Catatonia

Catatonia is a state of neurogenic motor immobility and behavioral abnormality m

anifested by stupor. It was first described in 1874 by Karl Ludwig Kahlbaum, in
Die Katatonie oder das Spannungsirresein[1] (Catatonia or Tension Insanity).
In the Diagnostic and Statistical Manual of Mental Disorders 5th edition cataton
ia is not recognized as a separate disorder, but is associated with psychiatric
conditions such as schizophrenia (catatonic type), bipolar disorder, post-trauma
tic stress disorder, depression and other mental disorders, narcolepsy, as well
as drug abuse or overdose (or both). It may also be seen in many medical disorde
rs including infections (such as encephalitis), autoimmune disorders, focal neur
ologic lesions (including strokes), metabolic disturbances, alcohol withdrawal[2
] and abrupt or overly rapid benzodiazepine withdrawal.[3][4][5]
It can be an adverse reaction to prescribed medication. It bears similarity to c
onditions such as encephalitis lethargica and neuroleptic malignant syndrome. Th
ere are a variety of treatments available; benzodiazepines are a first-line trea
tment strategy. Electro-convulsive therapy is also sometimes used. There is grow
ing evidence for the effectiveness of NMDA antagonists for benzodiazepine resist
ant catatonia.[6] Antipsychotics are sometimes employed but require caution as t
hey can worsen symptoms and have serious adverse effects.[7]
Contents [hide]
1
Features
2
Diagnostic criteria
2.1
Subtypes
2.2
Rating scale
3
Treatment
4
See also
5
References
6
External links
Features[edit]
Patients with catatonia may experience an extreme loss of motor skill or even co
nstant hyperactive motor activity. Catatonic patients will sometimes hold rigid
poses for hours and will ignore any external stimuli. Patients with catatonic ex
citement can suffer from exhaustion if not treated. Patients may also show stere
otyped, repetitive movements.
They may show specific types of movement such as waxy flexibility, in which they
maintain positions after being placed in them through someone else in which the
y resist movement in proportion to the force applied by the examiner. They may r
epeat meaningless phrases or speak only to repeat what the examiner says.
While catatonia is only identified as a symptom of schizophrenia in present psyc
hiatric classifications, it is increasingly recognized as a syndrome with many f
aces. It appears as the Kahlbaum syndrome (motionless catatonia), malignant cata
tonia (neuroleptic malignant syndrome, toxic serotonin syndrome), and excited fo
rms (delirious mania, catatonic excitement, oneirophrenia).[7] It has also been
recognized as grafted on to autism spectrum disorders.[8]
Diagnostic criteria[edit]
According to the DSM-V, "Catatonia Associated with Another Mental Disorder (Cata
tonia Specifier)" is diagnosed if the clinical picture is dominated by at least
three of the following:[9]
stupor (i.e., no psychomotor 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

)
mannerism (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
echolalia (i.e., mimicking another's speech)
echopraxia (i.e., mimicking another's movements)
Subtypes[edit]
Stupor is a motionless, apathetic state in which one is oblivious or does not re
act to external stimuli. Motor activity is nearly non-existent. Individuals in t
his state make little or no eye contact with others and may be mute and rigid. O
ne 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 aforemention
ed, the activity seems to lack purpose. The individual may also experience delus
ions or hallucinations.[10] It is commonly cited as one of the most dangerous me
ntal states in psychiatry.[11]
Malignant catatonia is an acute onset of excitement, fever, autonomic instabilit
y, delirium and may be fatal.[12]
Rating scale[edit]
Fink and Taylor developed a catatonia rating scale to identify the syndrome.[7]
A diagnosis is verified by a benzodiazepine or barbiturate test. The diagnosis i
s validated by the quick response to either benzodiazepines or electroconvulsive
therapy (ECT). While proven useful in the past, barbiturates are no longer comm
only used in psychiatry; thus the option of either benzodiazepines or ECT.
Treatment[edit]
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 1 2
mg of intramuscular lorazepam will often result in marked improvement within ha
lf an hour. In France, zolpidem has also been used in diagnosis, and response ma
y occur within the same time period. Ultimately the underlying cause needs to be
treated.[7]
Electroconvulsive therapy (ECT) is an effective treatment for catatonia. Antipsy
chotics should be used with care as they can worsen catatonia and are the cause
of neuroleptic malignant syndrome, a dangerous condition that can mimic catatoni
a and requires immediate discontinuation of the antipsychotic.[7]
Excessive glutamate activity is believed to be involved in catatonia; when first
-line treatment options fail, NMDA antagonists such as amantadine or memantine a
re used. Amantadine may have an increased incidence of tolerance with prolonged
use and can cause psychosis, due to its additional effects on the dopamine syste
m. Memantine has a more targeted pharmacological profile for the glutamate syste
m, reduced incidence of psychosis and may therefore be preferred for individuals
who cannot tolerate amantadine. Topiramate is another treatment option for resi
stant catatonia; it produces its therapeutic effects by producing glutamate anta
gonism via modulation of AMPA receptors.[13]