Catatonia is characterized by a group of certain symptoms that usually involve a lack of movement and communication and also include agitation, confusion, and restlessness. It is a psychomotor syndrome characterized by abnormal behavior.
What Is Catatonia?
Catatonia is a complex clinical syndrome that is associated with multiple life-threatening complications that occur in more than 10 percent of patients with acute psychiatric illness. It was first coined by Karl Ludwig Kahlbaum in 1874 and was described as “Die Katatonie oder das Spannungsirresein” (Catatonia or Tension Insanity). A study defines it as a “clinical syndrome characterized by a distinct constellation of psychomotor disturbances”. Even though this disorder is related to schizophrenia, it has been found that this condition is observed in other mental health conditions and neurological disorders. The DSM-5 has not recognized it as a specific disorder but it is associated with other psychological conditions such as schizophrenia or bipolar disorder.
Read More About Bipolar Disorder Here
People suffering from this disorder can experience several symptoms. The most common symptom is stupor (the inability to move, speak, or respond to stimuli). On the other hand, some people have other symptoms such as excessive movement or agitated behavior. It can last for a few hours, weeks, or even years. This disorder, if left untreated, can present life-threatening problems in a person’s life. One 2016 study 1 found that Benzodiazepines medications are the most common and effective treatment method in patients suffering from this disorder.
Studies have found that a significant risk factor associated with this disorder is the development of neuroleptic malignant syndrome that has a mortality rate of 10 percent. The prevalence rate of catatonia among psychiatric patients ranges between 7.6 percent to 38 percent. Research 2 has observed that only 10 to 15 percent of catatonic patients have an underlying diagnosis of Schizophrenia as measured in five studies dating from 1932 to 1986. So it is of utmost importance to consult a doctor immediately if an individual shows symptoms. There are usually three types of catatonia, namely Akinetic, Excited, and Malignant.
Types Of Catatonia
There are usually three types of this disorder. They are as follows:
1. Akinetic Catatonia
This is found to be the most common among patients. This type is associated with several symptoms such as a paucity of movement including immobility, staring, mutism, rigidity, withdrawal, and others. Sometimes they sit or lie in an unusual position and are not able to move.
2. Excited Catatonia
In this type, the person can move around but their movements are usually pointless or impulsive. Symptoms of this type include excessive or unusual movements:
- Agitation
- Restlessness
- Purposeless movements
3. Malignant Catatonia
The symptoms of this type are the most severe ones. Blood pressure, breathing rate, and heart rate can fluctuate in this case. If the vital signs fluctuate then it is of utmost importance to get immediate treatment. The mortality rate for this type is between 9% to 10% despite effective treatment measures. The symptoms of this type include:
- Delirium
- Fever
- Rigidity
- Sweating
Signs And Symptoms Of Catatonia
The symptoms can differ according to the type of this disorder. It is important to consult a doctor to rule out other related conditions before diagnosing catatonia. An individual must show at least 2 symptoms of this disorder in the last 24 hours before a doctor can diagnose it. The most common symptoms are:
- Stupor which is the inability to move or speak or they may appear to be staring into the distance
- Malnutrition due to lack of nutritional food intake
- Dehydration due to lack of water intake
- Echolalia 3 in which an individual only responds to the conversation by only repeating what they have heard
Other symptoms may include:
- Catalepsy (muscular rigidity)
- Negativism (lack of response or opposition to external stimuli)
- Echopraxia (mimicking another person’s movements)
- Mutism
- Grimacing
- Not responding to other people
- Not speaking
- Being in an unusual position
- Resisting people who try to adjust their body
- Agitation
- Repetitive meaningless movements
- Mimicking someone else’s speech
- Mimicking someone else’s movements
Other conditions can have similar symptoms like catatonia. They are:
- Acute Psychosis
- Encephalitis or inflammation of the brain tissue
- Neuroleptic Malignant Syndrome (NMS) (a rare but serious reaction of antipsychotic medications)
- Non-convulsive status epilepticus (severe seizure)
Comorbidities Associated With Catatonia
There are several comorbid conditions associated with this disorder. They are:
- Autism spectrum disorder
- Schizophrenia
- Brief psychotic disorder
- Schizophreniform disorder
- Schizoaffective disorder
- Bipolar and other related disorders
- Major depressive disorder
Read More About Major Depressive Disorder (Depression) Here
Causes Of Catatonia
According to the DSM-5, there are several conditions that may cause this disorder. They are:
- Neurodevelopmental disorder
- Psychotic disorders
- Bipolar disorders
- Depressive disorders
- Other medical conditions, such as cerebral folate deficiency, rare autoimmune disorders, and rare paraneoplastic disorders (related to cancerous tumors)
- Lack of neurotransmitters
- Brain abnormalities
- Some medications have side effects that can be a cause of developing this disorder. If you see any symptoms it is important to seek medical attention. This is considered a medical emergency. Medications such as clozapine can often cause an individual to develop this disorder
One study 4 also found that a sudden decrease in dopamine levels can cause this disorder. Another study 5 found a reduction in gamma-aminobutyric acid (GABA) can lead to this condition.
Diagnosis Of Catatonia
There are no definite tests to diagnose this disorder. However, the doctor may do a physical exam and a few tests to first rule out other conditions. The Bush Francis Catatonia Rating Scale (BFCRS 6 ) is a test often used to diagnose this disorder. The scale has 23 items scored from 0 to 3. 0 means the symptom is absent. 3 means the symptom is present.
The doctor may also conduct blood tests in order to rule out electrolyte imbalances. A pulmonary embolism or blood clot in the lungs can also lead to the symptoms associated with this disorder. A Fibrin D dimer blood test can also be useful. Studies indicate that this disorder is associated with D dimer levels. However, other conditions such as pulmonary embolism may affect D dimer levels as well. The doctor may order a CT or MRI in order to rule out a brain tumor or swelling that may cause similar symptoms.
Treatment For Catatonia
A 2018 study 7 showed that Electroconvulsive therapy (ECT) and medications are the only two clinically proven treatment methods to treat catatonia. One 2007 study 8 has found the effectiveness of the NMDA (N-methyl-D-aspartate) receptor antagonists, amantadine, and memantine for benzodiazepine resistance in patients suffering from this disorder. Common treatment approaches are mentioned below –
1. Medications
The first approach is usually using medications to treat the symptoms. The medications can include benzodiazepines, muscle relaxants, and in some cases tricyclic antidepressants. The first medication that is usually prescribed is benzodiazepines 9. This medication includes clonazepam (Klonopin), lorazepam (Ativan), and diazepam (valium). This medication helps to increase gamma-aminobutyric acid (GABA) in the brain. People with high ranking on Bush Francis Catatonia Rating Scale (BFCRS) usually respond well to benzodiazepines treatment.
Read More About Schizophrenia Here
There are other medications that are prescribed to the patient suffering from this disorder. They include:
- Amobarbital (barbiturate)
- Bromocriptine (Cycloset, Parlodel)
- Carbamazepine (Carbatrol, Epitol, Tegretol)
- Lithium Carbonate
- Thyroid hormone
- Zolpidem
The duration of medication is usually 5 days. If the symptoms don’t start to get better after 5 days the doctor may resort to other methods of treatment.
2. Electroconvulsive Therapy (ECT)
Electroconvulsive therapy 10 is found to be effective in treating patients suffering from this disorder. This therapy takes place in a hospital under medical supervision. The procedure is completely painless. At first, the person is sedated and a special machine is connected to deliver an electric shock to the brain. This procedure causes a one-minute seizure to the individual. This seizure is believed to cause changes in the neurotransmitters of the brain. This method has been found helpful to ease the symptoms.
Prevention Of Catatonia
Since the exact causes of developing this disorder are unknown it is difficult to devise a precautionary measure. It is worth mentioning that people suffering from this disorder should avoid taking excess neuroleptic medications such as chlorpromazine. Misuse of such medications can increase the symptoms of this disorder.
Can You Recover From This Disorder?
Usually, people suffering from Catatonia respond well to therapy and medications. However, if an individual doesn’t respond to the medications prescribed the doctor may prescribe alternative medications to keep the symptoms under control. One study 11 found that people who undergo the ECT treatment often have a high relapse rate and symptoms may usually reoccur within a year.
Catatonia At A Glance
- Catatonia is a complex clinical psychomotor syndrome that is associated with multiple life-threatening complications in patients with acute psychiatric illnesses.
- Catatonia are of three kinds—akinetic, excited, and malignant.
- Catatonia is characterized by abnormal behavior and a lack of both movement and communication.
- Common symptoms include stupor, echolalia, malnutrition, and dehydration. Other symptoms include irritability, seizure, echopraxia, catalepsy, negativism, etc.
- The causes of catatonia can be attributed to several factors, namely, comorbid psychiatric disorders, neurodevelopmental disorders, brain abnormalities, and other medical conditions such as cerebral folate deficiency, rare autoimmune disorders, rare paraneoplastic disorders, etc.
- Catatonia can be managed in the long-run only with medication and electroconvulsive therapy (ECT).
- Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016). Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World journal of psychiatry, 6(4), 391–398. https://doi.org/10.5498/wjp.v6.i4.391 [↩]
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- Patra KP, De Jesus O. Echolalia. [Updated 2021 Nov 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565908/ [↩]
- Park, J., Tan, J., Krzeminski, S., Hazeghazam, M., Bandlamuri, M., & Carlson, R. W. (2017). Malignant Catatonia Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and Literature Review. Case reports in critical care, 2017, 1951965. https://doi.org/10.1155/2017/1951965 [↩]
- Wijemanne, S., & Jankovic, J. (2015). Movement disorders in catatonia. Journal of neurology, neurosurgery, and psychiatry, 86(8), 825–832. https://doi.org/10.1136/jnnp-2014-309098 [↩]
- Nunes, A. L., Filgueiras, A., Nicolato, R., Alvarenga, J. M., Silveira, L. A., Silva, R. A., & Cheniaux, E. (2017). Development and validation of the Bush-Francis Catatonia Rating Scale – Brazilian version. Arquivos de neuro-psiquiatria, 75(1), 44–49. https://doi.org/10.1590/0004-282X20160168 [↩]
- Pelzer, A. C., van der Heijden, F. M., & den Boer, E. (2018). Systematic review of catatonia treatment. Neuropsychiatric disease and treatment, 14, 317–326. https://doi.org/10.2147/NDT.S147897 [↩]
- Carroll, B. T., Goforth, H. W., Thomas, C., Ahuja, N., McDaniel, W. W., Kraus, M. F., Spiegel, D. R., Franco, K. N., Pozuelo, L., & Muñoz, C. (2007). Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes. The Journal of neuropsychiatry and clinical neurosciences, 19(4), 406–412. https://doi.org/10.1176/jnp.2007.19.4.406 [↩]
- Zaman, H., Gibson, R. C., & Walcott, G. (2019). Benzodiazepines for catatonia in people with schizophrenia or other serious mental illnesses. The Cochrane database of systematic reviews, 8(8), CD006570. https://doi.org/10.1002/14651858.CD006570.pub3 [↩]
- Luchini, F., Medda, P., Mariani, M. G., Mauri, M., Toni, C., & Perugi, G. (2015). Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World journal of psychiatry, 5(2), 182–192. https://doi.org/10.5498/wjp.v5.i2.182 [↩]
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