Catatonia

Catatonia is a serious brain disorder that affects how a person moves, communicates, and responds to the world around them. Although it can have life-threatening complications, it is highly treatable with proper medical care.

Table of contents

• What is catatonia?
• Symptoms of catatonia
• Types of catatonia
• Causes and conditions associated with catatonia
• How catatonia affects the brain
• The inner experience of catatonia
• How catatonia is diagnosed
• Treatment options
• Outlook and prognosis

What is catatonia?

Catatonia is a disorder that disrupts how your brain works, affecting how a person processes and reacts to the world around them^[1]. People with catatonia often don’t react to things happening nearby or may react in ways that seem unusual. Impaired communication (difficulty expressing thoughts or understanding others), unusual movements or lack of movement, and behavior abnormalities are the most striking features of this condition^[1].

Catatonia is a neuropsychiatric syndrome (a condition affecting both the brain and mental health) characterized by abnormal movements, behaviors, and withdrawal^[2]. It is a state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake^[6].

German psychiatrist Karl Kahlbaum named and described catatonia in 1874, but it remains highly underdiagnosed^[1]. Until recent decades, catatonia was mistakenly believed to only occur in people with schizophrenia. However, doctors now understand that other mental illnesses and some conditions that affect the body’s metabolism can also cause catatonia^[4].

According to available research, catatonia happens in 0.5% to 2.1% of people receiving psychiatric care. That number climbs to around 10% for people who need inpatient mental health treatment^[1]. Most studies on the incidence of catatonia find it to be between 5% to 20% in the acute inpatient psychiatric setting^[2]. Catatonia doesn’t affect any population differently based on race or sex^[1].

Symptoms of catatonia

There are 12 officially accepted symptoms of catatonia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)^[1]. At least three of these symptoms must be present for the diagnosis of catatonia^[2]. The symptoms include:

• Agitation: This means a person acts upset or irritable. It only counts as a symptom of catatonia if it happens and it isn’t a response to something around the person having it^[1].
• Catalepsy: This is when a person holds a position in which someone places them. You can still move them around to make them take on a new pose^[1].
• Echolalia: This is when a person echoes or repeats sounds or words that someone else makes^[1].
• Echopraxia: This is when a person mimics or mirrors someone else’s movements^[1].
• Grimacing: This is holding the same facial expression, usually with stiff or tense facial muscles. Sometimes, it can take the form of smiling in inappropriate contexts^[1].
• Mannerism: This is when a person acts out motions or movements that could be normal but does them in an unusual or exaggerated way^[1].
• Mutism: This is when a person is either very quiet or totally silent^[1][4].
• Negativism: This is when a person either doesn’t respond to what’s happening around them or actively resists what’s happening, without a logical reason^[6].
• Posturing: Keeping the body in an unusual position^[4].
• Stereotypy: Repeated movements that don’t seem to have a purpose, such as playing with fingers, patting and rubbing the body, or repetitive movements of the mouth and jaw^[6].
• Stupor: Not responding to other people or the environment^[4].
• Waxy flexibility: Slight, even resistance to positioning by an examiner^[6].

Catatonia can also impact a person’s desire to eat and drink and control basic body functions, like temperature, breathing, and heart rate^[3]. Common signs include not being able to move, not being able to talk, not being very alert, difficulty following instructions, difficulty being moved, staring for long periods without focus, and copying others’ speech or actions without reason^[3].

Types of catatonia

Most episodes of catatonia can be classified as excited, retarded, or malignant^[2]. Symptoms can change during these episodes, and patients can have periods of withdrawal and periods of excitement^[2].

There are two main types based on movements and symptoms^[3]:

• Stuporous (or withdrawn/hypokinetic): This is the type people usually think of. The person is awake but doesn’t respond to their surroundings, seeming unaware. They are usually silent with little or no facial expression. They may hold unusual positions and resist anyone wanting to move them. They often don’t eat or drink and may lose control of their bladder or bowels^[4]. This type includes symptoms that make a person seem slow, like trouble talking, moving, staring, or getting “stuck” in positions^[3].
• Excited (or hyperkinetic): People with this type are very active and restless. They might pace, become aggressive, or do strange things. They may copy others’ actions or words. It can even escalate to self-harm^[4]. This type includes symptoms where the person appears overly sped up, such as having too much movement, talking as if on a loop, pacing, or other repeating behaviors that serve no purpose^[3].
• Mixed: This type includes qualities of both hyperkinetic and hypokinetic catatonia. A person may suddenly switch from one form to the other^[4].

If symptoms are severe, catatonia can become a medical emergency needing rapid treatment. This is sometimes referred to as malignant catatonia^[3]. Malignant catatonia is complicated by fever and autonomic disturbances (problems with automatic body functions like heart rate and temperature control), and it can be life-threatening^[10].

Causes and conditions associated with catatonia

The exact cause of catatonia is still unknown, and we don’t know why it affects some people but not others with similar conditions^[3]. Catatonia is often thought to happen secondary to another underlying illness^[2].

Catatonia is most common with the following kinds of conditions^[1]:

• Psychiatric conditions, which specifically affect mental health. Mood disorders such as bipolar disorder and depression are the most common disorders in which catatonia manifests^[2]. Catatonia happens more often in certain illnesses, such as bipolar disorder, depression, psychosis, and autism spectrum disorder^[3]. A psychotic disorder such as schizophrenia can also be associated with catatonia^[2].
• Neurological conditions, which specifically affect how the brain works^[1].
• Medical conditions, which affect how one or more systems in the body function^[1].

Catatonia is a syndrome that has been associated with several mental illness disorders but has also presented as a result of other medical conditions^[5]. There are three types: (1) catatonia associated with another mental disorder (catatonia specifier), (2) catatonic disorder due to another medical condition, and (3) unspecified catatonia^[6].

How catatonia affects the brain

Catatonia disrupts how certain parts of the brain work, causing a person to go into a “catatonic state.” The areas of the brain that are affected are those that control or manage movement, senses (vision, hearing, smell, touch, and taste), memory, thinking and concentration abilities, motivation, emotions, and judgment and self-control^[1].

Studies have shown that it impacts the connections between the parts of the brain that control movement and those responsible for more complicated processes, like memory, learning, and reasoning^[3]. Studies have suggested a connected pathway between the cortex, basal ganglia (brain structures that help control movement), and thalamus (a relay station in the brain) underpins these different subtypes and results in catatonic symptoms^[2].

Catatonia is a motor dysregulation syndrome involving difficulty initiating or terminating actions^[7]. Overall, catatonia seems to reflect an abnormality of neural circuitry that regulates movement involving the basal ganglia, thalamus, and cortex. This shares some similarities with Parkinson’s disorder^[7].

The precise mechanism of catatonia remains unclear. However, catatonia seems to involve several neurotransmitter (brain chemical) imbalances. These include inadequate dopamine activity, inadequate GABA signaling, and excessive signaling via glutaminergic NMDA receptors^[7].

The inner experience of catatonia

Patients with catatonia describe experiencing very intense emotional states^[8]. In studies on the subjective experience of catatonia, patients provided self-reports describing their experience. Their experience was less focused on the change in their movements and more on the change in their cognitive or affective experience. This included intense emotions that could not be controlled^[8].

The common themes that emerged from studies were overwhelming anxiety, fear, and depression^[8]. The dominant themes of thoughts, feelings, and behaviors described centered around yearning for or missing loved ones, heightened fear, intense anxiety, negative affect, aggression, obedience, and withdrawal^[8].

Because catatonia often interferes with a patient’s ability to communicate, especially when an episode is severe, protracted, or characterized by prominent mutism, excitement, or speech oddities, patients are often unable to describe their experiences during an acute episode^[8].

How catatonia is diagnosed

Patients who have symptoms of catatonia need to be evaluated by a medical doctor with experience diagnosing this condition^[3]. Individuals with catatonia often cannot provide a coherent history; however, collateral sources are crucial sources of relevant historical information. Thorough review of old records is needed to figure out possible causes of the behaviors of people with catatonia^[6].

The doctor will perform a physical exam to look for some of the signs described above. They may use a rating scale such as the Bush Francis Catatonia scale to measure symptoms^[3]. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination^[10].

The doctor will ask questions about your child’s medical and psychiatric history. The history should inquire into possible precipitating events, including infection, trauma, and exposure to toxins and other substances; previous similar episodes of catatonia; exposure to neuroleptics and other substances associated with catatonia; and comorbid disorders, including schizophrenia, mood disorders, psychological stressors, medical conditions, and obstetric conditions^[6].

In an emergency setting, treatable common causes of catatonia must be rapidly considered and ruled out. These include neuroleptic malignant syndrome (a dangerous reaction to certain medications), encephalitis (brain inflammation), nonconvulsive status epilepticus (a type of seizure disorder), and acute psychosis^[6].

Recognition of catatonia is essential because it is a highly treatable condition which responds to specific interventions. Alternatively, provision of nonspecific supportive care may often fail, especially in malignant catatonia^[7]. Catatonia is often misdiagnosed as delirium (a state of confusion). Although catatonia may appear similar to delirium, these are fundamentally distinct processes^[7].

Treatment options

Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines (a type of calming medication), such as lorazepam, and electroconvulsive therapy (ECT)^[10].

Most catatonia cases respond to benzodiazepines, especially lorazepam, but up to 30% do not^[13]. Lorazepam is the most commonly used treatment. When benzodiazepines fail, electroconvulsive therapy can be effective^[13].

Treatment modalities include pharmacotherapy and electroconvulsive treatment. Prompt treatment in the early phases of catatonic states is crucial to obtaining a lasting abatement of symptoms^[12]. The following medications have been used in the treatment of patients suffering from catatonia: benzodiazepines (such as clonazepam, lorazepam, and midazolam), carbamazepam, zolpidem, tricyclic antidepressants, muscle relaxants, amobarbital, reserpine, thyroid hormone, lithium carbonate, and bromocriptine^[12].

Because of the possible development of neuroleptic malignant syndrome, the use of traditional neuroleptics is avoided; second-generation (atypical) antipsychotics may be helpful in some cases but should still be used with caution^[12].

Refusal to eat necessitates the institution of parenteral nutrition (feeding through a vein)^[12]. Supervised activity is indicated. Prompt intervention may be needed to prevent collapse from exhaustion. The need to administer parenteral nutrition and fluids and to monitor vital signs may require a patient to be transferred from a psychiatric unit to a neurologic or medical unit^[12].

In some patients, catatonia remits only in response to ECT. Some patients may require weekly ECT on an outpatient basis^[12].

Outlook and prognosis

Catatonia can have life-threatening complications, but is very treatable with medication or other techniques^[1]. Although severe and life-threatening, catatonia has a good prognosis^[10].

Catatonia can last anywhere from a few hours to weeks, months, or years. It can reoccur frequently for weeks to years after the initial episode^[17]. Individual patients may have repeated episodes of catatonia. In some cases this may represent a genetically mediated form of periodic catatonia^[7].

Regular outpatient follow-up visits are advisable to check for the recurrence of catatonia^[12].