Catatonia : An Overview

Kapil S Kulkarni
Resident Doctor, Jagjivan Ram Hospital, Mumbai Central
Guided by- Dr Pinto, Dr Rawat, Dr Dave
 PRESENTATION
DEFINITION
HISTORICAL REVIEW
HYPOTHESIS
SYMPTOMS & SIGNS (PHENOMENOLOGY)
CAUSES OF CATATONIA
RATING SCALE
EXAMINATION
DIFFERENTIATING CATATONIA
COMMON D/D OF CATATONIA
TREATMENT OF CATATONIA
 DEFINITION
• A syndrome of multiple etiologies (organic or functional)
presenting with different features.
• Features are classified as motor and behavioral.

• Motor- posturing, catalepsy, stereotypy, mannerism, rigidity,

waxy flexibility, echopraxia, echolalia.
• Behavioral- withdrawal, excitement, grimace, stupor, mutism,
staring, negativism, verbigeration, perseveration, automatic
obedience, mitgehen, gegenhalten, ambitendency,
impulsivity, combativeness.
 HISTORICAL OVERVIEW
• Described in 1874 by Kahlbaum,
its neurological causes were also
appreciated.

• Kraepelin and Bleuler- Described

it relation to schizophrenia.

• 1976 – Abraham & Taylor – in

mania
• 1976 – Gelenberg – concept of
syndrome
• DSM-IV (1994) Diagnostic Criteria for Catatonic Disorder Due
to a General Medical Condition and also they classify it in
affective disorder “with catatonic symptoms” thus placing the
syndrome beyond the limits of schizophrenia.
 HYPOTHESIS OF CATATONIA
• G-aminobuteric acid (GABA) HYPOACTIVITY at the GABAA
receptor.

• Dopamine HYPOACTIVITY at the D2 receptor.

• Glutamate HYPOACTIVITY at the N-methyl-D-aspartate

(NDMA) receptor.

• Serotonin HYPERACTIVITY at the 5-HT1A receptor and

HYPOACTIVITY at the 5-HT2A receptor.
PHENOMENOLOGY
 PHENOMENOLOGY
• Excitement-
Extreme hyperactivity, constant motor unrest which is
apparently non purposeful. Not to be attributed to akathisia
or goal directed agitation.

• Immobility/ stupor-
Extreme hypo activity, immobile, minimally responsive to
stimuli.
 PHENOMENOLOGY
• Mutism-
Verbally unresponsive or minimally responsive.

• Staring-
Fixed gaze, little no visual scanning of environment,
decreased blinking.

• Posturing/ catalepsy-
Spontaneous maintenance of posture(s), including mundane.
(e.g. sitting or standing for long period without reacting)
 PHENOMENOLOGY
• Grimacing-
Maintenance of odd facial expression.

• Echopraxia/ echolalia-
Mimicking of examiner’s movement or speech.

• Stereotype-
Repetitive non goal directed motor activity (e.g. finger
play, repeatedly touching, pitting or rubbing self);
abnormality not inherent in act but in frequency.
 PHENOMENOLOGY
• Mannerism-
Odd, purposeful movement (hopping or walking tip toe, or
exaggerated caricatures of mundane movements);
abnormality inherent in act itself.

• Verbigerations-
Repeatation of phrases or sentences (like a scratched record);
it does not require stimulus to occur.
 PHENOMENOLOGY

• Rigidity-
Maintenance of rigid position despite of efforts to be moved,
exclude if cogwheel or tremors present.

• Negativism-
Apparently motiveless resistance to instructions or attempt to
move/ examine patient. Contrary behavior does exact
opposite of instructions.
 PHENOMENOLOGY

• Waxy flexibility-
During reposturing of patient, patient offers initial resistance
before allowing himself to be repositioned (similar to that of
bending candle).

• Withdrawal-
Refusal to eat, drink and/ or make eye contact.
 PHENOMENOLOGY
• Impulsivity-
Patient suddenly engages in inappropriate behavior
without provocation (e.g. runs down hallway, starts
screaming or takes off clothes). Afterwards can give no or
only facile explanation.

• Automatic obedience-
Exaggerated cooperation with examiners request or
spontaneous continuation of movement requested.
Mitgehen and mitmachen are types of automatic
obedience
 PHENOMENOLOGY

• Mitgehen-
Arm raising in response to light pressure of finger, despite
instruction to the contrary.

• Gegenhalten-
Resistance to passive movement which is proportional to
strength of the stimulus, appears automatic rather than
willful.
 PHENOMENOLOGY
• Ambitendancy-
Patient appears motorically “stuck” in indecisive, hesitant
movement.

• Grasp reflex-
As per neuro exam

• Perseveration-
Repeatedly returns to same topic or persists with movement.
even after stimulus is removed.
 PHENOMENOLOGY

• Combativeness-
Usually in undirected manner with no or only facile
explanations afterwards.

• Autonomic abnormality-
Temp, BP, pulse, RR, diaphoresis.
 DSM IV
• Mutism: refusal to speak
• Immobility: lack or paucity of movement
• Stereotypes: purposeless, repetitive movements
• Negativism: active or passive refusal to follow commands
• Mannerisms: repetitive, purposeful movements
• Posturing: maintenance of bizarre postures
• Grimacing: repetitive facial posturing
• Catalepsy or Waxy Flexibility: maintenance of posture
• Echopraxia or Echolalia: repetition of words or the imitation of
actions
• Excitement: purposeless, excessive movement
 DSM IV
• 1 criterion needed for general medical
condition or substance induced catatonia
• 2 criteria for catatonia that is associated with
a psychiatric condition
ICD 10
• Only under psychotic disorders.
• NO ORGANIC CATATONIA DESCRIBED !!
CAUSES OF CATATONIA
 CAUSES OF CATATONIA
• Organic (Secondary) –
1. Neurological
2. Metabolic
3. Nutritional
4. Drug related
5. Misc

• Functional (Primary) –
1. Schizophrenia
2. Mood disease (mania commonly)
3. Other Ψ
4. OCD
5. PTSD etc
 Organic catatonia - Neurological
• Brain stem, diencephalic, basal ganglia, lesions near III
ventricle, amygdala.
• Frontal lobe, Parietal lobe ds.
• Limbic & temporal lobe ds.
• Head injury, dementia, MS, atrophy.
• Encephalitis & other infections
• Epilepsy
 Organic catatonia - Metabolic
• Periodic catatonia
• DM, in DKA
• Thyroid dysfunction
• Hepatic failure
• Renal failure
• Porphyrias
• Nutritional- Wernickes, pellagra, B12 deficiency.
 Organic catatonia – Drugs
• Neuroleptics
• Alcohol
• Opioids
• Cannabis
• Disulfiram
• SSRI, TCA
 Common organic etiologies
• CNS structural damage/ Neoplasm
• Encephalitis and other CNS infections
• Seizures or EEG with epileptiform activity
• Metabolic disturbances
• Phencyclidine exposure
• Neuroleptic exposure
• CNS lupus
• Corticosteroids
• Porphyria and other conditions
• CVA
• Wernicke's encephalopathy
• Posttraumatic
• Multiple sclerosis
• Cerebral malaria
 Comparison of Psychiatric
Catatonia vs. Organic catatonia
 PRIMARY AND SECONDARY
CATATONIA
In Primary catatonia:
1. Patient responds to painful stimuli.
2. Patient usually keeps his eyes open most of the
times.
3. Patient’s reflexes would be normal.
4. No focal neurological deficits.
5. Patient avoid self injury. (arm test)
6. Overflow incontinence seen.
7. EEG pattern is that of awake test.
8. Lorezapam injection improves or continues to be
same.
How to differentiate between depressive
and schizophrenic catatonia
?
 How to differentiate between
depressive and schizophrenic catatonia
?
Depressive catatonia: Schizophrenic catatonia:
Depressive face Vigilant face
Veraguth sign Catatonic excitement
Athanassio’s (omega sign) Schnauzkrampf (snout
Eye movements spasm)
PMA retardation Scanning
Mood state Less marked
Past history
 Rating Scale

1. Bush-Francis Catatonia Rating Scale

2. Braunig Catatonia Rating Scale
3. Modified Roger’s scale
 Bush-Francis Catatonia Rating
Scale

• Use the presence or absence of items 1 - 14

for screening.
• Use the 0 - 3 scale for items 1 -23 to rate
severity.
Examination for Catatonia
 Examination for Catatonia

PROCEDURE EXAMINES

Observe patient while trying to Activity level

engage in a conversation Movements
Speech
Examiner scratches head in Echopraxia
exaggerated manner
Attempt to reposture, instructing Waxy
patient to "keep your arm loose"-> flexibility
moves arm with alternating
lighter and heavier force.
 Examination for Catatonia

PROCEDURE EXAMINES

Take the hand of the patient as if posturing

you are examining his pulse and
leave his hand

Patient does the exact opposite of Active

what is asked to do Negativism
Patient does not carry out any Passive
orders Negativism
Extend hand stating "DO NOT Shake Ambitendency
my hand". Forced
grasping
 Examination for Catatonia

PROCEDURE EXAMINES
Reach into pocket and Automatic
state,"Stick out your tongue, I obedience
want to stick a pin in it".

Check for grasp reflex. Grasp reflex

Some patients oppose all passive Gegenhalten

movements with the same degree
of force as that of which is been
applied by the examiner.
(Asked to co-operate)
 Examination for Catatonia
PROCEDURE EXAMINES

If examiner rapidly touches the Magnet

palm and steadily withdraws his reaction
finger the patient’s hand follows
the examiners hand like an iron
following magnet.
Patients body can be put to any Mitmachen
position without any resistance
although he has been instructed
to resist all movements.
Ask patient to extend arm. Place Mitgehen
one finger beneath hand and try to (Anglepoise
raise slowly after stating, "Do NOT lamp)
let me raise your arm".
 Examination for Catatonia

• Check chart for reports of previous 24-hour

period. In particular check for oral intake, I/O
Chart, vital signs, and any incidents.

• Attempt to observe patient indirectly, at least for

a brief period, each day.

• Record findings of one week in MSE.

DIAGNOSTIC EVALUATION OF CATATONIA
 Diagnostic evaluation of catatonia

Procedure Reason:
History Organicity
Physical exam Localizing neurologic signs
Biochemical Metabolic disease
Haemogram Malaria/Nutritional status
CPK NMS
EEG Seziures
CT or MRI of head SOL
Lumbar puncture Meningitis/encephalitis
Lorezpam inj Functional improves but
……….
 D/D
• Elective mutism
• Locked-in syndrome
• Stiff-Man syndrome
• Malignant hyperthermia
• Akinetic Parkinsonism
• Manic excitement
 Treatment of Catatonia
 LORAZEPAM.
Intravenous/intramuscularly
4 to 8 mg/day ,
3 to 5 days,
To be tapered.

 ELECTROCONVULSIVE THERAPY

 ANTIPSYCHOTICS

 ANTIDEPRESSANTS

 THYROID EXTRACTS
 Lethal Catatonia
• A severe form of Catatonia.

EARLY SIGNS –
• Increasing mental and physical agitation.
• Progresses to wild agitation and chorea which can
alternate with rigidity, stupor, mutism and refusal of
food / fluids.
OTHERS:
• Fever, hypotension and diaphoresis.
(which are similar to NMS)

SEVERE END STAGE CASES

• Convulsions, delirium, coma and even death.
DISTINCTION BETWEEN NMS & LETHAL CATATONIA

• Lethal Catatonia usually has a longer prodrome

of days to weeks.
• NMS also has the abnormal laboratory values.

• Treatment:
 Supportive care.
 ECT.
 Restarting or increase in antipsychotic dose.
 Short term use of lorazepam.
 TAKE HOME MESSAGE
 Despite low incidence,
catatonia is a serious
diagnostic and treatment
challenge.

 After the main causes of

secondary catatonia
have been ruled out,
primary catatonia should
be considered.

 If a trial of lorazepam
fails, ECT should be used.
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