Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology
Catatonia is a ‘behavioral syndrome marked by an inability to move normally, which can occur in the context of many underlying psychiatric disorders.’ Generally catatonia results as a subtype of an underlying disorder and is studied in relation to ‘acutely ill psychiatric (in)patients.’ Catatonia occurs in approximately 10% of patients, but as a whole the illness is difficult to assess and may often go unrecognized. Given the fact that catatonia often causes confusion amongst providers with other disorders, I thought this case was particularly interesting and warranted further research to broaden and deepen my understanding of the subject.
During my psychiatry rotation, I encountered a patient with catatonia secondary to schizophrenia and medication noncompliance. The patient in question was mute and exhibited waxy flexibility. The patient was blinking & breathing without issue but remained lying down throughout the entirety of the interview (and his stay in CPEP) and was unable to answer questions. According to the patient’s sister, the patient hasn’t been taking his medication over the past few weeks and began to exhibit similar symptoms to previous exacerbations prompting her to bring him to the ED for evaluation.
The article selected, published by the World Journal of Psychiatry evaluates ‘Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology.’ The authors use the introduction to discuss the different types of Catatonia (retarded and excited) and discuss the various signs & symptoms and presentation of each subtype. The researchers highlight the importance of diagnosing catatonia because of its risk of developing neuroleptic malignant syndrome and/or ‘malignant’ or ‘lethal’ catatonia. Equally important is being able to diagnose the underlying psychiatric diagnosis and it is often difficult to do so in a patient experiencing a catatonic state and affects the ability to adequately care for this patient population.
Diagnosis of patients with catatonia is very important. The authors discuss the different criteria that have been proposed for its diagnosis and ultimately find that the diagnosis can be made ‘based on the presence of at lease four of the catatonic signs originally described by Karl Kahlbaum in 1874…as well as the frequency of occurrence.’ These signs include immobility, mutisim, withdrawal and refusal to eat, staring, negativism, posturing, rigidity, waxy flexibility / catalepsy, stereotypy, echolalia or echopraxia and verbigeration.’ However the researchers highlight that newer criteria lead to the DSM V definition of three or more of the following criteria (cataplesy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerisms, sterotypies, drimacing, echolalia and echopraxia) to get greater specificity. Throughout the article, the authors note that a patient presenting with immobility and mutism should immediately be screened for catatonia to ensure the diagnosis doesn’t go missed. The differential diagnosis for catatonia is broad and includes many conditions that present with overlapping symptoms. Diagnoses to consider include Extrapyramidal Side-Effects, Neuroleptic Malignant Syndrome, Nonconvulsive status epilepticus, Abulia or akinetic mutism, Locked-in syndrome, vegetative state and stiff person syndrome.
In our psychiatry course we learned, benzodiazepine medication is used to break the catatonic state and the authors of the article recommend an initial dose of 1-2mg lorazepam. The patient that prompted this research had a diagnosis of schizophrenia and interestingly the article notes ‘an underlying diagnosis of schizophrenia may be associated with a less robust response to benzodiazepine treatment.’ For patients with poor response to medical treatment, ECT is another highly effective option for the treatment of catatonia. Given the severity of ECT, obtaining consent is necessary and often requires additional decision makers to move forward with the process.
The pathophysiology of catatonia is unknown and presents with a ‘wide range of psychomotor abnormalities.’ While all abnormalities might not be present in all patients, immobility and mutism are common amongst a majority. As providers, it is important to have a heightened awareness for patients who present with any of these symptoms to ensure the diagnosis of catatonia isn’t missed.
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https://www.uptodate.com/contents/catatonia-in-adults-epidemiology-clinical-features-assessment-and-diagnosis?search=catatonia&source=search_result&selectedTitle=2~70&usage_type=default&display_rank=2#H6713689
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