CATATONIA

Dr Sudip Aryal
Resident
Dept of Psychiatry & Mental Health
TUTH, IOM
Overview
●
Introduction ●
Rating Scales
●
History ●
Neurobiology
●
Epidemiology ●
Management
●
Clinical Features ●
Prognosis
●
Examination ●
DSM-5 and ICD-10
●
Common Causes ●
Summary
●
Differential Diagnosis ●
References
●
Subtypes
●
Laboratory Findings
Introduction

●
Catatonia is a neuropsychiatric syndrome with a
unique combination of mental, motor, vegetative,
and behavioral signs.

Catatonia : from psychopathology to neurobiology .1st

ed., 2008 (Stanley N. Carof et al,)
●
Few phenomena in psychiatry or neurology are as
enigmatic as catatonia.
●
This is a fact in large part due to the many
contradictions surrounding the concept.
●
Catatonia has been described as a disease, but also
as a syndrome.
●
It has been considered to be a subtype of
schizophrenia, and yet has been claimed to be more
common in afective disorders.
●
It has been reported to be both caused and
ameliorated by neuroleptic drugs.
●
It has been reported to represent a state of stupor
so profound that its sufferers die from medical
complications, and has also been reported to
represent a state of excitement so marked that
physical restraints are necessary.
-(Lohr and Wisniewski, 1987: 201)
History
Karl Ludwig Kahlbaum (1874)

●
Catatonia or Tension Insanity
●
Cerebral disorder accompanied by mental,
physical , and behavioral symptoms
●
Catatonia considered a distinct disease entity
●
Catatonia : mitis, gravis, protracta
●
Overall good prognosis
●
Derived from 19th century concept: Unitary
psychosis
Emil Kraepelin (1899)
●
Supported Kahlbaum’s comprehensive
nosological approach, Challenged unitary
concept of catatonia
●
20% dementia precox : Catatonia
●
Kraeplin vs Kahlbaum
– Unitary concept challenged
– Volitional symptoms emphasised (vs motor)
– Chronic course, poor prognosis
– Catatonia and hebephrenia: subtypes, same dz
Eugen Bleuler (1911)

●
Same motor and behaviour symptoms as above
●
50% hospitalised schizophrenic : catatonia
●
Rejected pathophysiological explanation, gave
psychoanalytic explanation
●
Manifestations of subconscious Freudian
complexes
●
Accessory symptoms, less important
Epidemiology

●
7-17% : Hospitalised patient, acute psychotic
episodes
●
13-31% : Mood disorders
●
<5% : Schizophrenia , last quarter century
●
Catatonic Schizophrenia: Average 57% decline
over the course of 20th century, same site study
Clinical Features
Excitement

●
Extreme Hyperactivity, constant motor unrest,
which is apparently non-purposeful.
●
Not to be attributed to akathisia or goal directed
agitation
Immobility/ Stupor

●
Extreme hypoactivity, immobile, minimally
responsive to stimuli
Mutism

●
Verbally unresponsive or minimally responsive
Staring

●
Fixed gaze, little or no visual scanning of
environment, decreased blinking
Posturing/ catalepsy

●
Spontaneous maintenance of posture(s),
including mundane (e.g. sitting or standing for
long periods without reacting)
Grimacing

●
Maintenance of odd facial expressions
Echopraxia/ Echolalia

●
Mimicking of examiner’s movements/ speech
Stereotypy

●
Repetitive, non-goal-directed motor activity (e.g.
finger-play- repeatedly touching, patting or
rubbing self)- abnormality not inherent in act but
in frequency
Mannerism

●
Odd, purposeful movements (hopping or walking
tiptoe, saluting passersby or exaggerated
caricatures of mundane movements)-
abnormality inherent in act itself
Verbigeration

●
Repetition of phrases or sentences (like a
scratched record)
Rigidity

●
Maintenance of a rigid position despite efforts to
be moved, exclude if cogwheeling or tremors
present.
Negativism

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Apparently motiveless resistance to instructions
or attempts to move/ examine the patient.
Contrary behaviour, does exact opposite of
instructions.
Waxy Flexibility

●
During reposturing of patient, patient offers
initial resistance before allowing himself to be
repositioned, similar to that of a bending candle.
Withdrawal

●
Refusal to eat, drink, and/or make eye contact
Impulsivity

●
Patient suddenly engages in inappropriate
behaviour (e.g. runs down hallway, starts
screaming or takes off clothes) without
provocation. Afterward can give no, or only a
facile expression
Automatic obedience

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Exaggerated cooperation with examiner’s
request or spontaneous continuation of
movement requested.
Mitgehen

●
“Anglepoise lamp” arm raising in response to
light pressure of finger, despite instruction to
contrary.
Gengenhalten

●
Resistance to passive movement which is
proportional to strength of the stimulus, appears
automatic rather than wilful.
Ambitendency

●
Patient appears motorically “stuck” in indecisive,
hesistant movement.
Grasp refex
Perseveration

●
Repeatedly returns to same topics or persists
with movement
Combativeness

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Usually in an undirected manner, with no, or only
a facile expression afterwards
Autonomic abnormality

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Temperature, Pulse, Respiratory Rate,
Diaphoresis
Examination of the patient

●
“Only a comprehensive and intensive application of
the clinical method can enable psychiatry to progress
and to increase the understanding of
psychopathological processes”
-Kahlbaum, 1874
Procedure Examines

Observe patient while trying to Activity level.

engage in a conversation Abnormal
movements.
Abnormal speech.
Examiner scratches head in Echopraxia
exaggerated manner

Examine arm for cogwheeling. Negativism. Waxy

Attempt to reposture, instructing flexibility.
patient to “keep your arm loose” – Gegenhalten.
move arm with alternating lighter Rigidity.
and heavier force.
Ask patient to extend arm. Place one Mitgehen
finger beneath hand and try to raise (passive
slowly after stating, “Do NOT let me obedience)
raise your arm”.
Extend hand stating “Do NOT shake Ambitendence
my hand”.
Reach into pocket and state, “Stick out Automatic
your tongue, I want to stick a pin in it”. obedience
Check for grasp reflex.
Check chart for reports of previous 24-hour period. In
particular check for oral intake, vital signs, and any
incidents
Attempt to observe patient indirectly, at least for a brief
period, each day.
Common Causes

●
Mood disorders
– Mania > Depression. Upto 50% in mania
– Referred to as manic (or depressive) stupor (or
excitement)
●
Schizophrenia (upto 10-15%)
●
General medical disorders
– Metabolic/ Endocrine disturbances
– Viral infections (including HIV)
– Typhoid fever
– Heat strokes
– Autoimmune disorders
– Drug related ( antipsychotic, dopaminergic
drugs, recreational drugs, BZD withdrawal,
opiate intoxication)
●
Neurological disorders
– Postencephalitic states
– Parkinsonism
– Seizure d/o (non convulsive status epilepticus)
– B/L globus pallidus disease
– Lesions of thalamus/ parietal lobe
– Frontal lobe disease
– General paresis
Diferential Diagnosis
Non-catatonic stupor Precipitating cause (e.g. cranial
trauma, anoxia, drug intoxication)

Encephalopathy Generally associated with a

somatic condition, reversible with
treatment of the underlying
medical condition
Stroke History of cerebrovascular
disease, focal neurological signs,
CT/MRI confirmation
Stiff man syndrome Rigidity and spasms caused by
sudden stimuli

Parkinson’s disease Symptoms improve with

administration of dopamine
agonists and anticholinergics,
cogwheel rigidity
Locked-in syndrome Total paralysis with only
vertical eye movement and
only winking, associated with
lesions of the pons and
cerebral peduncles
Malignant hyperthermia Hyperthermia due to inhaled
anaesthetics, autosomal
dominant, diagnosed with
muscle biopsy
Epileptic state Epileptiform activity by EEG

Autism Chronic with onset at infancy

Obsessive-compulsive Anxiety, knowledge of

disorder compulsive behaviour
(Severe forms)
Elective mutism Possible personality disorder
or underlying paranoia
Subtypes
Retarded catatonia

●
Mutism, inhibited movement, posturing,
negativism, and staring
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Postures : mundane or unusual
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Decreased response to voice and noxious stimuli
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Speech, spontaneous movement reduced
– Some pt: alert, aware of environment
●
Severe cases: no eating/drinking- stupor-
incontinence
Excited catatonia

●
Hyperkinesis, restlessness, stereotypy,
impulsivity, frenzy, and combativeness
●
Severe cases : Delirium, self harm, harm to
others
Malignant catatonia

●
Also known as lethal catatonia
●
Life threatening condition
●
Fever, autonomic instability, delirium, rigidity
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Typically fulminant, rapidly progressive
●
Signs of MC overlap with that of NMS
Other forms

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Periodic catatonia
– waxing and waning of catatonic signs
– periods of retarded catatonia alternating with
excited catatonia
Laboratory Findings in
catatonia
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Increased CPK
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Low serum iron
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Increased CSF homovanillic acid
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Frontal slowing on EEG that may be
intermittent-features wax and wane
●
Increased size of lateral ventricle or cerebellar
atrophy on brain imaging
●
Decreased sensory motor cortex functioning and
altered laterality on functional MRI and SPECT
Rating Scales

●
Bush-Francis Catatonia Rating Scale
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Rogers Catatonia Scale
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Modified Rogers Scale
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Northoff Catatonia Scale
●
Catatonia Rating Scale (Bräunig et al). (2000)
Neurobiology
●
Studies : Better understanding of neurological
mechanisms

●
Current knowledge still insufcient to formulate
an exhaustive pathophysiological description
Neuroanatomical Studies

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Brain lesions associated with catatonia
– frontal and parietal lobes, basal ganglia,
pons, Cerebellum, corpus callosum
●
Focal isolated brain lesions: catatonia rare
●
Dysfunction of neural circuits with involvement
of multiple structures rather than focal
alterations
Neurochemical studies

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Hypotheses
– Dysfunction of GABAergic system
BZD
– Dysfunction of glutamatergic system
Amantadine
– Dysfunction of dopaminergic system
controversial
Neuroimaging Studies
●
Lower levels of blood fow in the right
prefrontal lateral cortex and right posterior
parietal region
– Motor manifestations
●
Functional alterations in the medial
orbitofrontal cortex
– Affective component
●
Dysfunction of lateral section of orbitofrontal
cortex
– Behavioural manifestations
Genetic studies

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Association between the long arm of
chromosome 15q15 and periodic catatonia
●
Association of catatonia with Prader Willi
Syndrome 15q11-13
●
Genes coding for subunits of GABA-A localised
in chromosomal regions associated with PWS
●
Periodic catatonia : 27% risk in first degree
relatives
Management
●
Identification and treatment of any underlying
medical conditions
– Internal, neurologic, toxicological
●
Measures to reduce morbidity and mortality
associated with immobility and malnutrition
●
Prevent complications :
– Pressure ulcers, deep vein thrombosis with
pulmonary embolism, fever, infections, urine
retention and aspiration pneumonia
●
Integrated multi-disciplinary specialist
approach
– psychiatric, internist, nutritionist,
infectologist,,paramedical support
●
Measures to prevent medical complications
– Anticoagulant therapy with subcutaneous
heparin
– Placement of a urinary catheter
– Adequate nursing care
– Adequate parenteral and/or enteral hydration
and alimentation through a nasogastric tube
or PEG (percutaneous endoscopic
gastrostomy).
●
Benzodiazepines and ECT are most commonly
used and most effective treatment modalities.
●
IV Lorazepam : 70% remission rate
●
ECT : 85%
●
Malignant catatonia
– ECT : 89%, Lorazepam : 40%
●
Lorazepam challenge test
– 1 mg intravenous lorazepam
– If no response after 5 min, administer another
1 mg
●
If positive
– Treat with lorazepam increasing the dose up
to 24 mg/day
●
If negative
– Bilateral electroconvulsive therapy
(modifed from Dhossche and Watchel 2008)
Benzodiazepine and Zolpidem

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GABA-A Agonist action
●
Better response in acute cases, associated with
mood disorders : 70%
●
Low response in schizophrenia , long term
symptoms : 20-30%
●
Lorazepam : most commonly used
– Diazepam, Oxazepam, Clonazepam also
successfully used
●
Initial dose : 1-2 mg parenterally every 4-10 hrs
●
Increased upto 24 mg/day until resolution
●
Continue till complete remission
●
Synergistic action with ECT
●
Zolpidem : Rapid action but short duration, more
frequent administration
Electroconvulsive Therapy

●
Most effective, irrespective of etiology
●
High success in all forms, including MC and NMS
●
Better response : Younger age, longer seizure,
more severe vegetative impairment, early
initiation
●
Negative response : Delay in initiation
●
No standardized ECT t/t protocol
●
B/L electrode, brief pulse recommended
●
Continue atleast 6 cycles even if rapid response :
relapse prevention
●
MC,NMS : consider daily ECT
●
Avoid rapid interruption of BZD with ECT
initiation
– Exacerbation of catatonic manifestation
– Synergistic action : ECT + BZD
Other treatment modalities

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Repeated transcranial magnetic stimulation
(rTMS)
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NMDA antagonists
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Antiepileptics
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Atypical antipsychotics

●
BZD,ECT resistance, C/I, adjunct
Prognosis
Catatonia: DSM-5 & ICD-10
 DSM- 5
●
Catatonia Associated With Another Mental
Disorder (Catatonia Specifier) (293.89)
●
Catatonic Disorder Due to Another Medical
Condition (293.89)
– 3 or more of 12 symptoms
Stupor Catalepsy Waxy Mutism
Flexibility
Negativism Posturing Mannerism Stereotypy

Agitation Grimacing Echolalia Echopraxia

●
Unspecified Catatonia (293.89)
– Nature of the underlying mental disorder or
other medical condition is unclear,
– Full criteria for catatonia are not met,
– Insufcient information to make a more
specific diagnosis
ICD-10
●
Catatonic Schizophrenia (F20.2)
– General Diagnostic criteria for schizophrenia,
plus 1 or more of following should dominate:
●
Stupor
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Excitement
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Rigidity
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Posturing
●
Waxy Flexibility
●
Negativism
●
Other symp (Command
automatism or Perseveration

F06.1 Organic catatonic disorder

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Stupor/ Excitement/ Both, organic etiology
●
Stupor in Manic or Depressive episode
– Manic/ Depressive episode with Pf
Summary

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Catatonia is a syndrome
●
Catatonia is common
●
Catatonia has different faces
●
Many dz conditions cause catatonia
●
Rating Scales
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Benzodiazepine and ECT
References
●
Catatonia : From psychopathology to neurobiology, Stanley N.
Caroff et al- 1st ed.- 2008
●
Catatonia: A Clinician’s Guide to Diagnosis and Treatment, Max
Fink et al- 2003
●
The ICD-10 Classification of Mental and Behavioural Disorders-
Clinical descriptions and diagnostic guidelines- WHO- 1992
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DSM-5- American Psychiatric Association- 2013
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Sempler D. et al- Oxford Handbook of Psychiatry, 3rd ed.- 2015
●
N. Bartolommei et al- Catatonia: a critical review and
therapeutic recommendations- Journal of Psychopathology
2012