| Catatonia | |
|---|---|
| Other names | Catatonic syndrome |
 | |
| A patient in catatonic stupor | |
| Specialty | Psychiatry |
Catatonia is a state of psycho-motor immobility and behavioral abnormality. It was first described in 1874 by Karl Ludwig Kahlbaum as Die Katatonie oder das Spannungsirresein (Catatonia or Tension Insanity).
Though catatonia has historically been related to schizophrenia (catatonic schizophrenia), it is now known that catatonic symptoms are nonspecific and may be observed in other mental disorders and neurological conditions. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), catatonia is not recognized as a separate disorder, but is associated with such psychiatric conditions as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression, narcolepsy, drug abuse, and overdose. It may also be seen in many medical disorders, including infections (such as encephalitis), autoimmune disorders, meningitis, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia).
It can be an adverse reaction to prescribed medication and is similar to encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available. Benzodiazepines are a first-line treatment strategy. Electroconvulsive therapy is sometimes used. There is growing evidence of the effectiveness of the NMDA receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia. Antipsychotics are sometimes employed, but they can worsen symptoms and have serious adverse effects.
Signs and symptoms
Catatonia can be stuporous or excited. Stuporous catatonia is characterized by immobility during which patients may show reduced responsiveness to the environment (stupor), rigid poses (posturing), an inability to speak (mutism), and waxy flexibility (in which they maintain positions after being placed in them by someone else). Mutism may be partial and patients may repeat meaningless phrases (verbigeration) or speak only to repeat what someone else says (echolalia). People with stuporous catatonia may also show purposeless, repetitive movements (stereotypy). Excited catatonia is characterized by bizarre, non–goal-directed hyperactivity and impulsiveness.
Catatonia can occur in various psychiatric disorders, including major depressive disorder, bipolar disorder, schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. It appears as the Kahlbaum syndrome (motionless catatonia), malignant catatonia (neuroleptic malignant syndrome, toxic serotonin syndrome), and excited forms (delirious mania, catatonic excitement, oneirophrenia). It also is related to autism spectrum disorders.
Diagnosis
According to the DSM-5, "Catatonia Associated with Another Mental Disorder (Catatonia Specifier)" (code 293.89 [F06.1]) is diagnosed if the clinical picture is dominated by at least three of the following:
- stupor: no psycho-motor activity; not actively relating to environment
- catalepsy: passive induction of a posture held against gravity
- waxy flexibility: allowing positioning by examiner and maintaining that position
- mutism: no, or very little, verbal response (exclude if known aphasia)
- negativism: opposition or no response to instructions or external stimuli
- posturing: spontaneous and active maintenance of a posture against gravity
- mannerisms that are odd, circumstantial caricatures of normal actions
- stereotypy: repetitive, abnormally frequent, non-goal-directed movements
- agitation, not influenced by external stimuli
- grimacing: keeping a fixed facial expression
- echolalia: mimicking another's speech
- echopraxia: mimicking another's movements.
Other disorders (additional code 293.89 [F06.1] to indicate the presence of the co-morbid catatonia):
- Catatonia associated with autism spectrum disorder
- Catatonia associated with schizophrenia spectrum and other psychotic disorders
- Catatonia associated with brief psychotic disorder
- Catatonia associated with schizophreniform disorder
- Catatonia associated with schizoaffective disorder
- Catatonia associated with substance-induced psychotic disorder
- Catatonia associated with bipolar and related disorders
- Catatonia associated with major depressive disorder
- Catatonic disorder due to another medical condition
If catatonic symptoms are present but do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered.
Subtypes
Although catatonia can be divided into various subtypes, the natural history of catatonia is often fluctuant and different states can exist within the same individual.
- Stupor is a motionless state in which one is oblivious of, or does not react to, external stimuli. Motor activity is almost non-existent. People in this state make little or no eye contact with others and may be mute and rigid. One may remain in one position for a long period of time, and then go directly to another position immediately after the first position.
- Catatonic excitement is a state of constant purposeless agitation and excitation. People in this state are extremely hyperactive and may have delusions and hallucinations. Catatonic excitement is commonly cited as one of the most dangerous mental states in psychiatry.
- Malignant catatonia is an acute onset of excitement, fever, autonomic instability, and delirium and may be fatal.
Rating scale
Various rating scales for catatonia have been developed. The most commonly used scale is the Bush-Francis Catatonia Rating Scale (BFCRS). A diagnosis can be supported by the lorazepam challenge or the zolpidem challenge. While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT.
Treatment
Initial treatment is aimed at providing symptomatic relief. Benzodiazepines are the first line of treatment, and high doses are often required. A test dose of intramuscular lorazepam will often result in marked improvement within half an hour. In France, zolpidem has also been used in diagnosis, and response may occur within the same time period. Ultimately the underlying cause needs to be treated.
Electroconvulsive therapy (ECT) is an effective treatment for catatonia, however, it has been pointed out that further high quality randomized controlled trials are needed to evaluate the efficacy, tolerance, and protocols of ECT in catatonia.
Antipsychotics should be used with care as they can worsen catatonia and are the cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate discontinuation of the antipsychotic.
Excessive glutamate activity is believed to be involved in catatonia; when first-line treatment options fail, NMDA antagonists such as amantadine or memantine may be used. Amantadine may have an increased incidence of tolerance with prolonged use and can cause psychosis, due to its additional effects on the dopamine system. Memantine has a more targeted pharmacological profile for the glutamate system, reduced incidence of psychosis and may therefore be preferred for individuals who cannot tolerate amantadine. Topiramate is another treatment option for resistant catatonia; it produces its therapeutic effects by producing glutamate antagonism via modulation of AMPA receptors.
