Catatonia:How to Identify and Treat It
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Catatonia: How to identify and treat it Features that overlap with other syndromes make the diagnosis easy to overlook Steven L. Dubovsky, MD s catatonia a rare condition that belongs in the history books, or is Professor and Chair it more prevalent than we think? If we think we don’t see it often, Department of Psychiatry State University of New York at Buffalo how will we recognize it? And how do we treat it? This article Buffalo, New York Ireviews the evolution of our understanding of the phenomenology and Adjoint Professor of Psychiatry and Medicine therapy of this interesting and complex condition. University of Colorado Aurora, Colorado Amelia N. Dubovsky, MD Assistant Professor History of the concept Department of Psychiatry In 1874, Kahlbaum1,2 was the first to propose a syndrome of motor dys- University of Washington Seattle, Washington function characterized by mutism, immobility, staring gaze, negativism, stereotyped behavior, waxy flexibility, and verbal stereotypies that he Disclosures called catatonia. Kahlbaum conceptualized catatonia as a distinct dis- Dr. Steven L. Dubovsky receives grant or research support order,3 but Kraepelin reformulated it as a feature of dementia praecox.4 from Allergan, Janssen, Neurim, Neurocrine, and Tower Foundation. Dr. Amelia N. Dubovsky reports no financial Although Bleuler felt that catatonia could occur in other psychiatric dis- relationships with any company whose products are orders and in normal people,4 he also included catatonia as a marker of mentioned in this article, or with manufacturers of 3 competing products. schizophrenia, where it remained from DSM-I through DSM-IV. As was believed to be true of schizophrenia, Kraepelin considered catatonia to be characterized by poor prognosis, whereas Bleuler eliminated poor prognosis as a criterion for catatonia.3 In DSM-IV, catatonia was still a subtype of schizophrenia, but for the first time it was expanded diagnostically to become both a specifier in mood disorders, and a syndrome resulting from a general medical con- dition.5,6 In DSM-5, catatonic schizophrenia was deleted, and catatonia became a specifier for 10 disorders, including schizophrenia, mood dis- orders, and general medical conditions.3,5-9 In ICD-10, however, catato- nia is still associated primarily with schizophrenia.10 continued Current Psychiatry ALICIA BUELOW FOR CURRENT PSYCHIATRY Vol. 17, No. 8 17 A wide range of presentations from malignant catatonia, but it is usually Catatonia is a cyclical syndrome character- not associated with waxy flexibility and ized by alterations in motor, behavioral, and rigidity. vocal signs occurring in the context of med- Several specific subtypes of catatonia ical, neurologic, and psychiatric disorders.8 that may exist anywhere along dimen- The most common features are immobility, sions of activity and severity also have been waxy flexibility, stupor, mutism, negativ- described: Catatonia ism, echolalia, echopraxia, peculiarities Periodic catatonia. In 1908, Kraepelin of voluntary movement, and rigidity.7,11 described a form of periodic catatonia, with Features of catatonia that have been repeat- rapid shifts from excitement to stupor.4 edly described through the years are sum- Later, Gjessing described periodic catatonia marized in Table 18,12,13 (page 19). In general, in schizophrenia and reported success treat- presentations of catatonia are not specific to ing it with high doses of thyroid hormone.4 any psychiatric or medical etiology.13,14 Today, periodic catatonia refers to the rapid Catatonia often is described along a onset of recurrent, brief hypokinetic or continuum from retarded/stuporous to hyperkinetic episodes lasting 4 to 10 days Clinical Point excited,14,15 and from benign to malignant.13 and recurring during the course of weeks In general, Examples of these ranges of presentation to years. Patients often are asymptomatic include5,12,13,15-19: between episodes except for grimacing, presentations of Stuporous/retarded catatonia (Kahlbaum stereotypies, and negativism later in the catatonia are not syndrome) is a primarily negative syndrome course.13,15 At least some forms of periodic specific to any in which stupor, mutism, negativism, obses- catatonia are familial,4 with autosomal psychiatric or sional slowness, and posturing predomi- dominant transmission possibly linked to nate. Akinetic mutism and coma vigil are chromosome 15q15.13 medical etiology sometimes considered to be types of stupor- A familial form of catatonia has been ous catatonia, as occasionally are locked-in described that has a poor response to stan- syndrome and abulia caused by anterior cin- dard therapies (benzodiazepines and elec- gulate lesions. troconvulsive therapy [ECT]), but in view Excited catatonia (hyperkinetic variant, of the high comorbidity of catatonia and Bell’s mania, oneirophrenia, oneroid state/ bipolar disorder, it is difficult to determine syndrome, catatonia raptus) is character- whether this is a separate condition, or a ized by agitation, combativeness, verbig- group of patients with bipolar disorder.5 eration, stereotypies, grimacing, and echo Late (ie, late-onset) catatonia is well phenomena (echopraxia and echolalia). described in the Japanese literature.10 Malignant (lethal) catatonia consists of Reported primarily in women without catatonia accompanied by excitement, stu- a known medical illness or brain disor- por, altered level of consciousness, catalepsy, der, late catatonia begins with prodromal hyperthermia, and autonomic instability hypochondriacal or depressive symptoms with tachycardia, tachypnea, hyperten- during a stressful situation, followed by sion, and labile blood pressure. Autonomic unprovoked anxiety and agitation. Some dysregulation, fever, rhabdomyolysis, and patients develop hallucinations, delu- acute renal failure can be causes of morbid- sions, and recurrent excitement, along ity and mortality. Neuroleptic malignant with anxiety and agitation. The next stage syndrome (NMS)—which is associated involves typical catatonic features (mainly with dopamine antagonists, especially excitement, retardation, negativism, and Discuss this article at antipsychotics—is considered a form of autonomic disturbance), progressing to www.facebook.com/ malignant catatonia and has a mortality stupor, mutism, verbal stereotypies, and MDedgePsychiatry rate of 10% to 20%. Signs of NMS include negativism, including refusal of food. Most muscle rigidity, fever, diaphoresis, rigor, patients have residual symptoms follow- altered consciousness, mutism, tachycar- ing improvement. A few cases have been dia, hypertension, leukocytosis, and labora- noted to remit with ECT, with relapse when tory evidence of muscle damage. Serotonin treatment was discontinued. Late catato- Current Psychiatry 18 August 2018 syndrome can be difficult to distinguish nia has been thought to be associated with Table 1 Features of catatonia Feature Description MDedge.com/psychiatry Stupor Extreme hypoactivity and immobility. Absence of movement or reaction when awake; not actively relating to environment Excitement Purposeless hyperactivity. Agitation not influenced by external stimuli Mutism Extreme verbal unresponsiveness in the absence of aphasia Logorrhea Excessive, monotonous speech Staring Fixed gaze at a distance, often with limited tracking, little eye contact, and poor blinking to threat Posturing Spontaneous, active maintenance of rigid postures against gravity Grimacing Contortion of facial features Rigidity Maintaining stiff position despite efforts to move patient Psychological pillow Type of posturing involving a reclined position with head and shoulders raised as if on a pillow, maintained for extended periods Mannerisms Repetitive, idiosyncratic, purposeful caricatures of movements or gestures, such as using hands when talking Clinical Point Ambitendency Alternation between cooperation with and resistance to instructions Periodic catatonia Waxy flexibility Patient can be positioned in uncomfortable positions that patient maintains refers to recurrent, for long periods with slight resistance to examiner Automatic obedience Exaggerated cooperation with a request or excessive continuation of a brief hypokinetic requested movement or hyperkinetic Mitgehen Type of automatic obedience in which patient can be positioned in any posture with minimal effort, even when told to resist, but unlike in waxy episodes lasting flexibility, body part immediately returns to original position 4 to 10 days Mitmachen Variant of automatic obedience in which body can be put into any posture despite instructions to resist Catalepsy Maintenance of fixed sitting or standing position against gravity that appears uncomfortable with minimal movement in response to external stimuli, including pain Motor perseveration Persistence of a movement after the original intent or command has ceased Echopraxia Mimicking another’s movements Echolalia Nearly simultaneously mimicking another’s speech Stereotypy Involuntary, coordinated, rhythmic, and repetitive but purposeless movement or behavior, such as chewing, rocking, grimacing, shrugging, hand waving, opening and closing eyes, mouth and jaw movements; may involve self-injurious behaviors, such as self-hitting, biting, scratching; phonic stereotypies include sniffing, clicking, snorting, moaning, and other meaningless sounds Verbigeration Verbal stereotype consisting of continuously repeating (perseverating) meaningless words or phrases Aversion Avoidance of examiner when called Grasp Automatic grasping of