sign in sign up
<<
Home , Akinetic mutism, Catatonia, Echopraxia, Logorrhea (psychology)

: How to identify and treat it Features that overlap with other 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 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 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 of motor dys- University of Washington Seattle, Washington function characterized by mutism, immobility, staring gaze, negativism, stereotyped behavior, waxy flexibility, and verbal 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 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. , 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, , mutism, negativ- described: Catatonia ism, , , 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. 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 caused by anterior cin- dard therapies ( and elec- gulate lesions. troconvulsive therapy [ECT]), but in view Excited catatonia (hyperkinetic variant, of the high of catatonia and Bell’s , oneirophrenia, oneroid state/ , 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 disor- por, altered level of consciousness, , 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 antagonists, especially excitement, retardation, negativism, and Discuss this article at —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, , and labora- noted to remit with ECT, with relapse when tory evidence of muscle damage. 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 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 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 examiner’s hand Obstruction Sudden block of a movement Gegenhalten Motiveless resistance to movement by examiner of part of patient’s body with equal and opposite force to that of examiner Negativism Opposition or no response to instructions or external stimuli. Resistance to manipulation of limbs involving doing the opposite of what is asked, as opposed to simple resistance of gegenhalten Social negativism Turning away when addressed, refusing to open eyes, closing mouth when (withdrawal) offered food or liquids Combativeness Undirected aggression unprovoked by environmental threat and followed by no or a facile explanation Autonomic Dysregulation of blood pressure, pulse, respiration, temperature abnormalities Current Psychiatry Source: References 8,12,13 Vol. 17, No. 8 19 Table 2 cardiac arrest.11,12,16,20,21 Mortality approaches 12 Medical and neurologic causes 10%. In children and adolescents, catatonia of catatonia increases the risk of premature death (includ- ing by suicide) 60-fold.22 Structural CNS disease Infectious and anti-NMDAR Other CNS infections (including HIV) Not as rare as you might think Catatonia Seizure disorders With the shift from inpatient to outpatient Neurocognitive/neurodegenerative disorders care driven by deinstitutionalization, lon- (eg, Lewy body dementia, Wilson disease, gitudinal close observation became less Huntington disease) common, and clinicians got the impression Normal pressure that the dramatic catatonia that was com- Hypoxic mon in the hospital had become rare.3 The impression that catatonia was unimportant Subdural hematoma was strengthened by expanding industry Hypertensive encephalopathy promotion of medications Clinical Point while ignoring catatonia, for which the 3 Catatonia is Parkinsonism industry had no specific treatment. With Bilateral globus pallidus disease recent research, however, catatonia has been more common in Lesions of , parietal lobe, reported in 7% to 38% of adult psychiatric mood disorders, Down syndrome patients, including 9% to 25% of inpatients, 3,5 particularly Tertiary syphilis 20% to 25% of patients with mania, and 20% of patients with major depressive epi- mixed bipolar Endocrinopathies sodes.7 Catatonia has been noted in .6% to disorder, than in Autoimmune/inflammatory disorders (eg, SLE, MS) 18% of adolescent psychiatric inpatients schizophrenia Takotsubo cardiomyopathy (especially in communication and social dis- 5,8,22 5 Electrolyte disorders orders programs), some children, and 6% to 18% of adult and juvenile patients G6PD deficiency with (ASD).23 In Pernicious anemia the medical setting, catatonia occurs in 12% Thrombotic thrombocytopenic purpura to 37% of patients with delirium,8,14,17,18,20,24 Liver or kidney transplantation 7% to 45% of medically ill patients, including Burns those with no psychiatric history,12,13 and 4% Wasp sting of ICU patients.12 Several substances have Pregnancy/postpartum been linked to catatonia; these are discussed Deep brain stimulation later.11 Contrary to earlier impressions, cata- Source: References 5,13,15 tonia is more common in mood disorders, G6PD: glucose-6-phosphate dehydrogenase; HIV: human immunodeficiency virus; MS: multiple sclerosis; NMDAR: particularly mixed bipolar disorder, espe- N-methyl-d-aspartate receptor; SLE: systemic lupus cially mania,5 than in schizophrenia.7,8,17,25 erythematosus

Pathophysiology/etiology Conditions associated with catatonia have late-onset schizophrenia or bipolar disorder, different features that act through a final or to be an independent entity. common pathway,7 possibly related to the Untreated catatonia can have serious neurobiology of an extreme fear response medical complications, including deep vein called tonic immobility that has been con- thrombosis, , aspiration served through evolution.8 This mechanism pneumonia, infection, metabolic disorders, may be mediated by decreased dopamine decubitus ulcers, malnutrition, dehydration, signaling in , orbitofrontal, and contractures, thrombosis, urinary retention, limbic systems, including the hypothalamus rhabdomyolysis, acute renal failure, sepsis, and basal forebrain.3,17,20 Subcortical reduc- Current Psychiatry 20 August 2018 disseminated intravascular coagulation, and tion of dopaminergic neurotransmission appears to be related to reduced GABAA Table 3 receptor signaling and dysfunction of Medications and substances that N-methyl-d-aspartate (NMDA) receptors induce catatonia with glutaminergic excess in striato-cortical MDedge.com/psychiatry or frontal cortico-cortical systems.13,20,26,27 CNS depressant intoxication and withdrawal, including alcohol Up to one-quarter of cases of catatonia are Antipsychotics secondary to medical (mostly neurologic) Abrupt withdrawal of antipsychotics, including 15 5,13,15 factors or substances. Table 2 (page 20) clozapine lists common medical and neurological Withdrawal of benzodiazepines and causes. Medications and substances known dopaminergic drugs to cause catatonia are noted in Table 3.5,8,13,16,26 toxicity Corticosteroids (eg, dexamethasone) Opiates Catatonia can be a specifier, or a Interferon separate condition Quinolones DSM-5 criteria for catatonia are sum- Levetiracetam marized in Table 4.28 With these features, Azithromycin Clinical Point catatonia can be a specifier for depressive, Disulfiram Up to one-quarter bipolar, or psychotic disorders; a complica- Methylphenidate of cases of catatonia tion of a medical disorder; or another sepa- Gamma hydroxybutyric acid rate diagnosis.8 The diagnosis of catatonia Cannabinoids are secondary to in DSM-5 is made when the clinical picture Cocaine medical (mostly is dominated by ≥3 of the following core Amphetamines neurologic) factors features8,15: Mescaline or substances • motoric immobility as evidenced by cat- Phencyclidine alepsy (including waxy flexibility) or stupor Source: References 5,8,13,16,26 • excessive purposeless motor activity that is not influenced by external stimuli Table 4 • extreme negativism or mutism • peculiarities of voluntary movement DSM-5 criteria for catatonia such as posturing, stereotyped movements, Stupor prominent mannerisms, or prominent Catalepsy grimacing Waxy flexibility • echolalia or echopraxia. Mutism DSM-5 criteria for the diagnosis of cata- Negativism tonia are more restrictive than DSM-IV cri- Posturing teria. As a result, they exclude a significant Mannerism number of patients who would be consid- Stereotypy ered catatonic in other systems.29 For exam- Agitation ple, DSM-5 criteria do not include common Grimacing features noted in Table 18,12,13 (page 19), such Echolalia as rigidity and staring.14,29 If the diagno- Echopraxia sis is not obvious, it might be suspected in Source: Reference 28 the presence of >1 of posturing, automatic obedience, or waxy flexibility, or >2 of echopraxia/echolalia, gegenhalten, nega- tivism, mitgehen, or stereotypy/vergibera- There are several catatonia rating scales tion.12 Clues to catatonia that are not included containing between 14 and 40 items that are in formal diagnostic systems and are easily useful in diagnosing and following treat- confused with features of include ment response in catatonia (Table 5,8,13,15,29 whispered or robotic speech, uncharacteris- page 22). Of these, the Kanner Scale is pri- tic foreign accent, tiptoe walking, hopping, marily applied in neuropsychiatric settings, Current Psychiatry rituals, and odd mannerisms.5 while the Bush-Francis Catatonia Rating Vol. 17, No. 8 21 Table 5 patient and family, review of all medications, Catatonia rating scales history of substance use with toxicology as indicated, physical examination focusing Bush-Francis Catatonia Rating Scale on autonomic dysregulation, examination Modified Rogers Scale for delirium, and laboratory tests as sug- Northoff Catatonia Rating Scale gested by the history and examination that Braunig Catatonia Rating Scale may include complete blood count, creatine Catatonia Kanner Scale kinase, serum iron, blood urea nitrogen, elec- Source: References 8,13,15,29 trolytes, creatinine, prolactin, anti-NMDA antibodies, thyroid function tests, serology, Table 6 metabolic panel, human immunodeficiency 8,15,16 Differential diagnosis of catatonia virus testing, EEG, and neuroimaging. Autism Dystonia A complex differential diagnosis Tardive dyskinesia Manifestations of numerous psychiatric Akathisia Clinical Point and neurologic disorders can mimic or be Tic disorders identical to those of catatonia. The differen- Some psychiatric and Neuroleptic withdrawal dyskinesias tial diagnosis is complicated by the fact that Neuroleptic malignant syndrome medical disorders some of these disorders can cause catatonia, Akinetic Parkinsonism/Parkinson’s disease can mimic and/or which is then masked by the primary dis- Locked-in syndrome cause catatonia, order; some disorders (eg, NMS) are forms Stiff man syndrome which can make the of catatonia. Table 65,8,12,19,26,30 lists conditions Partial complex seizures to consider. differential diagnosis Nonconvulsive Some of these conditions warrant discus- complex Delirium sion. ASD may have catatonia-like features such as echolalia, echopraxia, excitement, Metabolic stupor combativeness, grimacing, mutism, log- orrhea, verbigeration, catalepsy, manner- Serotonin syndrome isms, rigidity, staring and withdrawal.8 Paratonia Catatonia may also be a stage of deteriora- Vegetative state (coma vigil) tion of autism, in which case it is character- Mania ized by increases in slowness of movement and speech, reliance on physical or verbal Source: References 5,8,12,19,26,30 prompting from others, passivity, and lack of motivation.23 At the same time, catatonic features such as mutism, stereotypic speech, repetitive behavior, echolalia, posturing, Scale (BFCRS) has had the most widespread mannerisms, purposeless agitation, and use. The BFCRS consists of 23 items, the first rigidity in catatonia can be misinterpreted 14 of which are used as a screening instru- as signs of ASD.8 Catatonia should be sus- ment. It requires 2 of its first 14 items to diag- pected as a complication of longstanding nose catatonia, while DSM-5 requires 3 of ASD in the presence of a consistent, marked 12 signs.29 If the diagnosis remains in doubt, change in motor behavior, such as immobil- a test can be instruc- ity, decreased speech, stupor, excitement, or tive.9,12 The presence of catatonia is sug- mixtures or alternations of stupor and excite- gested by significant improvement, ideally ment.8 Freezing while doing something, dif- assessed prospectively by improvement of ficulty crossing lines, or uncharacteristic BFCRS scores, shortly after administration persistence of a particular behavior may also of a single dose of 1 to 2 mg or herald the presence of catatonia with ASD.8 5 mg diazepam IV, or 10 mg orally. Catatonia caused by a neurologic or met- Further evaluation generally consists of a abolic factor or a substance can be difficult Current Psychiatry 22 August 2018 careful medical and psychiatric histories of to distinguish from delirium complicated by catatonia. Delirium may be identified in Table 7 patients with catatonia by the presence of Principles of treatment a waxing and waning level of conscious- of catatonia ness (vs fluctuating behavior in catatonia) MDedge.com/psychiatry and slowing of the EEG.12,15 Antipsychotic Early treatment is important medications can improve delirium but Treat pressure ulcers in stupor and fever in excited catatonia worsen catatonia, while benzodiazepines Treat underlying illnesses and withdraw can improve catatonia but worsen delirium. unnecessary medications Among other neurologic syndromes that Avoid high-potency antipsychotics; second- can be confused with catatonia, locked- generation antipsychotics are sometimes used in syndrome consists of total immobility for comorbid psychosis except for vertical extraocular movements Restart recently discontinued dopamine and blinking. In this state, patients attempt to communicate with their eyes, while cata- Reverse hyperthermia tonic patients do not try to communicate. Monitor for autonomic instability There is no response to a lorazepam chal- Ensure adequate hydration to prevent kidney lenge test. Stiff man syndrome is associ- injury Clinical Point Maintain nutrition ated with painful spasms precipitated by Treatment with touch, noise, or emotional stimuli. Baclofen Initiate /pulmonary can resolve stiff man syndrome, but it embolism prophylaxis agents that have can induce catatonia. Paratonia refers to Prevent contractures and aspiration anticonvulsant generalized increased motor tone that is Source: References 12,15,23,31 properties idiopathic, or associated with neurodegen- (benzodiazepines, eration, encephalopathy, or medications. barbiturates) and The only motor sign is increased tone, and other signs of catatonia are absent. benzodiazepines, the most commonly uti- ECT are effective Catatonia is usually associated with some lized of which has been lorazepam.7,13,32 motor behaviors and interaction with the Treatment begins with a lorazepam chal- environment, even if it is negative, while lenge test of 1 to 2 mg in adults and 0.5 to the coma vigil patient is completely unre- 1 mg in children and geriatric patients,9,15 sponsive. Frontotemporal dementia is pro- administered orally (including via nasogas- gressive, while catatonia usually improves tric tube), IM, or IV. Following a response without residual dementia.30 (≥50% improvement), the dose is increased to 2 mg 3 times per day. The dose is further increased to 6 to 16 mg/d, and sometimes Benzodiazepines, ECT are the up to 30 mg/d.9,11 Oral is less effective usual treatments than sublingual or IM administration.11 Experience dictates that the general prin- Diazepam can be helpful at doses 5 times ciples of treatment noted in Table 712,15,23,31 the lorazepam dose.9,17 A zolpidem chal- apply to all patients with catatonia. Since the lenge test of 10 mg orally or via nasogastric first reported improvement of catatonia with tube has also been utilized.15 Response is in 1930,6 there have been no con- brief and is usually followed by lorazepam, trolled studies of specific treatments of cata- although zolpidem up to 40 mg/d has been tonia.13 Meaningful treatment trials are either used for ongoing treatment.9 naturalistic, or have been performed only for One alternative benzodiazepine proto- NMS and malignant catatonia.5 However, col utilizes an initial IV dose of 2 mg loraz- multiple case reports and case series sug- epam, repeated 3 to 5 times per day; the gest that treatments with agents that have dose is increased to 10 to 12 mg/d if the first anticonvulsant properties (benzodiazepines, doses are partially effective.16 A lorazepam/ barbiturates) and ECT are effective.5 diazepam approach involves a combination Benzodiazepines and related com- of IM lorazepam and IV diazepam.11 The . Case series have suggested a 60% protocol begins with 2 mg of IM lorazepam. pounds Current Psychiatry to 80% remission rate of catatonia with If there is no effect within 2 hours, a second Vol. 17, No. 8 23 Table 8 Alternatives to benzodiazepines and electroconvulsive therapy Medication Details Amobarbital Response rate up to 60% NMDA antagonists (also dopaminergic) 100 to 600 mg 10 to 20 mg Catatonia Dopaminergic agents Carbidopa/levodopa (levodopa dose 25 to 100 mg) Methylphenidate 10 to 40 mg Anticonvulsants Valproate (possible GABAergic mechanism) 600 to 4,000 mg (anti-glutaminergic) 200 mg Carbamazepine (unknown mechanism) 100 to 1000 mg Dantrolene Occasionally helpful Anti-glutaminergic drugs Minocycline Dextromethorphan/quinidine Lithium (multiple actions) Clinical Point SSRIs Fluoxetine In case series, the Fluvoxamine effectiveness of Anticholinergic agents Benztropine Trihexyphenidyl electroconvulsive Second-generation antipsychotics Aripiprazole 3 to 30 mg therapy for Olanzapine 2.5 to 20 mg catatonia has been Risperidone 0.5 to 8 mg 53% to 100% Ziprasidone 40 to 160 mg Clozapine 150 to 800 mg Repetitive transcranial magnetic Fast rTMS (may be GABAergic); 10 Hz stimulation Source: References 13,15,17,20,25

GABA: gamma-aminobutyric acid; NMDA: N-methyl-d-aspartate; rTMS: repetitive transcranial magnetic stimulation; SSRIs: selective serotonin reuptake inhibitors

2 mg dose is administered, followed by an treatment with benzodiazepines, but clini- IV infusion of 10 mg diazepam in 500 ml of cal reports suggest that doses in the range normal saline at 1.25 mg/hour until cata- of 4 to 10 mg/d are effective.32 tonia remits. ECT was first used for catatonia in 1934, An Indian study of 107 patients (mean when Laszlo Meduna used chemically age 26) receiving relatively low doses of induced seizures in catatonic patients who lorazepam (3 to 6 mg/d for at least 3 days) had been on tube feeding for months and found that factors suggesting a robust no longer needed it after treatment.6,7 As response include a shorter duration of was true for other disorders, this approach catatonia and waxy flexibility, while pas- was replaced by ECT.7 In various case sivity, mutism, and auditory hallucina- series, the effectiveness of ECT in catatonia tions describing the patient in the third has been 53% to 100%.7,13,15 Right unilateral person were associated with a poorer acute ECT has been reported to be effective with response.31 Catatonia with marked retar- 1 treatment.21 However, the best-established dation and mutism complicating schizo- approach is with bitemporal ECT with a phrenia, especially with chronic negative suprathreshold stimulus,9 usually with an symptoms, may be associated with a lower acute course of 6 to 20 treatments.20 ECT has response rate to benzodiazepines.20,33 been reported to be equally safe and effec- Maintenance lorazepam has been effective tive in adolescents and adults.34 Continued in reducing relapse and recurrence.11 There ECT is usually necessary until the patient Current Psychiatry 24 August 2018 are no controlled studies of maintenance has returned to baseline.9 ECT usually is recommended within 24 hours for treatment-resistant malig- Related Resources nant catatonia or refusal to eat or drink, • Gibson RC, Walcott G. Benzodiazepines for catatonia in people with schizophrenia and other serious mental MDedge.com/psychiatry and within 2 to 3 days if medications are illnesses. Cochrane Database Syst Rev. 2008;(4):CD006570. not sufficiently effective in other forms of • Newcastle University. Catatonia. https://youtu.be/_s1lzxHRO4U. 12,15,20 catatonia. If ECT is initiated after a Drug Brand Names benzodiazepine trial, the benzodiazepine Amantadine • Symmetrel Flumazenil • Romazicon antagonist flumazenil is administered first Amobarbital • Amytal Fluoxetine • Prozac 9 Aripiprazole • Abilify Fluvoxamine • Luvox to reverse the anticonvulsant effect. Some Azithromycin • Zithromax Levetiracetam • Keppra experts recommend using a muscle relaxant Baclofen • Lioresal Lithium • Eskalith, Lithobid other than succinylcholine in the presence Benztropine • Cogentin Lorazepam • Ativan Carbamazepine • Memantine • Namenda 7 of evidence of muscle damage. Carbatrol, Tegretol Methylphenidate • Ritalin Alternatives to benzodiazepines and Carbidopa/levodopa • Minocycline • Minocin Sinemet Olanzapine • Zyprexa ECT. Based on case reports, the treatments Ciprofloxacin • Cipro Risperidone • Risperdal described in Table 813,15,17,20,25 (page 24) have Clozapine • Clozaril Succinylcholine • Anectine Dantrolene • Dantrium Topiramate • Topamax been used for patients with catatonia who Dexamethasone • Decadron Trihexyphenidyl • Artane do not tolerate or respond to standard Dextromethorphan/ Valproate • Depakote Clinical Point treatments. The largest number of case quinidine • Neudexta Ziprasidone • Geodon Diazepam • Valium Zolpidem • Ambien Most experts reports have been with NMDA antago- Disulfiram • Antabuse nists, while the presumed involvement would recommend of reduced dopamine signaling suggests initiating treatment that dopaminergic medications should be of catatonia with helpful. Dantrolene, which blocks release increased subcortical prefrontal dopamine lorazepam, followed of calcium from intracellular stores and release resulting from serotonin 5HT2A by ECT if necessary has been used to treat malignant hyper- antagonism and 5HT1A agonism by other thermia, is sometimes used for NMS, often SGAs, could also be helpful or at least not with disappointing results. harmful in catatonia. Lorazepam is usu- Whereas first-generation antipsychot- ally administered along with these medi- ics definitely increase the risk of catato- cations to ameliorate treatment-emergent nia and second-generation antipsychotics exacerbation of catatonia. (SGAs) probably do so, SGAs are some- There are no controlled studies of any of times necessary to treat persistent psy- these treatments. Based on case reports, most chosis in patients with schizophrenia who experts would recommend initiating treat- develop catatonia. Of these medications, ment of catatonia with lorazepam, followed clozapine may be most desirable because by ECT if necessary or in the presence of life- of low potency for dopamine receptor threatening catatonia. If ECT is not available, blockade and modulation of glutamater- ineffective, or not tolerated, the first alterna- gic signaling. Partial dopamine agonism tives to be considered would be an NMDA by aripiprazole, and the potential for antagonist or an anticonvulsant.20 continued

Bottom Line Much more common than many clinicians realize, catatonia can be overlooked because symptoms can mimic or overlap with features of an underlying medical or neurologic disorder. Suspect catatonia when one of these illnesses has an unexpected course or an inadequate treatment response. Be alert to characteristic changes in behavior and speech. A benzodiazepine challenge can be used to diagnose and begin treatment of catatonia. Consider electroconvulsive therapy Current Psychiatry sooner rather than later, especially for severely ill patients. Vol. 17, No. 8 25 15. Oldham MA, Lee HB. Catatonia vis-à-vis delirium: the Course varies by patient, significance of recognizing catatonia in altered mental underlying cause status. Gen Hosp Psychiatry. 2015;37(6):554-559. 16. Tuerlings JH, van Waarde JA, Verwey B. A retrospective The response to benzodiazepines or ECT study of 34 catatonic patients: analysis of clinical ‘ can vary from episode to episode11 and is care and treatment. Gen Hosp Psychiatry. 2010;32(6): 631-635. 22 similar in adults and younger patients. 17. Ohi K, Kuwata A, Shimada T, et al. Response to Many patients recover completely after a benzodiazepines and the clinical course in malignant catatonia associated with schizophrenia: a case report. single episode, while relapse after remis- Medicine (Baltimore). 2017;96(16):e6566. doi: 10.1097/ Catatonia sion occurs repeatedly in periodic cata- MD.0000000000006566. 18. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms tonia, which involves chronic alternating appearing before autonomic symptoms help distinguish stupor and excitement waxing and waning neuroleptic malignant syndrome from malignant catatonia. Intern Med. 2016;55(19):2893-2897. 11 over years. Relapses may occur frequently, 19. Lang FU, Lang S, Becker T, et al. Neuroleptic malignant or every few years.11 Some cases of catato- syndrome or catatonia? Trying to solve the catatonic dilemma. Psychopharmacology (Berl). 2015;232(1):1-5. nia initially have an episodic course and 20. Beach SR, Gomez-Bernal F, Huffman JC, et al. Alternative become chronic and deteriorating, possi- treatment strategies for catatonia: a systematic review. Gen Hosp Psychiatry. 2017;48:1-19. bly paralleling the original descriptions of 21. Kugler JL, Hauptman AJ, Collier SJ, et al. Treatment the natural history of untreated catatonia, of catatonia with ultrabrief right unilateral electroconvulsive therapy: a case series. J ECT. 2015;31(3): Clinical Point while malignant catatonia can be compli- 192-196. cated by medical morbidity or death.4 The 22. Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment Many patients with use in a prospective naturalistic cohort of children and long-term prognosis generally depends on adolescents with catatonia. Eur Child Adolesc Psychiatry. catatonia recover the underlying cause of catatonia.5 2015;24(4):441-449. 23. DeJong H, Bunton P, Hare DJ. A systematic review of completely after a interventions used to treat catatonic symptoms in people References with autistic spectrum disorders. J Autism Dev Disord. single episode 1. Kahlbaum KL. Catatonia. Baltimore, MD: John Hopkins 2014;44(9):2127-2136. University Press; 1973. 24. Wachtel L, Commins E, Park MH, et al. Neuroleptic 2. Kahlbaum KL. Die Katatonie oder das Spannungsirresein. malignant syndrome and delirious mania as malignant Berlin: Hirschwald; 1874. catatonia in autism: prompt relief with electroconvulsive therapy. Acta Psychiatr Scand. 2015;132(4):319-320. 3. Tang VM, Duffin J. Catatonia in the history of psychiatry: construction and deconstruction of a disease concept. 25. Fink M, Taylor MA. Catatonia: subtype or syndrome in Perspect Biol Med. 2014;57(4):524-537. DSM? Am J Psychiatry. 2006;163(11):1875-1876. 4. Carroll BT. Kahlbaum’s catatonia revisited. Psychiatry Clin 26. Khan M, Pace L, Truong A, et al. Catatonia secondary to Neurosci. 2001;55(5):431-436. synthetic cannabinoid use in two patients with no previous psychosis. Am J Addictions. 2016;25(1):25-27. 5. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160(7):1233-1241. 27. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms appearing before autonomic symptoms help distinguish 6. Fink M, Fricchione GL, Rummans T, et al. Catatonia is neuroleptic malignant syndrome from malignant catatonia. a systemic medical syndrome. Acta Psychiatr Scand. Intern Med. 2016;55(19):2893-2897. 2016;133(3):250-251. 28. Diagnostic and statistical manual of mental disorders, 5th 7. Medda P, Toni C, Luchini F, et al. Catatonia in 26 patients ed. Washington, DC: American Psychiatric Association; with bipolar disorder: clinical features and response to 2013. electroconvulsive therapy. Bipolar Disord. 2015;17(8): 892-901. 29. Wilson JE, Niu K, Nicolson SE, et al. The diagnostic criteria and structure of catatonia. Schizophr Res. 2015;164(1-3): 8. Mazzone L, Postorino V, Valeri G, et al. Catatonia in patients 256-262. with autism: prevalence and management. CNS Drugs. 2014;28(3):205-215. 30. Ducharme S, Dickerson BC, Larvie M, et al. Differentiating frontotemporal dementia from catatonia: a complex 9. Fink M, Kellner CH, McCall WV. Optimizing ECT technique neuropsychiatric challenge. J Neuropsychiatry Clin in treating catatonia. J ECT. 2016;32(3):149-150. Neurosci. 2015;27(2):e174-e176. 10. Kocha H, Moriguchi S, Mimura M. Revisiting the concept of 31. Narayanaswamy JC, Tibrewal P, Zutshi A, et al. Clinical late catatonia. Compr Psychiatry. 2014;55(7):1485-1490. predictors of response to treatment in catatonia. Gen Hosp 11. Lin CC, Hung YL, Tsai MC, et al. Relapses and recurrences Psychiatry. 2012;34(3):312-316. of catatonia: 30-case analysis and literature review. Compr 32. Thamizh JS, Harshini M, Selvakumar N, et al. Psychiatry. 2016;66:157-165. Maintenance lorazepam for treatment of recurrent 12. Saddawi-Konefka D, Berg SM, Nejad SH, et al. Catatonia in catatonic states: a case series and implications. Asian J the ICU: An important and underdiagnosed cause of altered Psychiatr. 2016;22:147-149. mental status. A case series and review of the literature. Crit 33. Ungvari GS, Chiu HF, Chow LY, et al. Lorazepam for Care Med. 2013;42(3):e234-e241. chronic catatonia: a randomized, double-blind, placebo- 13. Wijemanne S, Jankovic J. Movement disorders in catatonia. J controlled cross-over study. Psychopharmacology (Berl). Neurol Neurosurg Psychiatry. 2015;86(8):825-832. 1999;142(4):393-398. 14. Grover S, Chakrabarti S, Ghormode D, et al. Catatonia 34. Flamarique I, Baeza I, de la Serna E, et al. Long-term in inpatients with psychiatric disorders: a comparison effectiveness of electroconvulsive therapy in adolescents of schizophrenia and mood disorders. Psychiatry Res. with schizophrenia spectrum disorders. Eur Child Adolesc 2015;229(3):919-925. Psychiatry. 2015;24(5):517-524.

Current Psychiatry 26 August 2018