Catatonia

What is Catatonia?

Catatonia is a mental health condition where a person experiences abnormal movements, changes in behavior, and bouts of withdrawal. This condition is typically associated with mood disorders, but it can also appear in conjunction with psychotic, medical, neurological, and other disorders. Researchers believe that between 5% and 20% of patients in an acute psychiatric care setting could be experiencing catatonia.

An episode of catatonia might cause a person to become excessively agitated (excited), slow down significantly (retarded), or even develop life-threatening symptoms (malignant). What’s particularly tricky about this condition is that a person’s symptoms can shift or come and go. For example, a person might experience periods of withdrawal followed by periods of extreme agitation. Researchers think this shifting nature of symptoms may be due to connections between certain parts of the brain: the cortex, basal ganglia, and thalamus.

Proper identification and treatment of catatonia are critical because it can interfere with a patient’s overall psychiatric and medical treatments, make diagnoses more complicated, and in severe cases, potentially be fatal if left untreated.

How is catatonia diagnosed? Some tools and criteria help doctors identify catatonia, such as the Bush-Francis Catatonia Rating Scale and the Northoff Catatonia Scale. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), a widely-used guide in psychiatry, specifies 12 symptoms indicative of catatonia. These include stupor (a state of near-unconsciousness), catalepsy (involuntary stiffness or rigidity), mutism (not speaking), and many more. At least three of these symptoms must be present to confirm a diagnosis of catatonia.

There are common symptoms, but some specific indicators, like waxy flexibility (resistance to positioning), posturing (holding an abnormal body position), and automatic obedience (unquestioned obedience to commands), are more often associated with catatonia. It’s important to make an accurate diagnosis as symptoms can overlap with other illnesses.

What Causes Catatonia?

Catatonia, a condition that often causes unusual movements or lack of movement, confusion, and other symptoms, typically develops due to another underlying health issue. It’s common for it to be connected to mental health disorders. For example, those with mood disorders like bipolar disorder or depression may experience symptoms of catatonia. People with a psychotic disorder, like schizophrenia, might also show signs of catatonia. In fact, in the past, having symptoms of catatonia was sometimes used to help diagnose schizophrenia.

When symptoms of catatonia appear, it’s often due to a mental health issue, but numerous medical causes can lead to catatonia as well. For instance, brain-related problems like strokes, tumors, or conditions like Parkinson’s disease can lead to this condition. It can also be brought on by autoimmune disorders, certain cancers, infections, metabolic issues, and exposure to specific drugs or poisons.

With so many possible causes, it’s important to thoroughly investigate any new case of catatonia, especially when the person doesn’t have a significant history of psychiatric issues. Looking for an underlying cause can help determine the best approach to treatment.

Risk Factors and Frequency for Catatonia

Catatonia, a condition often linked with a variety of illnesses, is primarily studied among psychiatric patients. The rate of catatonia can vary significantly among different patient groups and studies.

• In general, studies have found that about 0.5% to 2.1% of all psychiatric patients experience catatonia, although some studies suggest this figure could be as high as 17.1%.
• One investigation using DSM-III-R criteria found the rate to be 24.4%.
• For patients with mood disorders, the rates are typically higher, between 13% and 27%.
• Catatonia has historically been linked with schizophrenia, and early studies from the 1910s discovered rates of 50% and 19.5%.
• Later findings indicated a rate of 16.9% amongst 990 patients studied between 1938 and 1960.
• More modern studies suggest variable rates between 10.3% and 40.2%.
• Overall, in patients with schizophrenia, the rate of catatonia has been found to be as low as 1% and as high as 50%.

Signs and Symptoms of Catatonia

Catatonia is a syndrome with various types and causes, making its symptoms widely diverse and their presentation a little tricky. Primarily linked to psychiatric disorders like depression, mania, or psychosis, catatonia symptoms often follow the worsening of one of these conditions.

A patient experiencing excited catatonia might exhibit odd behaviours like pointless actions, agitation or unusual postures. They may also repeat certain movements or copy the speech or actions of other people. On the other hand, a patient with withdrawn catatonia is more likely to be unresponsive, displaying very little speech or movement. Symptoms may be inconsistent, mixed, or change in severity throughout the course of the illness. If a medical condition triggers these symptoms, additional psychiatric symptoms like mania or psychosis might also manifest.

A physical examination is crucial in diagnosing catatonia, and it also helps distinguish it from similar conditions. Analysing the patient’s limb movements and resistance can provide key information. For instance, ‘waxy flexibility’ (when a patient’s limbs can be moved into new positions and they hold them) and ‘catalepsy’ (position against gravity) are indicative of catatonia. Stiff, uniform rigidity might point to neuroleptic malignant syndrome, whereas inconsistent rigor suggests serotonin syndrome. ‘Cogwheel rigidity’ (rigidity with regular interruptions) is associated with side effects from neuroleptic medications.

There also exists a specific assessment for catatonia called the ‘Bush Francis Catatonia Rating Scale’ which includes the following steps:

• Conversing normally with the patient to observe them.
• Scratching your own head in an exaggerated way to see if the patient mimics this.
• Passively moving the patient’s arm to check for ‘cogwheeling’.
• Applying light pressure to an extended arm and asking the patient not to allow their arm to be raised.
• Extending your hand for a handshake and instructing the patient not to shake it.
• Pretending to reach for a pin in your pocket and telling the patient you want to stick it in their tongue.
• Checking for a grasp reflex.
• Observing nutrition intake, vital signs, and any instances of restlessness.

Lastly, additional daily observations can be conducted to identify other symptoms of catatonia such as abnormal movements and speech, rigidity and other reflexes.

Testing for Catatonia

Catatonia is a condition diagnosed mainly through observation of the patient’s behavior, and it doesn’t necessarily require lab tests or imaging. However, these tests can help determine what is causing the catatonia.

For example, an EEG (electroencephalogram) is a test that checks the electrical activity in your brain. If you have catatonia due to a mental health disorder, this test might show general slowing in brain activity. The EEG can also help to show if seizures are causing the catatonia, as they can sometimes cause it too.

While an MRI or CT scan (types of imaging that create detailed pictures of the inside of your body) can’t directly show catatonia, they could reveal abnormalities in the brain that may be causing it. Similarly, imaging of the rest of the body could expose tumors that might be causing brain inflammation which can trigger catatonia.

Other tests can check for diseases or physical conditions that may lead to catatonia and can be managed. For instance, metabolic screens can check for health issues such as diabetic ketoacidosis (a serious diabetes complication), glomerulonephritis (a type of kidney disease), liver dysfunction, among others.

Additionally, tests looking for inflammatory markers and autoantibodies can help identify autoimmune causes of catatonia. It’s also important to frequently monitor vital signs like heart rate, body temperature, and breathing, as autonomic instability (problems with the automatic functions of your body, like your heart rate or blood pressure) might point to malignant catatonia. This is a severe form of catatonia, characterized by fever, high blood pressure, rapid heart rate, and rapid breathing, which can be life-threatening if not treated quickly.

In a patient with newly diagnosed catatonia, mental health causes are usually considered first. However, it’s crucial not to overlook physical causes, especially if a mental health condition doesn’t readily explain the symptoms.

Treatment Options for Catatonia

When treating catatonia, a serious condition that can cause physical immobility and behavioral abnormalities, the first step is to stop taking any medications that might be contributing to the condition. This includes drugs such as neuroleptics, steroids, stimulants, anticonvulsants, and dopamine depleters.

After this, doctors usually administer a medication called lorazepam. This is often referred to as the lorazepam “challenge”. This tricky name simply means that the doctors give the patient a dose of lorazepam to see if their symptoms improve. A significant number of patients, between 60% – 80%, see some improvement in symptoms within 15 to 30 minutes after taking the medication.

If this medication works, it can then be scheduled for regular doses, often three times a day. The exact dosage can be adjusted as necessary until the symptoms are under control. Interestingly, patients suffering from catatonia do not become sleepy or drowsy as might be expected with this medication. Instead, once the correct dosage is found, they become alert and interactive.

While the lorazepam is being used to manage the symptoms, it’s also important to treat the underlying cause of catatonia. The dose of lorazepam can then be slowly lowered over time. If it’s reduced too quickly, catatonia symptoms might return. For some patients, it can take months to gradually reduce the dosage. If a patient becomes sedated, it’s usually a sign that the dose can be further reduced.

If catatonia symptoms do not improve after about a week of using lorazepam, and treating the underlying cause hasn’t brought any improvements, another treatment option is electroconvulsive therapy (ECT). ECT is also recommended for severe cases of catatonia. It often used in combination with lorazepam.

What else can Catatonia be?

Different medical conditions might seem very similar but are distinct. Here’s a list of conditions that could possibly be confused with each other due to their similar symptoms:

• Anterior circulation stroke
• Cardioembolic stroke
• Central pontine myelinolysis
• Cerebral venous thrombosis
• Complex partial seizures
• Lewy body dementia
• Fibromuscular dysplasia
• Glioblastoma multiforme
• Vascular surgery for atrioventricular malformations

These terms might sound complex, but these are just different types of health conditions that doctors have to consider in their diagnosis process. Differentiating amongst these and arriving at the correct diagnosis is essential for prescribing effective treatment.

What to expect with Catatonia

Catatonia, a type of mental health condition, tends to react positively to a specific treatment using a medication called lorazepam. This means that the outcome or future health status for patients with catatonia is usually good. Research indicates that up to 80% of patients improve after being given lorazepam.

Possible Complications When Diagnosed with Catatonia

People experiencing an excited stage may display violent behavior or become involved in incidents causing physical harm. They may also experience unstable automatic processes within the body such as heart rate, digestion, and respiratory rate.

Some people may refuse to eat, which can lead to dehydration. Complications like pneumonia, a severe lung infection, and neuroleptic malignant syndrome, a potentially deadly reaction to antipsychotic drugs, can also develop. Furthermore, there’s a risk of developing deep vein thrombosis (DVT), a blood clot in a deep vein, and pulmonary embolism, a potentially life-threatening condition where a blockage occurs in the lung’s main artery.

Other possible issues include the development of pressure ulcers, which are wounds that develop due to prolonged pressure on the skin, and muscle contractions.

• Engage in violent acts or suffer trauma
• Have unstable bodily functions
• Refuse to eat
• Experience dehydration
• Develop pneumonia
• Develop neuroleptic malignant syndrome
• Deep vein thrombosis (DVT) and pulmonary embolism risks
• Develop pressure ulcers
• Experience muscle contractions

Preventing Catatonia

It’s important to teach family members and friends how to recognize the early signs of a mental health condition called catatonia. This early detection can help prevent further complications related to this condition. The quicker unusual or abnormal behavior is noticed, the sooner treatment can start. This early treatment can greatly reduce the overall sickness and health disruption the patient may experience.