Understanding Catatonia: Symptoms, Diagnosis & Treatment Options

Catatonia is derived from Greek, where Kata means down and tonos means tension.

In catatonia, there is an abnormality in the muscular tension and a varied number of motor symptoms along with behavioral and affective symptoms.

Clinical Features of Catatonia

1. Stupor (Immobility)
2. Excitement (Agitation)
3. Mutism
4. Posturing
5. Catalepsy (Perseveration of Posture)
6. Waxy Flexibility (Cerea flexibilites)
7. Negativism
8. Mannerism
9. Stereotypy
10. Echolalia
11. Echopraxia
12. Grimacing
13. Automatic Obedience
14. Mitmachen
15. Mitgehen
16. Ambitendency
17. Forced Grasping
18. Grasp Reflex
19. Magnetic Reaction
20. Gegenhalten (Opposition)
21. Obstruction (Blocking or Sperrung)
22. Perseveration

Freeman and Gander's Types of Perseveration

1. Compulsive Repetition
   • Act is repeated until a new instruction is given.
   • For instance, continuous tapping until directed otherwise.
2. Impairment of Switching
   • Repetition persists even after a new task is assigned.
   • Difficulty switching from one action to another.
3. Ideational Perseveration: The patient verbally repeats words or phrases during responses to questions.

Special Forms of Verbal Perseveration:

• Logoclonia
  • Repeating the last syllable of a word.
  • Example: "I'm going to a movieeeeee."
• Palilalia
  • Repeating a perceived-oriented word with increasing frequency.
  • Example: "I'm going to a movie I'm going to a movie I'm going to a movie."

Also read: Examination Of Uncooperative Patient  

Catatonia Symptoms 

1. It's not sufficient for just one symptom to be present to diagnose catatonia.
2. Studies propose varying thresholds, ranging from at least two to four symptoms.
3. A commonly considered and favorable number of symptoms for diagnosis is three.
4. DSM-5, a widely used diagnostic manual, describes 12 catatonic symptoms.
5. It suggests a threshold of at least three symptoms for a catatonia diagnosis.

Three Categories of Catatonia as Per DSM-5

Catatonia Associated with Another Mental Disorder:

• This category includes catatonia, which is associated with various mental disorders, such as neurodevelopmental disorders (e.g., autism spectrum disorders), psychotic disorders, bipolar disorder, depressive disorder, or other mental disorders.

Catatonia Due to Another Medical Condition:

• This category encompasses catatonia that arises due to various medical conditions. Examples include neurological conditions (e.g., encephalitis, head trauma, cerebrovascular diseases), metabolic diseases (e.g., diabetic ketoacidosis, hypercalcemia, hepatic encephalopathy, homocystinuria), and other medical conditions.

Unspecified Catatonia:

• This category is used when the nature of the underlying disorder is unclear or when the full criteria for catatonia are not met.
• It provides flexibility, especially in emergencies where there might not be sufficient information for a more specific diagnosis.
• This allows for a provisional diagnosis and the initiation of treatment.

Also read: Delusional Disorders : History, Classification 

ICD-11 Criteria for Catatonia 

According to ICD 11, it is the marked disturbance in voluntary control of movements characterized by several of the following:

• Extreme Slowing or Absence of Motor Activity: marked disturbance in voluntary control, like stupor.
• Mutism: little to no verbal response.
• Purposeless Motor Activity: Unrelated to external stimuli, suggesting excitement or agitation.
• Assumption or Maintenance of Rigid, Unusual, or Bizarre Postures: describing posturing or resistance to instructions.
• Resistance to Instructions or Attempts to Be Moved: Like negativism.
• Automatic Compliance with Instructions (Automatic Obedience): Not mentioned in DSM-5 but included in

ICD 11 catatonia classification

1. Catatonia associated with another mental disorder:
   • May be diagnosed in the context of certain specific mental disorders, including mood disorder, schizophrenia, and autism spectrum disorder.
2. Catatonia induced by psychoactive substances, including medications
   • Occurs during or shortly after consumption of psychoactive substances or
   • During use of a psychoactive medication
3. Catatonia: Unspecified
   • May also be caused by disorders or diseases classified elsewhere

Laboratory Examinations

• Laboratory examinations are done to rule out other conditions, which are based on the history or whatever information of the patient.
• The first line of tests comprises:
  • CBC, KFT, LFT, TFT, LFT, Blood sugar
  • Creatine phosphokinase (CPK) levels
  • Drug screen of urine
  • ECG, CT, MRI Brain.
• Imaging is considered when there is a 1st episode or when the diagnosis of underlying catatonia is unclear.
  • EEG,  Culture—blood and urine
  • HIV, Syphilis tests
  • Autoantibody test: Autoantibodies may be a cause of catatonia.
  • It can also be done if the underlying cause is not clear.

CSF examination

Lab findings in catatonia :

• Increase in the creatine phosphokinase (CPK) levels.
• Low serum iron levels.
• Increase in the CSF of homovanillic acid.
• In imaging, an increase in the size of the lateral ventricle or cerebellar atrophy.
• EEG: frontal slowing (intermittent).
• FMRI: Decrease in sensory-motor cortex functioning.
• Spect-altered laterality.
• Cognitive problems: These can also be assessed in attention, motor, or visio-spatial functioning.

Also read: Innovative Approaches to Obesity Treatment 

Treatment

• Catatonia patients are at risk of multiple life-threatening complications, such as NMS. Hence, rapid treatment is required.
• General principles of catatonia are specific treatment of catatonia, treatment of disorders underlying catatonia, and prevention and management of medical complications of catatonia.
• DSM V includes the diagnosis of unspecified catatonia to encourage early treatment while searching for the cause.
• The challenge tests may provide support in clarifying the diagnosis and help in deciding the appropriate treatment.

1. Protocol for the Lorazepam Challenge for catatonia
   • Lorazepam is a non-selective positive allosteric modulator of the GABA-A receptor.
   • There should be an assessment of baseline catatonic features using standard instruments such as BFCRS, and the scores at baseline and after treatment should be compared.
   • 1-2 mg IV lorazepam should be administered and reassessed for catatonic features after 5 minutes or 1 mg administered  and reassessed after 5 minutes. If no change, 1 mg IV is given again, and the response is checked after 10 minutes or oral route.
   • If administered via IM route, it should be reassessed after 15 minutes, or if 2 mg is administered orally, then it should be reassessed after 30 minutes.
   • A 50% reduction in score represents a positive response.
   • If not a positive response, further challenges are considered ideally parenteral and assessed.
   • A good response on the first day appears predictive of the overall response of lorazepam.
   • In various studies, it is seen that low serum iron is reported as predictive of poor response with benzodiazepines.
2. Zolpidem challenge tests:
   • Zolpidem is a modulator of the GABA A a1 subunit.
   • The recommended dose for diagnostic and/or therapeutic tests is 10 mg orally or sometimes 5 mg in older patients.
   • The onset of action is 10–30 minutes.
   • The response to zolpidem should be observed and compared.
   • First-line treatment 00:07:08
   • Benzodiazepines and ECT are first-line treatments that have shown good responses in patients with catatonia.
   • The factors to be considered while choosing a drug are that benzodiazepine or ECT are the side effects profile of the drug

Also read: Comprehensive Guide To Schizophrenia 

Benzodiazepines

• Benzodiazepines can be given through IV, IM, or oral route.
• The choice of route depends on clinical appropriateness, availability of drugs, rapidity of response, and experience of using these routes.
• In benzodiazepines, Lorazepam is the preferred agent.
• Sometimes, high doses may be required up to 16 mg/dl and are usually divided into 2-4 doses.
• Benzodiazepines should not be stopped abruptly. It should be tapered gradually.
• When there is relapse with withdrawal, ensure treatment of any underlying condition and try slower taper.
• If there is no remission with benzodiazepines, ECT is preferred.

ECT

• Bilateral ECT is preferred for 2-3 sessions per week.
• The number of sessions is decided based on treatment response, risks, and side effects to the patients.
• A mean of around 9 sessions may be given in the management of patients with ETC.

Other Therapies

1. Other therapies are preferred when 1st line therapies are unavailable, cautioned, ineffective, or partially effective.
2. NMDA receptor antagonists such as amantadine or memantine can be used in the treatment of catatonia.
3. Dopamine precursors such as levodopa, agonists such as bromocriptine, and reuptake inhibitors such as methylphenidate are also useful.
4. Dopamine antagonists such as second-generation antagonists and partial agonists such as Aripiprazole have also been shown to have a role in the treatment of catatonia.
5. Moreover, anticonvulsants such as carbamazepine, valproate, and topiramate have been used in some studies.
6. Some evidence of response has been seen with anticholinergic drugs such as benztropine and trihexyphenidyl.
7. Some miscellaneous drugs, such as muscle relaxants, corticosteroids, and lithium, are useful in treatment, especially in periodic or recurrent catatonia.
8. The alternatives to ECT are repetitive transcranial magnetic stimulation (rTms) and transcranial direct current stimulation (tDCS).

Also read : Dysthymic Disorder Criteria And Clinical Features 

FAQ’S

Q. Is catatonia a reversible condition?

Ans. Most cases are reversible with definite and appropriate treatment if they are identified  early.

Q. How can I support someone with catatonia?

Ans. The major support would be to ensure safety for patients and encourage them to get medical advice from healthcare professionals.

Hope you found this blog helpful for your Psychiatry Residency Clinical Psychiatry preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.