Catatonia

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Catatonia is a syndrome of psychic and motoric disturbances. Karl Ludwig Kahlbaum first described it in 1874: Die Katatonie oder das Spannungirresein^[1] (Catatonia or Tension Insanity). In the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (DSM-IV) it 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 and other mental disorders, as well as drug abuse or overdose (or both). It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances and abrupt or overly rapid benzodiazepine withdrawal.^[2][3][4] It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available, and depending on the case, one or more drugs may be used, including antipsychotics and benzodiazepines.

Clinical features

Patients with catatonia may experience an extreme loss of motor skills or even constant hyperactive motor activity. Catatonic patients will sometimes hold rigid poses for hours and will ignore any external stimuli. Patients with catatonic excitement can die of exhaustion if not treated. Patients may also show stereotyped, repetitive movements. They may show specific types of movement such as waxy flexibility, in which they maintain positions after being placed in them by someone else, or gegenhalten (lit. "counterhold"), in which they resist movement in proportion to the force applied by the examiner. They may repeat meaningless phrases or speak only to repeat what the examiner says.

While catatonia is only identified as a form of schizophrenia in present psychiatric classifications, it is increasingly recognized as a syndrome with many faces. It appears as the Kahlbaum syndrome (retarded catatonia), malignant catatonia (neuroleptic malignant syndrome, toxic serotonin syndrome), and excited forms (delirious mania, catatonic excitement, oneirophrenia).^[5] It has also been recognized as grafted on to autistic spectrum disorders.^[6]

Diagnostic criteria

According to the DSM-IV, the "With catatonic features" specifier can be applied if the clinical picture is dominated by at least two of the following:

• motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor
• excessive motor activity (purposeless, not influenced by external stimuli)
• extreme negativism (motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
• peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing
• echolalia or echopraxia

Subtypes

Stupor is a motionless, apathetic 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 the activity seems to lack purpose.

Fink and Taylor developed a catatonia rating scale to identify the syndrome. ^[5] A diagnosis is verified by a benzodiazepine or barbiturate test. The diagnosis is validated by the quick response to either benzodizepines or electroconvulsive therapy (ECT). While 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 relief from the catatonic state. Benzodiazepines are the first line of treatment, and high doses are often required. A test dose of 1–2 mg 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.^[5]

Electroconvulsive therapy (ECT) is an effective treatment for catatonia as well as for most of the underlying causes (e.g. psychosis, mania, depression). 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.^[5]

A version known as "catatonia-like deterioration" occurs in 17% of autistic adults. This form is made worse by antipsychotics. Unlike catatonic stupors, this deterioration happens very gradually. The only way to cure it is to keep the patient constantly active and the activities must have an end goal or they will not work. Stress must be reduced by not pressurising, keeping life predictable and by limiting choice as making choices is very stressful for catatonics.^{[citation needed]}

References

• Caroff, Stanley N, MD (Editor); Mann, Stephen C (Editor); Francis, Andrew (Editor); Fricchioni, Gregory L, MD (Editor);Catatonia: From Psychopathology to Neurobiology; American Psychiatric Publishing, Inc. 2004

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