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Catatonic Schizophrenia

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.


Presentation

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:

  • Purposeless motions
  • Repetitive movements (stereotypical behaviour) of the body, esp. of the extremities or digits
  • Resistance to change in appearance or body posture even though they appear uncomfortable
  • Maintain same position for hours
  • Abnormal facial contortions which may be mistaken for tardive dyskinesia
  • Echolalia (repeating what a person says(
  • Echopraxia (mimicking movements of another person)
  • Command automatism meaning the individual will obey all instructions without any hesitation or questioning why
Anorexia
Enuresis
  • On admission, he demonstrated near-complete mutism, frequent enuresis and encopresis, and severe psychomotor retardation.[ncbi.nlm.nih.gov]
Trismus
  • A case is reported where long standing trismus was the presenting factor in a case of catatonic schizophrenia. The investigations and treatment are described.[ncbi.nlm.nih.gov]
Infrequent Blinking
  • --Staring, while in deep thought, with infrequent blinking.[bluelight.org]
Negativism
  • Onset of illness appears to be among young adults and mutism, stupor, mannerisms, stereotypes and negativism were the common catatonic symptoms observed.[ncbi.nlm.nih.gov]
  • During the withdrawal stage, stupor, waxy flexibility, muscular rigidity, mutism, blocking, negativism, and catalepsy (cerea flexibilitas) may be seen.[medical-dictionary.thefreedictionary.com]
Flat Affect
  • Symptoms such as avolition, impaired social interaction, and flat affect become more frequent over the 25 years of follow-up. Hallucinations and delusions become less frequent.[ncbi.nlm.nih.gov]
  • Meanwhile, other symptoms of schizophrenia — such as disorganized speech, flat affect, catatonic, or disorganized behavior — are not present or are less prominent than these positive symptoms. 2 2.[psycom.net]
Denial
  • Our lack of knowledge of her symptoms and how to help meant that we were all living our own lives in denial. I have suffered guilt, pain, hate, love and many more emotions due to my Mother’s problems.[amandagreenauthor.co.uk]
  • 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.[symptoma.com]
Manic Behavior
  • Those experiencing catatonic excitement will exhibit manic behaviors such as babbling or speaking incoherently. Parrot-like repetition or echoing of words, known as echolalia, is also a common catatonic behavior.[psychology.about.com]
Stupor
  • Despite therapists' attention to nonverbal behavior, mutism and stupor are particularly effective hindrances to communication in psychotherapy.[ncbi.nlm.nih.gov]
  • Code F44.2 Dissociative stupor 2016 2017 2018 2019 Billable/Specific Code Type 1 Excludes catatonic stupor ( R40.1 ) stupor NOS ( R40.1 ) Type 2 Excludes catatonic disorder due to known physiological condition ( F06.1 ) depressive stupor ( F32 , F33[icd10data.com]
  • […] is rapid alteration between the extremes of excitement and stupor.[medical-dictionary.thefreedictionary.com]
Apathy
  • It is often considered to be more of a personality disorder; see schizotypal personality disorder. simple schizophrenia a form characterized by gradual loss of drive, social withdrawal, and emotional apathy, but without prominent psychotic features.[medical-dictionary.thefreedictionary.com]
  • A. apathy and delusion B. lack of motivation, blunted affect, and apathy C. bizarre behavior and delusions D. asociality, anhedonia, and periodic excitability 4. The statement made by Steve “My co-workers envy me and are out to take me down.[nurseslabs.com]
  • ., difficulty paying attention, social withdrawal, apathy, a reduction in speech). This subtype is distinguished from the “residual phase” of schizophrenia.[psycom.net]
  • Doctors call this apathy. Struggling with the basics of daily life. They may stop bathing or taking care of themselves. No follow-through. People with schizophrenia have trouble staying on schedule or finishing what they start.[webmd.com]
Flail Arm
  • These motor activities — such as frenzied pacing, turning around in circles, flailing arms or making loud noises — appear to have no purpose or motivating factors. This kind of behavior is called catatonic excitement. Extreme resistance.[knowyourdisease.com]
  • They may flail arms, pace back and forth, make loud noises, and engage in a variety of nonsensical movements. These movements typically have no purpose and the individual lacks rationale behind them.[mentalhealthdaily.com]
Disturbed Gait
  • The presence of speech disturbance, gait abnormalities, movement disorders, and cognitive decline may indicate an underlying metabolic disorder.[ncbi.nlm.nih.gov]
Slurred Speech
  • The speaker may find it hard to follow as the speech may be a slurred speech or also confused. In fact, sometimes, the patient also believes somebody is messing her or his mind. Catatonic schizophrenia symptoms can include hallucinations .[epainassist.com]

Workup

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).

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Treatment

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:

  • Use of benzodiazepines is recommended as they tend to work rapidly. These agents do not cure the catatonia but relieve the symptoms. Valium is often the drug of choice and results in marked improvement of the catatonic features. Other benzodiazepines like lozazepam can also be used. For emergency cases, midazolam maybe used intravenously and the patient’s respiratory and hemodynamic status must be monitored.
  • In the majority of patients with catatonic schizophrenia, the second line treatment is electroconvulsive therapy (ECT). The treatment is effective but often several sessions are required [5] [6] [7].
  • If benzodiazepines and ECT fail to work or their benefits are mild, then use of NMDA antagonists is recommended. Drugs like memantine and amantadine used to treat neurodegenerative disorders (eg. Alzheimer disease and Parkinson disease) may help. Unfortunately patients often develop tolerance and the drugs also have potent adverse effects. The newer anticonvulsant, topiramate has also been used to treat catatonia and does work in some people. It acts by modulating the effects of glutamate.
  • Other drugs used to treat catatonia include tricyclic antidepressants, muscle relaxants, lithium, bromocriptine, thyroid hormone, reserpine and barbital derivatives [8] [9].
  • Once the patient has recovered from catatonia, the drugs must be gradually withdrawn. However, in individuals with recurrent catatonia, a low maintenance dose of the drug is required.

Prognosis

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.

Etiology

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 [4].

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 [3].

Epidemiology

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 [1].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of schizophrenia is related to an excess of dopamine in the brain [2]. 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.

Prevention

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.

Summary

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 [1].

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 [2] [3].

Patient Information

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.

References

Article

  1. England ML, Ongür D, Konopaske GT, Karmacharya R. Catatonia in psychotic patients: clinical features and treatment response. J Neuropsychiatry Clin Neurosci. 2011 Spring;23(2):223-6
  2. Ungvari GS. Catatonia in DSM 5: controversies regarding its psychopathology, clinical presentation and treatment response. Neuropsychopharmacol Hung. 2014 Dec;16(4):189-94.
  3. Ramdurg S, Kumar S, Kumar M, Singh V, Kumar D, Desai NG. Catatonia: Etiopathological diagnoses and treatment response in a tertiary care setting: A clinical study. Ind Psychiatry J. 2013 Jan;22(1):32-6.
  4. Koch A, Reich K, Wielopolski J, Clepce M, Fischer M, Kornhuber J, Thuerauf N. Catatonic dilemma in a 33-year-old woman: a discussion. Case Rep Psychiatry. 2013;2013:542303.
  5. Jovanović N, Lovretić V, Kuzman MR. The use of electroconvulsive therapy and general anaesthesia in catatonic schizophrenia complicated by clozapine - induced pancytopenia - case report. Psychiatr Danub. 2014 Sep;26(3):285-7.
  6. Unal A, Bulbul F, Alpak G, Virit O, Copoglu US, Savas HA. Effective treatment of catatonia by combination of benzodiazepine and electroconvulsive therapy. J ECT. 2013 Sep;29(3):206-9.
  7. Philbin D, Mulryan D, O'Grady M. Catatonic schizophrenia: therapeutic challenges and potentially a new role for electroconvulsive therapy? BMJ Case Rep. 2013 Jul 29;
  8. Yamashita S, Miyaoka T, Nagahama M, Ieda M, Tsuchie K, Wake R, Horiguchi J. Treatment of Paroxysmal Perceptual Alteration in Catatonic Schizophrenia by Switching to Aripiprazole from Risperidone. Clin Schizophr Relat Psychoses. 2013 Sep 18:1-12
  9. Sasaki T, Hashimoto T, Niitsu T, Kanahara N, Iyo M Treatment of refractory catatonic schizophrenia with low dose aripiprazole. Ann Gen Psychiatry. 2012 May 3;11(1):12.

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Last updated: 2019-07-11 20:41