Physical Deformity as Sequela of Chronic Catatonia and Response to Electroconvulsive Therapy A Case Report SugnyaniDevi, MBBS,* Rishikesh V. Behere, MD,Þ Shivarama Varambally, MD,* Naren P. Rao, MD,* Ganesan Venkatasubramanian, MD,* and Bangalore N. Gangadhar, MD* Abstract: Chronic catatonia with posturing can cause joint contractures leading to greater morbidity associated with the physical deformity. We report a case of a young man with chronic catatonic schizophrenia with posturing of bilateral upper limbs in flexion leading to fixed flexion contracture of left metacarpophalangeal joints. Initiation of electrocon- vulsive therapy along with physical rehabilitation measures helped him regain full range of motion in the right upper limb. The fixed flexion contracture, however, remained resistant to intensive treatment efforts. Early interventions in the form of electroconvulsive therapy and physi- cal rehabilitation can be useful in reversing such potentially disabling complications. Key Words: catatonia, contracture, ECT (J ECT 2011;27: e49Ye50) Dear Editor: Psychosis presenting with chronic catatonia is being rec- ognized more frequently in clinical practice. Catatonia can be associated with significant medical complications. 1 Joint con- tractures are an uncommon, but serious complication of prolonged catatonic posturing. Physical hand deformities associated with psychiatric disorders have been termed as the ‘‘psycho flexed hand.’’ 2 Timely intervention increases the chance that the con- tracture can be reversed before permanent physical deformity results. CASE REPORT Mr L. is a 26-year-old, single man with well-adjusted premorbid personality, no comorbid medical or neurological illness, and a significant family history of psychosis in a first- degree relative. He presented with an insidious-onset, continu- ous illness characterized by mutism, posturing, negativism, decreased oral intake, disorganized behavior, holding his neck in flexion, and keeping his left upper limb flexed at the elbow joint with fisting of both hands for 7 years. On examination, he was apathetic, mute, and poorly kempt. Systemic examination was normal except for presence of pallor. Examination of the left hand revealed fixed flexion contracture of third, fourth, and fifth digits of the left hand at metacarpophalangeal joints and proxi- mal interphalangeal joints with wasting of thenar muscles. He scored 17 on the Bush Francis Catatonia Rating scale. Blood investigations showed microcytic hypochromic anemia with hemoglobin 9.9 mg/dL, which was corrected with iron supplements. Biochemical parameters inclusive of liver, renal, and thyroid function tests; blood sugar levels; and serum electrolyte levels were within normal limits. Further investiga- tions for evaluation of a possible organic cause for catatonia including serum VDRL test, HIV test, ceruloplasmin level, and neuroimaging of the brain did not reveal any abnormality. A diagnosis of catatonic schizophrenia was made. He was started on a trial of intravenous injection of lor- azepam 2 mg 3 times a day to which there was no improve- ment in catatonic symptoms, and hence electroconvulsive therapy (ECT) was initiated. The patient started talking, eating by himself, and walking inside the ward after 6 sessions ECT. The posturing significantly improved, and he was able to extend his neck and both upper limbs at elbow and wrist joints. How- ever, the fixed flexion contracture of the left hand persisted. An opinion was sought from the Department of Neurological Rehabilitation, and he was advised to undertake wax baths with gradual pressure stretching and wrist cock-up splint to prevent further wrist contracture. During the course of his hospital stay, his catatonic symptoms worsened after stopping of ECT, and hence he was started on maintenance ECT twice a week, which was tapered to once weekly and stopped over a 2-month period. On discharge, he maintained improvement in catatonic symptoms and had gained full range of move- ments in his right upper limb; however, fixed flexion con- tracture of the left hand persisted. DISCUSSION A contracture develops when elastic tissue is replaced by inelastic fibrous tissue. 3 This makes it hard to stretch the area and prevents normal movement. Contractures occur primarily in the skin, underlying tissue, muscle, tendon, and joint area. Immobilization is one of the important causes of joint contrac- ture. 4 Treatment of contracture includes manual techniques such as joint mobilization and stretching and casting or splinting to provide constant stretch to soft tissue and prevent further contracture. 3 In the above case, Mr L. had chronic catatonia with posturing of 7 years’ duration, which was untreated. Prolonged immobilization contributed to formation of contractures. Inter- ventions before total replacement of elastic tissue with fibrous tissue can prevent occurrence of permanent deformity. Initiation of ECT resulted in rapid resolution of posturing, which along with physical rehabilitation measures enabled him to regain movement in his right upper limb. The left hand, which had already developed a fixed flexion contracture, however, was re- sistant to intensive interventions. BRIEF CLINICAL REPORT LETTERS Journal of ECT & Volume 27, Number 3, September 2011 www.ectjournal.com e49 From the *Department of Psychiatry, Kasturba Medical College, Manipal; and †Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India. Received for publication November 19, 2010; accepted January 14, 2011. Reprints: Rishikesh V. Behere, MD, Department ofPsychiatry, Kasturba Medical College, Manipal 576104, India (e-mail: rvbehere@gmail.com). There are no financial disclosures from any of the authors related to this article. The authors declare no conflict of interest. Copyright * 2011 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0b013e3182107172 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.