Catatonia

Primer

Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome, apart from thorough and repeated observation, a clinical examination is needed.

Prevalence

Catatonia is typically diagnosed in an inpatient setting and can occur in up to 35% of individuals with schizophrenia. However, the majority of catatonia involve patients with depressive or bipolar disorders.

Pathophysiology

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.

Diagnostic Criteria

Classification

Catatonia can be classified under one of three categories:

  • Catatonia Associated With Another Mental Disorder (e.g. - marked psychomotor disturbance in neurodevelopmental, psychotic, bipolar, depressive, or other mental disorder)
  • Catatonic Disorder Due to Another Medical Condition
  • Unspecified Catatonia
Only Criterion A needs to be met to have a diagnosis of Catatonia Associated With Another Mental Disorder (Catatonia Specifier)
Criterion A

The clinical picture is dominated by at least 3 of the following symptoms:

  1. Stupor (i.e., no psychomotor activity; not actively relating to environment)
  2. Catalepsy (i.e., passive induction of a posture held against gravity)
  3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
  4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
  5. Negativism (i.e., opposition or no response to instructions or external stimuli)
  6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
  7. Mannerism (i.e., odd, circumstantial caricature of normal actions)
  8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
  9. Agitation, not influenced by external stimuli
  10. Grimacing
  11. Echolalia (i.e., mimicking another’s speech)
  12. Echopraxia (i.e., mimicking another’s movements)
Criterion A, B, C, D, and E must ALL be met to have a diagnosis of Catatonic Disorder Due to Another Medical Condition
Criterion B

There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

Criterion C

The disturbance is not better explained by another mental disorder (e.g.,a manic episode).

Criterion D

The disturbance does not occur exclusively during the course of a delirium.

Criterion E

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Screening and Diagnosis

Catatonic symptoms may be present in any of the following five psychotic disorders: brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and substance/medication-induced psychotic disorder. It may also be present in some of the neurodevelopmental disorders, in all of the bipolar and depressive disorders, and in other mental disorders.

  • Screening Tool: Use items 1-14 as “absent” or “present”
  • Scale: Rate items 1-23 on a scale of 0-3
  • 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 behavior and/or chart documentation. Rate items only if well defined. If uncertain, rate the item as “0”. [1]

bush-francis_catatonia_rating_scale.pdf

Differential Diagnosis

  • Before the catatonia specifier is used in neurodevelopmental, psychotic, bipolar, depressive, or other mental disorders, a wide variety of other medical conditions need to be ruled out; these conditions include, but are not limited to, medical conditions due to infectious, metabolic, or neurological conditions.
  • Catatonia can also be a side effect of a medication. Because of the seriousness of the complications, particular attention should be paid to the possibility that the catatonia is attributable to neuroleptic malignant syndrome.
  • A separate diagnosis of catatonic disorder due to another medical condition is not given if the catatonia occurs exclusively during the course of a delirium or neuroleptic malignant syndrome. If the individual is currently taking neuroleptic medication, consideration should be given to medication-induced movement disorders (e.g., abnormal positioning may be due to neuroleptic-induced acute dystonia) or neuroleptic malignant syndrome (e.g., catatonic-like features may be present, along with associated vital sign and/or laboratory abnormalities).

Treatment

Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines and electroconvulsive therapy.[2]

Resources

References

1) http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1996.tb09814.x/abstract
2) Sienaert, P., Dhossche, D. M., Vancampfort, D., De Hert, M., & Gazdag, G. (2014). A clinical review of the treatment of catatonia. Frontiers in psychiatry, 5.