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Catatonia

Catatonias

Catatonia refers to a complex neurological disorder that can present with a range of behavior and movement features. The individual is often indifferent to the external environment. Most patients have a comorbid disorder like manic disorder, depression or schizophrenia. Catatonia is treated pharmacologically or with electroconvulsive treatment (ECT).


Presentation

Patients with catatonia usually cannot provide any history. So the history is usually obtained from the family or caregiver and may include the following:

In an emergency setting one must always rule out:

Catatonia is a syndrome associated with many clinical features, most of which are nonspecific these include:

  • Ambitendency 
  • Automatic obedience 
  • Aversion 
  • Catalepsy 
  • Echolalia 
  • Echopraxia 
  • Excitement 
  • Forced grasping 
  • Gegenhalten 
  • Grimacing 
  • Immobility 
  • Mannerisms 
  • Mitgehen 
  • Mitmachen 
  • Mutism 
  • Negativism Obstruction 
  • Perseveration 
  • Posturing 
  • Psychological pillow 
  • Rigidity 
  • Speech may reveal logorrhea, echolalia
  • Staring
  • Stereotypical motions
  • Stupor which is the most classic feature of the disorder. It often presents with mutism and immobility
  • Verbigeration 
  • Waxy flexibility

Physical exam

Other signs include:

Several rating scales to help make a diagnosis of catatonia developed. Determine comorbid conditions like, schizophrenia, mood disorders or any medical disorder. Headache, fever, and a nuchal rigidity in an acutely ill patient are suggestive of encephalitis. The presence of severe muscle rigidity, hyperthermia and autonomic dysregulation, suggests neuroleptic malignant syndrome. Acute psychosis may present with delusions, paranoia, hallucinations, or threatening behaviors.

Fever
  • RESULTS: The most common symptoms in patients with neuroleptic malignant syndrome were fever (87.7 %), rigor (85.9 %), laboratory evidence of muscle injury (70.5 %), and tachycardia (62.1 %) and in patients with catatonia were mutism (78.0 %), rigor ([ncbi.nlm.nih.gov]
  • Besides supportive care like hydration and control of fever, the two basic treatments are use of medications and electroconvulsive therapy (ECT).[symptoma.com]
  • In all cases, the administration of antipsychotics has been suspended as soon as fever and autonomic disturbances occurred.[doi.org]
Streptococcal Infection
  • Infection (PANDAS), antiphospholipid syndrome, renal and hepatic transplant, Langerhans carcinoma Pharmacological, toxic and other Typical and atypical antipsychotics (use and withdrawal) including clozapine, levodopa, amantadine, serotonergic drugs[ncbi.nlm.nih.gov]
Fecal Incontinence
  • incontinence Odd gait [ clarification needed ] Passivity Eyerolling Stiff muscles Catalepsy Physiological pillow [ clarification needed ] Difficulty crossing lines [ clarification needed ] Gegenhalten Ambitendency – contradictory behavior Rituals – repetitive[en.wikipedia.org]
  • After this, he became bedridden, would refuse feeds and resist to be fed, developed stiffness of the body, would refuse being lifted, had urinary and fecal incontinence, became almost mute or would have echolalia for few minutes, had posturing, and weight[jgmh.org]
  • An overview of associated conditions of catatonia in children and adolescents is provided in Table 1. 7-22 The frequencies of the most common catatonic symptoms in children and adolescents are shown in Table 2. 8 Rates for urinary and fecal incontinence[primarypsychiatry.com]
Negativism
  • During week three of hospitalization, she was given olanzapine with subsequent improvement in her negativism.[ncbi.nlm.nih.gov]
  • History of the concept In 1874, Kahlbaum 1,2 was the first to propose a syndrome of motor dysfunction characterized by mutism, immobility, staring gaze, negativism, stereotyped behavior, waxy flexibility, and verbal stereotypies that he called catatonia[mdedge.com]
  • Negativism — Behavior characterized by resistance, opposition, and refusal to cooperate with requests, even the most reasonable ones.[medical-dictionary.thefreedictionary.com]
Stupor
  • In catatonic stupor, i.e. immobility and stupor, the first-line therapy is electrotherapy, preferably at an earliest possible stage. In mania, catatonia may become manifest also as psychomotor excitement.[ncbi.nlm.nih.gov]
  • Stuporous catatonia is characterised by immobility during which people may hold rigid poses ( stupor ), an inability to speak ( mutism ), as well as waxy flexibility, in which they maintain positions after being placed in them by someone else.[en.wikipedia.org]
  • […] to excited, 14,15 and from benign to malignant. 13 Examples of these ranges of presentation include 5,12,13,15-19 : Stuporous/retarded catatonia (Kahlbaum syndrome) is a primarily negative syndrome in which stupor, mutism, negativism, obsessional slowness[mdedge.com]
Altered Mental Status
  • When the patient's altered mental status could not otherwise be explained, benzodiazepine withdrawal-induced catatonia was considered.[ncbi.nlm.nih.gov]
  • A 16-year-old boy with a history of attention deficit hyperactivity disorder (ADHD) and a mild learning disability diagnosed at age 12 presented to our emergency department with altered mental status.[innovationscns.com]
  • Catatonia vis-à-vis delirium: The significance of recognizing catatonia in altered mental status. Gen. Hosp. Psychiatry 2015, 37, 554–559. [ Google Scholar ] [ CrossRef ] [ PubMed ] Grover, S.; Ghosh, A.; Ghormode, D.[mdpi.com]
Clonus
  • It has similar characteristics and course, but is precipitated by serotonergic medications and typically has gastrointestinal symptoms, hyperreflexia or clonus. 18 Unlike NMS or malignant catatonia, it is a toxic response that occurs in a dose-related[doi.org]
Mydriasis
  • The pediatric and psychiatric examination revealed motor stereotypes, mannerism, bilateral mydriasis, and visual hallucinations. Laboratory and brain imaging explorations were initially negative.[ncbi.nlm.nih.gov]
Neonatal Seizures
  • He had a history of neonatal seizures, had been stabilized with vigabatrin, and was seizure free without treatment for several months.[ncbi.nlm.nih.gov]

Workup

  • Comprehensive physical exam with emphasis on neurological deficits and mental status.
  • Differentiate between functional or organic cause.
  • Needs medical admission or a psychiatric assessment.

Investigations:

  • Complete blood count
  • Electrolytes
  • Renal and liver function
  • Thyroid function
  • Blood glucose
  • Creatine phosphokinase
  • Urine drug screen

Other investigations depend on physical findings: 

White Matter Lesions
  • Repeat magnetic resonance imaging revealed extensive periventricular white matter lesions not present on admission scans, and she was diagnosed with DPHL. DISCUSSION: No treatment for DPHL has been proven to be widely effective.[ncbi.nlm.nih.gov]

Treatment

Catatonia is managed by a multidisciplinary team including a neurologist, ophthalmologist, hematologist, psychiatrist and an internist [7] [8]. Hospital admission is required as most patients refuse to eat, are unable to care for themselves and have autonomic instability. Because of fever, dehydration many require IV hydration. It is vital to treat catatonia as early as possible. The longer the treatment is delayed the less responsive are the symptoms.

Besides supportive care like hydration and control of fever, the two basic treatments are use of medications and electroconvulsive therapy (ECT). The most important thing is to diagnose and treat the malignant catatonia like NMS, acute psychosis, encephalitis and non-convulsive status epilepticus immediately. These are neurological emergencies that are best managed in the ICU. Patients who cannot eat may require TPN or a feeding tube. Some patients may need admission to the psychiatric ward to prevent harm to themselves or others.

Pharmacologic therapy

There are many medications which have been used to treat catatonia but the benzodiazepines are the drugs of choice.[9] Others include:

Once the symptoms subside, the drug can be gradually withdrawn. In some cases, low dose maintenance treatment with drugs may be required. After drug treatment, improvement is seen within 48 hours.

Electroconvulsive treatment (ECT)

ECT is indicated for patients who fail to respond to medical therapy or those who have NMS or malignant catatonia or catatonic schizophrenia. The response is often immediate but patients may require several treatments over several weeks. Unfortunately, relapses do occur after a 12 month period and repeat treatments are required. After ECT treatment, patient can be discharged when the symptoms improve.[10]

Prognosis

The prognosis for catatonia depends on the cause. It has been observed that idiopathic cases do spontaneously recover in 10-40% of cases, regardless of treatment. When benzodiazepines are used, the response rates are much better. Failure to institute treatment early, generally has a poor prognosis. Children with cationic schizophrenia generally have a poor prognosis compared to children with other forms of schizophrenia. Many patients with mental disorders and catatonia need inpatient psychiatric treatment. Because of immobility, patients with catatonia are also at a high risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall about 70% of patients have a good response to treatment. But cognitive impairment and deficits in daily living activities are reported. After ECT high rate of relapse occurs within 12 months.

Complications

  • Dehydration
  • Malnutrition
  • Immobility
  • Pulmonary embolism
  • Significant harm to self and others
  • After a first episode of catatonia, repeat episodes are very common.

Etiology

Catatonia has many causes but the most common include the following:

Epidemiology

The exact incidence of catatonia is unknown but the rates are down from previous decades. Few reports from psychiatric in patients have been published on the prevalence but it is felt that these numbers are not valid because they do not reflect the patients on other medical wards or the general population. Further the difficulty in making the diagnosis and different diagnostic criteria used have led to confusion in the literature. In psychiatry wards, catatonia prevalence has been reported to be from 7-17%. The disorder is rare in children and often presents in adults. A slightly higher prevalence has been observed in female schizophrenics.

Sex distribution
Age distribution

Pathophysiology

The exact cause of catatonia is unknown but several hypotheses exist based on abnormal neurotransmitter levels. It is believed that there is a deficiency in the inhibitory neurotransmitter GABA. This may also explain why the benzodiazepines, which increase GABAergic activity, have a therapeutic response. Similarly the excitatory neurotransmitter, glutamate, has been suggested as an underlying cause of catatonia.

Others believe that catatonia may be due to sudden and massive blockade of dopamine receptors and this may explain why antipsychotics are not always beneficial or may precipitate worsening of the disorder.[6]

Prevention

Since the cause of catatonia is not known there is no preventive method. However, patients who have medical disorders like schizophrenia, depression, bipolar disorder should follow up closely with their healthcare provider. For healthcare professionals it is important to be aware of the signs and symptoms of the disorder, because the earlier catatonia is treated, the better is the prognosis.

Summary

Catatonia is a physical state of partial/complete indifference to external stimuli in an individual who is apparently awake. Catatonia is an important medical disorder with dramatic presentation. The disorder is underdiagnosed and not well recognized. The prevalence of catatonia has declined but is not miniscule.

Catatonia can occur in people of all ages and is associated with a range of comorbid disorders. The typical signs and symptoms range from complete immobility, mutism, movement disorders and impairment of voluntary expression of thoughts. The behavior can range from echolalia, automatism, or agitation. Catatonia has been classified in several ways but the most common classification as per DSM-5 is as follows:

  • Catatonia associated with a mental disorder (eg. schizophrenia or mood disorder)
  • Catatonic disorder due to another medical disorder
  • Unspecified catatonia

Another classification includes dividing catatonia as follows:

  • Systemic catatonia that is usually not genetically determined, has a higher prevalence and occurs early age and is more frequent in males. It is often associated with mid gestational infections
  • Periodic catatonia has no difference in age of onset or prevalence, but has a genetic origin and often seen in schizophrenia [1] [2] [3] [4] [5].

Catatonia can often be mistaken for other disorders like neuroleptic malignant syndrome (NMS), nonconvulsive status epilepticus, acute psychosis, conversion disorder, malingering, and psychogenic movement disorders. There is a vast differential for catatonia but it is important to rule out life threatening malignant catatonia due to NMS or serotonin syndrome.

Diagnostic criteria (DSM-5)

DSM-5 criteria for diagnosis of catatonia require presence of at least 3 of the following features:

Even though catatonia is often associated with schizophrenia, the majority of cases are associated with mood disorders (depression and bipolar disorder).

Patient Information

Catatonia is a complex disorder where the individual suddenly becomes unresponsive to external stimuli. The patient is awake but indifferent to what is going on in the environment. There are many causes of catatonia and it is often seen in patients with manic disorder, depression and schizophrenia. The disorder can occur in both genders and in all ages. The signs and symptoms are quite variable but the individual may become stiff, tends to repeat words, is unable to swallow, walk and have fever. Once the diagnosis is made, patients are admitted. Fluids are usually given. The treatment is either medications or electroconvulsive therapy. The outcome in most patients is good but recurrences are common.

References

Article

  1. Ungvari GS Catatonia in DSM 5: controversies regarding its psychopathology, clinical presentation and treatment response. Neuropsychopharmacol Hung. 2014 Dec;16(4):189-94
  2. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the treatment of catatonia. Front Psychiatry. 2014 Dec 9;5:181.
  3. Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry. 2014 Nov 19.
  4. Padhy SK, Parakh P, Sridhar M. The catatonia conundrum: controversies and contradictions. Asian J Psychiatr. 2014 Feb;7(1):6-9.
  5. Gonzales N, Quinn DK, Rayburn W. Perinatal catatonia: a case report and literature review. Psychosomatics. 2014 Nov-Dec;55(6):708-14.
  6. Dhossche DM, Sienaert P, van der Heijden FM. [Mechanisms of catatonia]. Tijdschr Psychiatr. 2015;57(2):99-103
  7. Hidasi Z, Salacz P, Csibri E. [Movement disorders is psychiatric diseases]. Neuropsychopharmacol Hung. 2014 Dec;16(4):205-11.
  8. Clinebell K, Azzam PN, Gopalan P, Haskett R. Guidelines for preventing common medical complications of catatonia: case report and literature review. J Clin Psychiatry. 2014 Jun;75(6):644-51.
  9. Pot AL, Lejoyeux M. [Catatonia]. Encephale. 2015 Jun;41(3):274-9.
  10. Luchini F, Medda P, Mariani MG, Mauri M, Toni C, Perugi G. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry. 2015 Jun 22;5(2):182-92.

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Last updated: 2019-07-11 22:41