Catatonia

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).[1]

This article is about the catatonic state. For other uses, see Catatonia (disambiguation).
Not to be confused with Katatonia, cataplexy, catalepsy, or Catalonia.

Catatonia
Other namesCatatonic syndrome
A patient in catatonic stupor
SpecialtyPsychiatry

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), catatonia is not recognized as a separate disorder, but is associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression, narcolepsy, drug abuse or overdose (or both). It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders,[2] meningitis, focal neurological lesions (including strokes),[3] alcohol withdrawal,[4] abrupt or overly rapid benzodiazepine withdrawal,[5][6][7] cerebrovascular disease, neoplasms, head injury,[8] and some metabolic conditions: homocystinuria, diabetic ketoacidosis, hepatic encephalopathy and hypercalcaemia.[8]

It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica [9] and neuroleptic malignant syndrome.[10] There are a variety of treatments available; benzodiazepines are a first-line treatment strategy. Electroconvulsive therapy is also sometimes used. There is growing evidence for the effectiveness of the NMDA receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia.[11] Antipsychotics are sometimes employed but require caution as they can worsen symptoms and have serious adverse effects.[12]

Signs and symptoms

Catatonia can be stuporous or excited. Stuporous catatonia is characterized by immobility during which individuals may show reduced responsiveness to the environment (stupor), rigid poses (posturing), an inability to speak (mutism), or waxy flexibility, in which they maintain positions after being placed in them by someone else. Mutism may be partial and they 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 is a syndrome that 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).[12] It has also been recognized as related to autism spectrum disorders.[13]

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:[8]

  • stupor (i.e., no psycho-motor activity; not actively relating to environment)
  • catalepsy (i.e., passive induction of a posture held against gravity)
  • waxy flexibility (i.e., allow positioning by examiner and maintain position)
  • mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
  • negativism (i.e., opposition or no response to instructions or external stimuli)
  • posturing (i.e., spontaneous and active maintenance of a posture against gravity)
  • mannerisms (i.e., odd, circumstantial caricature of normal actions)
  • stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
  • agitation, not influenced by external stimuli
  • grimacing (i.e., keeping a fixed facial expression)
  • echolalia (i.e., mimicking another's speech)
  • echopraxia (i.e., mimicking another's movements)

Other disorders (additional code 293.89 [F06.1] to indicate the presence of the co-morbid catatonia):

If catatonic symptoms are present but they do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered.[14]

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.[15]

  • Stupor is a motionless state in which one is oblivious or does not react to external stimuli. Motor activity is nearly non-existent. Individuals in this state make little or no eye contact with others and may be mute and rigid. One might 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. Individuals in this state are extremely hyperactive, although, as aforementioned, the activity seems to lack purpose. The individual may also experience delusions or hallucinations.[16] It is commonly cited as one of the most dangerous mental states in psychiatry.[17]
  • Malignant catatonia is an acute onset of excitement, fever, autonomic instability, delirium and may be fatal.[18]

Rating scale

Various rating scales for catatonia have been developed.[19] The most commonly used scale is the Bush-Francis Catatonia Rating Scale (BFCRS).[20] A diagnosis can be supported by the lorazepam challenge [21] or the zolpidem challenge.[22] 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.[12]

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.[23]

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.[12]

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.[24]

See also

References
  1. "Zur Entwicklung der Psychiatrie - ein Internet-Atlas von Dr. Hans-Peter Haack" (in German). Archived from the original on 9 February 2008. Retrieved 29 June 2017.
  2. Rogers, Jonathan P; Pollak, Thomas A; Blackman, Graham; David, Anthony S (July 2019). "Catatonia and the immune system: a review". The Lancet. Psychiatry. 6 (7): 620–630. doi:10.1016/S2215-0366(19)30190-7. ISSN 2215-0366. PMC 7185541. PMID 31196793.
  3. Haroche, Alexandre; Rogers, Jonathan; Plaze, Marion; Gaillard, Raphaël; Williams, Steve Cr; Thomas, Pierre; Amad, Ali (16 June 2020). "Brain imaging in catatonia: systematic review and directions for future research". Psychological Medicine: 1–13. doi:10.1017/S0033291720001853. ISSN 1469-8978. PMID 32539902.
  4. Geoffroy PA, Rolland B, Cottencin O (May–June 2012). "Catatonia and alcohol withdrawal: a complex and underestimated syndrome". Alcohol Alcohol. 47 (3): 288–90. doi:10.1093/alcalc/agr170. PMID 22278315.
  5. Rosebush PI; Mazurek MF. (August 1996). "Catatonia after benzodiazepine withdrawal". Journal of Clinical Psychopharmacology. 16 (4): 315–9. doi:10.1097/00004714-199608000-00007. PMID 8835707.
  6. Deuschle M, Lederbogen F (January 2001). "Benzodiazepine withdrawal-induced catatonia". Pharmacopsychiatry. 34 (1): 41–2. doi:10.1055/s-2001-15188. PMID 11229621.
  7. Kanemoto K, Miyamoto T, Abe R (September 1999). "Ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal". Seizure. 8 (6): 364–6. doi:10.1053/seiz.1999.0309. PMID 10512781.
  8. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 119–121. ISBN 978-0-89042-555-8.
  9. Cheyette, S. R.; Cummings, J. L. (1995). "Encephalitis lethargica: lessons for contemporary neuropsychiatry". The Journal of Neuropsychiatry and Clinical Neurosciences. 7 (2): 125–134. doi:10.1176/jnp.7.2.125. ISSN 0895-0172. PMID 7626955.
  10. Lee, Joseph W. Y. (February 2010). "Neuroleptic-induced catatonia: clinical presentation, response to benzodiazepines, and relationship to neuroleptic malignant syndrome". Journal of Clinical Psychopharmacology. 30 (1): 3–10. doi:10.1097/JCP.0b013e3181c9bfe6. ISSN 1533-712X. PMID 20075641.
  11. Carroll, Brendan T.; Goforth, Harold W.; Thomas, Christopher; Ahuja, Niraj; McDaniel, William W.; Kraus, Marilyn F.; Spiegel, David R.; Franco, Kathleen N.; Pozuelo, Leopold; Muñoz, Camilo (1 October 2007). "Review of Adjunctive Glutamate Antagonist Therapy in the Treatment of Catatonic Syndromes". The Journal of Neuropsychiatry and Clinical Neurosciences. 19 (4): 406–412. doi:10.1176/jnp.2007.19.4.406. ISSN 0895-0172.
  12. Fink M, Taylor MA: CATATONIA: A Clinician's Guide to Diagnosis and Treatment, Cambridge U Press, 2003"
  13. Dhossche D et al.: Catatonia in Autism Spectrum Disorders, Elsevier, Amsterdam, 2006
  14. Michael B. First (2013). DSM-5® Handbook of Differential Diagnosis. American Psychiatric Publishing. p. 49. ISBN 978-1-58562-998-5.
  15. Shorter, Edward; Fink, Max (2018). The Madness of Fear: A History of Catatonia. Oxford University Press. ISBN 978-0-19-088119-1.
  16. Nolen-Hoeksema. Abnormal psychology. (6th ed., p. 224)
  17. Maric, J. (2000). Clinical Psychiatry. Nolit, Belgrade.
  18. Semple, David. "Oxford hand book of psychiatry" Oxford press. 2005.
  19. Sienaert, Pascal; Rooseleer, Jonas; De Fruyt, Jürgen (December 2011). "Measuring catatonia: a systematic review of rating scales". Journal of Affective Disorders. 135 (1–3): 1–9. doi:10.1016/j.jad.2011.02.012. ISSN 1573-2517. PMID 21420736.
  20. Bush, G.; Fink, M.; Petrides, G.; Dowling, F.; Francis, A. (February 1996). "Catatonia. I. Rating scale and standardized examination". Acta Psychiatrica Scandinavica. 93 (2): 129–136. doi:10.1111/j.1600-0447.1996.tb09814.x. ISSN 0001-690X. PMID 8686483.
  21. Sienaert, Pascal; Dhossche, Dirk M.; Vancampfort, Davy; De Hert, Marc; Gazdag, Gábor (2014). "A Clinical Review of the Treatment of Catatonia". Frontiers in Psychiatry. 5. doi:10.3389/fpsyt.2014.00181. ISSN 1664-0640.
  22. Thomas, Pierre; Cottencin, Olivier; Rascle, Claire; Vaiva, Guillaume; Goudemand, Michel; Bieder, Jacques (1 January 2007). "Catatonia in French Psychiatry: Implications of the Zolpidem Challenge Test". Psychiatric Annals. 37 (1). doi:10.3928/00485713-20070101-02. ISSN 0048-5713.
  23. Leroy, Arnaud; Naudet, Florian; Vaiva, Guillaume; Francis, Andrew; Thomas, Pierre; Amad, Ali (21 June 2017). "Is electroconvulsive therapy an evidence-based treatment for catatonia? A systematic review and meta-analysis". European Archives of Psychiatry and Clinical Neuroscience. 268 (7): 675–687. doi:10.1007/s00406-017-0819-5. ISSN 0940-1334. PMID 28639007.
  24. Carroll, BT.; Goforth, HW.; Thomas, C.; Ahuja, N.; McDaniel, WW.; Kraus, MF.; Spiegel, DR.; Franco, KN.; et al. (2007). "Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes". J Neuropsychiatry Clin Neurosci. 19 (4): 406–12. doi:10.1176/appi.neuropsych.19.4.406. PMID 18070843. Archived from the original on 13 December 2007.
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