How do you approach a case of apparent worsening catatonia despite high-dose benzodiazepines and ongoing ECT?

In my experience, this may reflect an incorrect or incomplete diagnosis, comorbid medical problems, or side effects of medications. ECT is a great treatment for catatonia, and I start to have doubts about everything, but ECT, if ECT doesn't work. I think re-evaluating diagnosis, ensuring that we know precisely what is causing catatonia, if that's what it is, looking at the patient's medical condition, and doing another or more thorough medical workup, considering other medications they are presc...

Keep pushing the benzo if they aren't being too sedated by it - I've had one patient on Ativan 32 mg a day. Another patient, Valium 20 mg IV bid and Ativan 16 IV QID. There are some resistant cases to benzos, so then the next step is Ambien. If the catatonia is secondary to a psychotic disorder, then I use Namenda, and if it's a mood disorder, then amantadine. Also depends on how many sessions of ECT.

Because I often work with people with trauma and dissociation, the people I have seen with catatonia are often reenacting their traumatic state of mind just after the abuse occurred. Often, they feel very trapped and become suicidal, not to die but as an escape from the terrifying situation that has been inflicted on them. Besides suicide, another escape is to dissociate and to go as far inside themselves as they possibly can. They just disappear into the unconscious mind. For them, that's catat...

It is definitely important to evaluate for other neurologic/medical conditions that may be exacerbating the catatonia. I had a patient with hyperparathyroidism and refractory catatonia who needed a parathyroidectomy to get control of the catatonia.

In a previous inpatient position, we saw many cases of highly refractory catatonia requiring high doses of benzos (30+ mg of lorazepam daily). The ECT service routinely used flumazenil prior to treatments, with very good success. They would then admin...

We try to push the BZD dose up as much as we can to get as much benefit as possible, but sometimes it does not do the trick. Then we change to ECT, and we must taper down the BZDs in order to get a good quality seizure. If neither of these works, then something is probably off; look at the diagnosis again.