRS Olanzapine, ECT (8 Recovered
2018 schizophrenia schizophrenia after (score of sessions)b (symptom free)
delivery 18)
Ekici et al., 28 Negative Infective 24 weeks of Psychomotor BFCRS olanzapine (20 mg/day), partial remission
2021 endocarditis gestation excitation, (score of ECTb, lorazepam (7,5 mg/ (BFCRS score: 4;
(methicillin- negativism, reduced 11) day) disorganized
resistant self-care, mutism, speech)
staphylococcus withdrawal of food
aureus) and drink, fever,
tachycardia, elevated
CRP level
Farias and 36 Major depression Psychotic major 36 weeks of Mutism, difficulty Clinical Lorazepam (8 mg/day), partial remission
Hartnett, with catatonic depression gestation moving, waxy aripiprazole, escitalopram (improved mood,
2022 features flexibility, fluctuating BFCRS score 0)
alertness, and
internal
preoccupation,
depression.

Abbreviations: ECT = electroconvulsive therapy; BFCRS=Bush-Francis Catatonia Rating Scale; CRS=Catatonia Rating Scale
a. Dose ranged from 100 V for 0,1 s to 100 V for 0,2 s
b. No other information was available
c. Unilateral, low-voltage ECT to non-dominant hemisphere
d. Right unilateral ECT (pulse width = 1,2 ms, frequency = 50 Hz, current = 0,6 A)
e. Bilateral ECT with a stimulus of 20 % given with a Thymatron DGx ECT machine
f. Right unilateral electrode placement to minimize cognitive effects, continuous foetal heart rate and uterine activity monitoring for 20 min before ECT and 60 min after ECT; no
gynaecological complications were detected
g. Brief pulses up to 75 millicoulombs using the Thymatron System IV
h. Left anterior right temporal electrode placement using Thymatron System IV with bidirectional constant current. Energy dosing at about 40 % (parameters: 7.5 s stimulus duration, 30
Hz frequency, 0.5 msec pulse).
During each ECT, the foetal heart rate was monitored and no ECG alterations were observed. No cognitive abnormalities or gynaecological complications were detected except the first
case (Gralnick, 1946), in which insulin coma was part of the treatment.

patients receiving ECT recovered, one had partial remission, one had pregnancies/deliveries (Nahar et al., 2017), but this figure is likely an
minimal improvement, and in one case the outcome of treatment was underestimation due to the lack of consensus and awareness of catatonic
not reported. symptomatology among clinicians. It is not known if catatonic signs and
An early review on fetal damage due to ECT, insulin coma, chlor­ symptoms emerging in pre- and post-partum have any specific patterns
promazine or reserpine described 33 cases in which the mother pre­ or whether their treatment response differs from that of catatonic pre­
sented with severe agitation and/or catatonic withdrawal (Sobel, 1960). sentations associated with other psychiatric, medical, and neurological
This article focuses on fetal damage caused by biological treatments of disorders. We were able to identify two small retrospective case series
that era and provides no detailed information about catatonia (Table 2). and twenty case reports which suggest that the catatonic syndrome
occurring during the peripartum period is similar to catatonia observed
4. Discussion in other contexts. In addition, standard treatments of catatonia appear to
have comparable efficacy and tolerability during the peripartum period.
Catatonia presenting during pregnancy or in the postpartum period It is of note that in seven of the reported cases, catatonic patients
has received almost no attention in the contemporary literature. None of received typical antipsychotic medication together with BZD or ECT. It
the five comprehensive resource textbooks on catatonia published dur­ is generally accepted that the use of typical antipsychotics in catatonia is
ing the past two decades have mentioned its occurrence during the essentially contraindicated due to their effect of worsening catatonic
peripartum (Fink and Taylor, 2006; Mann et al., 2003; Caroff et al., symptoms and increasing the risk of neuroleptic malignant syndrome.
2004; Ungvari, 2006; Shorter and Fink, 2018). Yet, catatonic phenom­ The formerly widely used Kraepelinian conceptualization of catatonia as
ena emerging in PP were already mentioned by Kraepelin in the sixth a subtype of schizophrenia can explain why first-generation antipsy­
edition of his textbook: “We observe quite frequently the occurrence of chotics were, and occasionally still are used for catatonic patients. In
catatonic disease following childbed, but the nature of internal relationship DSM-5 the classification of catatonia was significantly changed and now
has not been clarified so far.” (Kraepelin, 1990). Given the paucity of it is closer to Kahlbaum's original concept, i.e., catatonia is a syndrome
recent research, analysis of the historical literature may provide which can be associated with different psychiatric and medical condi­
important insights in this area, but an historical review is beyond the tions (Takács et al., 2021), such that typical antipsychotics are less likely
scope of the present study which focused on the modern published to be indicated in the context of catatonia.
literature. However, findings from small series or individual case reports are
The review of current literature did not yield any well-designed, limited by the volume and details of the data presented, and subject to
prospective, or controlled studies on the subject of catatonia during publication bias favoring positive outcomes. It has been well-known that
pregnancy or the postpartum period. The frequency of PP presenting catatonia during pregnancy or the postpartum period poses a major risk
with catatonic symptoms is broadly estimated to occur in 2–5/10,000 for the life of a mother and her infant and disrupts the bonding between

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L. Csihi et al. Schizophrenia Research 263 (2024) 257–264

them. The usually severe anxiety, mood changes and frightening psy­ Burrow, J.P., Spurling, B.C., Marwaha, R., 2022. In: Catatonia. StatPearls Publishing,
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This review of the literature failed to yield any well-designed, pro­ 2006. Cambridge University Press, Cambridge, 256 p.
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covering only two small retrospective case series and twenty case re­ Gervasoni, N., Aubry, J.-M., 2008. A catatonic syndrome in a postpartum major
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treated in most cases with benzodiazepines or electroconvulsive Grigoriadis, S., Graves, L., Peer, M., Mamisashvili, L., Dennis, C.L., Vigod, S.N.,
therapy. Steiner, M., Brown, C., Cheung, A., Dawson, H., Rector, N., Guenette, M.,
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Funding source analysis. J. Clin. Psychiatry 80 (4), 18r12412. https://doi.org/10.4088/
JCP.18r12412.
the manuscript was prepared without funding. Grigoriadis, S., Graves, L., Peer, M., Mamisashvili, L., Ruthirakuhan, M., Chan, P.,
Hennawy, M., Parikh, S., Vigod, S.N., Dennis, C.L., Steiner, M., Brown, C.,
Cheung, A., Dawson, H., Rector, N., Guenette, M., Richter, M., 2020. Pregnancy and
CRediT authorship contribution statement delivery outcomes following benzodiazepine exposure: a systematic review and
meta-analysis. Can. J. Psychiatry 65 (12), 821–834. https://doi.org/10.1177/
0706743720904860.
G Gazdag and GS Ungvari designed the project; L Csihi and G Gazdag Grover, S., Sahoo, S., Chakrabarti, S., Basu, D., Singh, S.M., Avasthi, A., 2018. ECT in the
performed the literature search and prepared the first draft of the postpartum period: a retrospective case series from a tertiary health care center in
India. Indian J. Psychol. Med. 40, 562–567. https://doi.org/10.4103/IJPSYM.
manuscript; GS Ungvari, SN Caroff and SC Mann critically reviewed and
IJPSYM_105_18.
corrected the manuscript. All authors approved the final version of the Hirjak, D., Sartorius, A., Kubera, K.M., Wolf, R.C., 2019. Antipsychotic-induced motor
text. symptoms in schizophrenic psychoses-Part 2 : catatonic symptoms and neuroleptic
malignant syndrome. Nervenarzt 90 (1), 12–24. https://doi.org/10.1007/s00115-
018-0581-6.
Declaration of competing interest Jones, I., Smith, S., 2009. Puerperal psychosis: identifying and caring for women at risk.
Adv. Psychiatr. Treat. 15 (6), 411–418. https://doi.org/10.1192/apt.
bp.107.004333.
Dr. Caroff received research grants for unrelated projects from Kallen, B., Borg, N., Reis, M., 2013. The use of central nervous system active drugs during
Neurocrine Biosciences and Eagle Pharmaceuticals and served as pregnancy. Pharmaceuticals 6 (10), 1221–1286. https://doi.org/10.3390/
ph6101221.
consultant for Neurocrine Biosciences and Adamas Pharmaceuticals.
Kitabayashi, Y., Hamamoto, Y., Hirosawa, R., Narumoto, J., Fukui, K., 2007. Postpartum
The other authors have no declarations of interest to report. catatonia associated with atypical posterior reversible encephalopathy syndrome.
J. Neuropsychiatr. Clin. Neurosci. 19 (1), 91–92. https://doi.org/10.1176/
jnp.2007.19.1.91a.
Acknowledgement Kraepelin, E., 1990. Psychiatry. A Textbook for Students and Physicians, , 6th editionVol.
1. Science History Publication, Watson Publishing International, Canton, MA
We thank Dr. Walter Jaimes-Albornoz for his valuable comments for (Translated from the original published by J.A. Barth, Leipzig. 1899).
Lai, J.-Y., Huang, T.-L., 2004. Catatonic features noted in patients with post-partum
an earlier version of the manuscript.
mental illness. Psychiatry Clin. Neurosci. 58 (2), 157–162. https://doi.org/10.1111/
j.1440-1819.2003.01210.x.
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