Catatonia presenting as acute post-operative pain

Catatonia is a relatively common but rarely recognized condition with features that may be seen in up to 20% of hospitalized patients. Some of these features, such as immobility, mutism, unresponsiveness, bizarre behavior and impaired cognition are similar to the manifestations of delirium and medication over-treatment with opioids and benzodiazepines. The pain specialist must be able to recognize the features of catatonia and implement specific interventions in order to avoid potentially serious medical complications and the risk of incomplete recovery, particularly as the interventions for catatonia, delirium and overuse of sedating medication differ considerably. The University of Michigan Acute Pain Service was consulted to evaluate a 46 year-old man with “pain so bad he could not even talk” who had undergone a proctocolectomy, end ileostomy, and small bowel resection with primary anastomosis for treatment of ulcerative colitis refractory to medical management. On assessment, he was grimacing, grunting and was unresponsive though resisted passive movement of his arm. Review of the medical record revealed errors in recording and continuation of home medications including benzodiazepines, which likely contributed to his condition. Once catatonia was recognized and appropriate treatment was given, including higher doses of benzodiazepines, the patient began to recover and continued to improve throughout the hospital course. In this case, catatonia was mistaken for altered mental status due to uncontrolled post-operative pain. We will review the diagnosis of catatonia including its clinical features, prevalence, predisposing factors and treatment. We will present in table format the criteria distinguishing catatonia from other common causes of altered mental status that a pain specialist may encounter such as delirium, over-medication, and other psychoses.