Catatonia is a severe heterogeneous neuropsychiatric and medical syndrome with motor and/or behavioural signs. At times, it can be life-threatening, especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia is not just a psychiatric syndrome and can accompany both psychiatric and medical illnesses.
Catatonia can be classified under 1 of 3 categories under the DSM-5:
The clinical picture is dominated by at least 3 of the following symptoms:
WRENCHES can be used to remember the core features of catatonia:W - Waxy flexibilityR - RigidityE - EchopraxiaN - NegativismC - CatalepsyH - High level of motor activityE - EcholaliaS - Stupor, StereotypyThere is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
The disturbance is not better explained by another mental disorder (e.g. - a manic episode).
The disturbance does not occur exclusively during the course of a delirium.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
WRENCHES mnemonic, catatonia can also be remembered by breaking it down into the categories of decreased, increased, and abnormal psychomotor activity:Three subtypes of catatonia have been categorized: stuporous, excited, and malignant. It should be noted that these subtypes are not recognized in the DSM-5.
| Name | Rater | Description | Download |
|---|---|---|---|
| Bush-Francis Catatonia Rating Scale (BFCRS) | Patient | The screening section marks items #1-14 as either “absent” or “present.” The full scale rates items #1-23 on a scale of 0-3. The ratings are made based on the observed behaviors during the examination, with the exception of completing the items for “withdrawal” and “autonomic abnormality,” which may be based upon either observed behaviours and/or chart documentation. Rate items only if well defined. If uncertain, rate the item as “0”.[7] | Download BFCRS |
Several models for the development of catatonia have been proposed, but catatonia remains very poorly understood. The dysfunctional neurotransmitter model proposes that a combination of reduced GABA activity in the frontal cortex, increased N-methyl-D-aspartate glutamatergic activity in the posterior parietal cortex, and dampened dopaminergic action in the basal ganglia is responsible for catatonia.[8] The neural network and circuits model suggests that disruption in the mesoencephalofrontal system (brainstem → basal ganglia → limbic system and cerebral cortex). More recent functional imaging studies have shown activity changes in orbitofrontal, prefrontal, motor cortical, and parietal regions.[9]
A variety of medical conditions may cause catatonia, especially neurological conditions (e.g. - neoplasms, head trauma, cerebrovascular disease, encephalitis) and metabolic conditions (e.g. - hypercalcemia, hepatic encephalopathy, homocystinuria, diabetic ketoacidosis). The associated physical examination findings, laboratory findings, and patterns of prevalence and onset reflect those of the etiological medical condition.
Prior to the physical exam, it is important to check the chart for reports from previous 24 hours; check for oral intake, vital signs, any behaviour changes or incidents. A physical examination based on the Bush-Francis Catatonia Rating Scale can help guide the exam for catatonia:
| Sign | Exam | Pathological Response |
|---|---|---|
| Posturing | Observe the patient | Patient takes on postures on without any clear purpose |
| Grimacing | Observe the patient | Grimacing is posturing of muscles of facial expression |
| Stereotypy | Observe the patient | Excessive repetition of a normally goal-directed behaviour (like buttoning a shirt 30 times an hour) |
| Mannerisms | Observe the patient | Mannerisms are more purposeless than stereotypy |
| Verbigeration | Observe the patient | Repeating a certain word or sentence WITHOUT a stimulus |
| Perseveration | Talk to the patient | Repeating a word or phrase WITH a stimulus (i.e. - repeating something a clinician has said) |
| Mutism | Observe the patient while trying to engage in conversation | Mute |
| Grasp reflex | Firmly place two fingers in patient's palm | Tightly grasps your fingers (± even if asked not to) |
| Opposition (Gegenhalten) | Instruct patient to “keep your arm loose”, move patient's arm horizontally back and forth by the wrist, with varying degrees of lighter and heavier force | Automatically resists movement in each direction, matching your strength with each move (i.e. - the more you push the stronger resistance you get) |
| Negativism | Ask patient to look at you | Turns away |
| Echopraxia | Scratch your head or nose in an exaggerated way | Copies (±even if asked not to) |
| Waxy flexibility | Reposition patient's arm into an unusual (but painless) position | Initial resistance, then allows self to be repositioned and holds the pose (e.g. > 1 minute) |
| Anglepoise (Mitgehen) | Say, “Don’t let me raise your arm,” then push patient's arm in different directions with just your finger | You can move patient's arm with the lightest touch (“like an anglepoise lamp”) |
| Automatic obedience | • Reach into your pocket and say: “Stick out your tongue, I need to stick a pin in it”. • Extend your hand, saying, “Please don’t shake my hand | • Sticks tongue out (Don’t actually poke with a pin!) • Shakes your hand (± won’t let go) |
| Ambitendence | • Extend your hand, saying, “Please don’t shake my hand” • Instruct: “Please walk to the end of the room and back | • Oscillates (e.g. - reaching out then retracting hand repeatedly) • Takes a step away, then back, then away again |
Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines and electroconvulsive therapy.[13] Unfortunately, studies on the treatment of catatonia remains limited to mostly open-label studies or case reports.[14][15]
| 1st line | ECT, lorazepam IV, q6-8 hours x 2-3 days (zolpidem could be considered)[16] |
|---|---|
| 2nd line | Memantine 10mg PO daily, titrate over 3-4 days to 20mg daily Amantadine 100mg PO daily, titrated over 3-4 days to 600mg (in divided doses) (Prescribe the above as monotherapy or in combination with a benzodiazepine) |
| 3rd line | Valproic acid 500-1500mg PO daily Carbamazepine 300-600mg PO daily (May be useful if the catatonia is related to underlying mania) |
| Last line | Aripiprazole 10-30mg PO daily Olanzapine 2.5-10mg PO daily Clozapine 200-300mg PO Daily There is the potential to worsen catatonia or cause conversion to a malignant catatonia. |