Catatonia
Kristen Shirey, M.D.
Duke University Hospital
Internal Medicine and Psychiatry
Catatonia
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Common
Signs are easily identifiable
Many faces
NMS is a form of malignant catatonia
Differential diagnosis
Syndrome of motor dysregulation
Good-prognosis condition
Easy to treat
Catatonia is common
• Prevalence is estimated at 6-15% of adult
psychiatric inpatients
• Approximating incidence at 10%, catatonia
may be 2-3 times more common than
suicide in the United States
• Immobility & mutism often recognized
while whispered/robotic voice, pacing, or
other purposeless movement missed
• Rating scale has inter-rater reliability >0.90
[Norhoff et al. Movement Disorders 1999 14/3; 404-416]
Definition of catatonia
• First described by Kahlbaum in 1874 as a
specific motor dysfunction, phase of
progressive illness including stages of
mania, depression, psychosis ending in
dementia
• Includes 3 distinct categories of
symptoms: hypo/hyperkinetic, affective &
behavioral
• Excellent review by Taylor & Fink AMJP 2003;
160:1233-41
Classic signs of catatonia
• Stupor
Extreme hypoactivity, immobility,
minimally responsive to stimuli
(including pain)
• Mutism
Verbally minimally responsive
• Negativism
Involuntary/amotivational resistance,
oppositional behavior (Gegenhalten)
Additional signs
• Automatic obedience
Exaggerated cooperation with
examiner’s request; mitgehen
• Stereotypy
Repetitive, non-goal-directed motor
acitivity, echopraxia, echolalia,
verbigeration
• Catalepsy/Posturing
Maintains postures ie. pillow-sign,
waxy flexibility
Other sx
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Excitement
Staring
Grimacing
Mannerisms: odd, purposeful movements
Rigidity
Impulsivity
Ambitendency (alternating cooperation and
opposition)
• Combativeness
ProcedureBush
Examines
Observe patient while trying to engage in a conversation
Activity level
Abnormal movements
Abnormal speech
Examiner scratches head in exaggerated manner
Echopraxia
Examine arm for cogwheeling. Attempt to reposture,
instructing patient to "keep your arm loose" - move arm
with alternating lighter and heavier force.
Negativism
Waxy flexibility
Gegenhalten
Ask patient to extend arm. Place one finger beneath hand Mitgehen
and try to raise slowly after stating, "Do NOT let me raise
your arm".
Extend hand stating "Do NOT shake my hand".
Ambitendency
Reach into pocket and state,"Stick out your tongue, I
want to stick a pin in it".
Automatic obedience
Check for grasp reflex.
Grasp reflex
Check chart for reports of previous 24-hour period. In
particular check for oral intake, vital signs, and any
incidents.
Attempt to observe patient indirectly, at least for a brief
period, each day.
DSM IV => specifier of schizophrenia,
mood disorder or general medical
condition
2 out of following 5 criteria:
• Motoric immobility ( catalepsy, waxy flexibility,
stupor)
• Excessive motor activity (purposeless, not
influenced by external stimuli)
• Extreme negativism (rigid posture, resistance to
instructions, gegenhalten, mutism)
• Peculiarities of voluntary movement (grimacing,
bizarre postures, stereotyped movements)
• Echolalia or echopraxia
Fink’s proposed catatonia classification
• Diagnostic criteria:
A. Immobility, mutism or stupor
for at least 1 hour + one of
the following:
Catalepsy, automatic
obedience, posturing,
observed or elicited at least
twice
B. In the absence of immobility,
mutism or stupor, need to
observe or elicit at least twice
at least two of the following:
stereotypy, echophenomena,
catalepsy, automatic
obedience, posturing,
negativism, ambitendency
• Catatonia:
1. Non-malignant catatonia:
criteria A
2. Delirious mania (excited
catatonia): criteria B +
severe mania or excitement
3. Malignant catatonia A or B
+ fever and autonomic
instability
• Modifiers:
i. 2/2 Mood disorder
ii. 2/2 General medical
condition or toxic state
iii. 2/2 a Brain disorder
iv. 2/2 Psychotic disorder
Malignant Catatonia
• Dopamine loss, sympathetic overdrive
lead to hyperadrenergic state.
• Tachycardia, fever (hotness of body),
hypertension, diaphoresis ensue
• Increased vagal tone in the heart
stimulates mechanoreceptors, which in
turn modulate sympathetic tone ->
hypotension, bradycardia, and even
asystole…
Clinical features of MC/NMS
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Fever
Muscle rigidity
Dyskinesia
Posturing, waxy flexibility, catalepsy, mutism
Dysarthria, dysphagia, sialorrhea
Altered consciousness, may appear comatose
Autonomic instability: lability of blood pressure,
tachycardia, vasoconstriction, diaphoresis
Early signs of MC/NMS
• Mania with fever
• Any catatonic features within 24h of
antipsychotic initiation
• Autonomic instability or sialorrhea within 24 h of
antipsychotic initiation
• Rapidly developed EPS symptoms with
administration of low dose of antipsychotic
Drugs associated with
MC/NMS
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All antipsychotics
Metoclopramide
ATD combined with AP
Lithium
MAOIs
CBZ
Valproic acid
Cyclobenzaprine
Alpha-methyltyrosine
• Abrupt withdrawal from
antipsychotic
• dopamine agonists
BZD
antihistamines
anticholinergics
• Intoxication with:
disulfiram
corticosteroids
PCP, cocaine
antihistaminergics
anticholinergics
Abnormal labs in MC/NMS
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Proteinuria
Myoglobinuria
Very high CPK
High LDH
Leukocytosis (10-25k)
Thrombocytosis
Low serum iron
• Diffuse EEG slowing
• Abnormal electrolytes:
Low calcium
Low magnesium
High potassium
• Elevated LFTs:
AST, ALT,
rarely
bilirubin
Clinical risk factors for
MC/NMS
• Dehydration
• Exposure to high
temperatures
• Agitation
• Thyrotoxicosis
• Basal ganglia
disorder:
TD
akathisia
• EPS from Rx
• Past hx catatonia
• Past hx NMS
• Receiving high
potency AP or >1 AP
• IM antipsychotic
• AP + ATD or mood
stabilizers
• Recent alcohol
abuse with liver
dysfunction
Most commonly associated
with psychiatric disorders
• Bipolar and schizophrenia
• Withdrawal from dopaminergic
medications or cocaine (also implicated in
NMS)
• Withdrawal from BZD (must exclude
nonconvulsive status epilepticus)
• Medical causes (up to 16%)
Medical conditions associated with
catatonia
• Endocrinopathies: hypoparathyroidism, thyrotoxicosis,
pheochromocytoma
• Infections: viral, HIV, typhoid fever
• Tumors: esp fronto-temporal lesions
• Stroke: esp anterior brain regions
• Traumatic brain injuries: subdural hematoma
• Epilepsy: post-ictal immobility & NCSE
• Autoimmune: SLE
• Heat stroke
• Toxins: tetanus, staph., fluoride, strychnine
• Poisoning: salicylates, inhalational anesthesics
False positives
• Mutism alone is not sufficient; need at least 1
or 2 other motor symptoms
• Stupor alone is not sufficient (EEG)
• Parkinson disease, in particular akinetic
parkinsonism, OCD, tic disorder, Tourette
syndrome
• Malignant hyperthermia (rare AD genetic d/o)
• Stiff-person syndrome and locked-in
syndrome
Catatonia has a good prognosis
• No RCTs of in Rx of catatonia
• Management is well-defined
• Important to treat emergently, as catatonia
can evolve in life-threatening condition
• “When properly treated almost all episodes
of catatonia fully resolve” Fink & Taylor
• “Most likely cause of failure is … prolonged
inadequate treatment” Fink & Taylor
Treatment of catatonia
• Benzodiazepines, most studied are
lorazepam and clonazepam at high doses:
70% response within 4 days
• ECT bilateral usually 8- 15 sessions
3x/week
• Benzodiazepines suspend the symptoms;
ECT treats underlying disease
• Antipsychotics ineffective, often
detrimental
Acute management
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Hospitalization
BZD challenge
BZD treatment trial
Maintain fluid and electrolyte balance
Avoid antipsychotic agents
Avoid prolonged immobility
Identify and correct underlying
neuropsychiatric or medical cause
• If not improved in 4 days => ECT
• Tx may be augmented with NMDA
antagonists amantadine or memantine
Conclusions
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Common
Signs are easily identifiable
Many faces
NMS is a form of malignant catatonia
Differential diagnosis
Syndrome of motor dysregulation
Good-prognosis condition
Easy to treat