Catatonic schizophrenia is a subtype of schizophrenia which presents with a range of abnormal motor movements. The disorder is marked by predominantly catatonic symptoms which are often difficult to treat because most antipsychotics can worsen the catatonia.
The most common feature of catatonic schizophrenia is a disturbance in the individual’s movement. The majority of individuals will have an obvious decrease in voluntary movements and become catatonic. In between the inactivity there may be periods of excess motion which is known as catatonic excitement.
Other features of the disorder include the following:
Before making a diagnosis of catatonia, the primary diagnosis of schizophrenia must be made. To diagnose of catatonic schizophrenia, the abnormal movement behaviour must be predominant. The abnormal movements and symptoms may include stupor, excitement, posturing, and negativism, rigidity, waxy flexibility, automatic compliance and echolalia.
A complete medical and mental health history of the family and details about pregnancy must be obtained. Use of medications and other illicit agents must be sought. Even though schizophrenia is not associated with any abnormal laboratory work, these studies must be performed to rule out other organic causes of schizophrenia and/or catatonia. Besides a complete blood count, liver, thyroid and renal function tests are required. Electrolyte levels, urine testing for illicit drugs and brain imaging are also needed. Other tests depend on the symptoms. If there is suspicion of Wilson disease, urinary and serum copper, and ceruloplasmin levels are needed.
Other tests include ruling out syphilis, human immunodeficiency virus (HIV) infection, Lyme disease, systemic lupus erythematosus and Cushing syndrome. Some experts even recommend a lumbar puncture to examine the CSF fluid for infection.
A thorough neuropsychiatric exam is needed to obtain baseline levels of cognition, memory, concentration and ability to perform executive function. There are some individuals who will not communicate and appear to have catatonic schizophrenia. In such cases, a preliminary diagnosis of schizophrenia is made and the patient is closely followed until there is more evidence of other symptoms to confirm the diagnosis. It is important to note that presence of catatonia does not mean an individual has schizophrenia because there are many other causes of the disorder (eg. medications, organic brain disease, use of alcohol, metabolic disturbances).
The treatment of catatonic schizophrenia is more difficult compared to the usual schizophrenic patient. In general, use of antipsychotic drugs can make the catatonia worse, because of their antidopaminergic effects. Use of antipsychotics drugs in the presence of catatonia also increases the risk of developing neuroleptic malignant syndrome (NMS), which is fatal if not recognized and treated promptly. If neuroleptic malignant syndrome is suspected, the antipsychotic drug must be discontinued immediately and the patient admitted for observation in the ICU. The risk of NMS is less with the second generation antipsychotics but not completely zero. The second generation antipsychotics are used to treat catatonic schizophrenics but under close observation.
If the patient is refusing to eat, parenteral nutrition may be required. If the patient poses a risk to him/herself or others, a 1:1 psychiatric attendant must be present at all times.
The medical treatment of catatonia involves the following:
The prognosis of schizophrenia overall is poor. Full recovery or cure is very unusual. Most individuals have progression of the disease and do not become fully functional citizens. The nature of symptoms is unpredictable with many periods of waxing and waning. While positive symptoms of schizophrenia do respond well to treatment, the negative symptoms are persistent. Many individuals with schizophrenia are neglected, have a poor diet and lead a life of poverty. Homelessness, incarceration and other medical illnesses are common. Many schizophrenics’ have a poor and unhealthy lifestyle that include smoking, poor nutrition, lack of exercise and poor medical care. Most remain non-complaint with medications.
Presence of catatonia significantly worsens the prognosis as the disorder is difficult to treat. These individual are vulnerable and often suffer from violence. Even in hospital they remain isolated and are sedated for prolonged times. The drugs have many adverse effects and often impair the patient’s life. Overall, schizophrenics have a 5% lifetime risk of suicide.
The cause of schizophrenia is not known but has been linked to genes and the environment. Catatonia is thought to be caused by abnormal function of the GABA and glutamate neurotransmitter systems in the brain. It is believed that there is most likely an abnormal breakdown of the neurotransmitters in the prefrontal lobe and thalamus. In addition, blockade of dopamine receptor leads to catatonic symptoms. Deficiency of GABA which is an inhibitory neurotransmitter or an increase in glutamine, which is an excitatory neurotransmitter, may lead to uncontrolled motor behaviour. Others believe that the etiology may be related to an inherent response to fear, which when activated, leads to a completely immobile state.
There is some research indicating that the immune system may be defective in schizophrenia. Overactivity of the immune system may result in overexpression of certain cytokines in the brain, and lead to dysfunction of neurotransmitters. Elevated levels of proinflammatory cytokines have been found in some patients with schizophrenia .
It is believed that the disorder may have genetic and perinatal risk factors. Besides genetic factors, advanced paternal age is also a risk factor for catatonic schizophrenia. The risk of schizophrenia in biological relatives of individuals with schizophrenia is about 10% and if both parents have schizophrenia, the risk of the child having the disorder can be as high as 40%. Perinatal factors linked to schizophrenia include a viral infection during pregnancy and malnourishment. Infants born during the winter months seem to be at a higher risk of developing schizophrenia. A relatively new study suggest that heavy use of marijuana among teenagers may speed up the onset of psychosis in those already at risk for developing psychotic illness .
The lifetime prevalence of schizophrenia in the general population is about 1%. Other studies show that the risk of schizophrenia is much higher in developed countries compared to those which are underdeveloped. Further, immigrants who come to developed countries tend to show increased rates of schizophrenia, and this risk also extends to the second generation. Schizophrenia most commonly presents in the 2nd to 3rd decade of life. The initial first few years prior to diagnosis are the most turbulent because the diagnosis is not made or there is denial by the patient and family. Both genders have an equal presupposition to schizophrenia but the onset of the disorder is a few years later in females. There is no race or culture which is immune from schizophrenia .
The pathophysiology of schizophrenia is related to an excess of dopamine in the brain . Over the past few decades, research points to abnormalities in the function of certain neurotransmitters like dopamine in the limbic system and prefrontal cortex. Newer brain imaging techniques have shown that the potential pathology resides in the limbic system in most schizophrenic patients.
There are no specific preventive measures to prevent catatonic schizophrenia. Because the cause of catatonic schizophrenia is not known, prevention is difficult. However, patients and families need to be educated about the symptoms and signs as early treatment appears to have better outcomes. Patients should try and avoid certain infections by getting vaccinated. Catatonic symptoms due to certain medications or illicit drugs can be reversed by discontinuing the offending agent.
Catatonic schizophrenia is one of the five subtypes of schizophrenia that is characterized by extremes in behaviour. At one end of the spectrum, the individual may not be able to speak or move and be stuck in a catatonic stupor and at the other end of the spectrum may be hyperactive, use repetition in speech and engage in bizarre body movements. At both extremes the behaviour of the individual is not logical or normal .
Before one makes a diagnosis of catatonic schizophrenia, a general diagnosis of schizophrenia must be made. The catatonic symptoms can present with any subtype of schizophrenia. To make the diagnosis of catatonic schizophrenia, the catatonic symptoms must be dominant  .
Catatonic schizophrenia is a rare subtype of schizophrenia characterized by severe disturbances in motor behavior. Once catatonic schizophrenia is diagnosed, the family and patient need to be educated about the signs and symptoms of the disorder. Moreover the family needs to know the adverse effects of the drugs used to treat the disorder. The family should be encouraged to administer the medications and ensure compliance; otherwise relapse of schizophrenia can occur. All families should be taught about neuroleptic malignant syndrome. The moment the patient develops fever, a visit to the emergency room is highly recommended. Attempts to treat catatonia with alternative medicine is not recommended as there is little evidence that it works.