What is Catatonic Schizophrenia?
Schizophrenia used to be broken down into five different types, which included disorganized schizophrenia, paranoid schizophrenia, leftover schizophrenia, unclassified schizophrenia, and catatonic schizophrenia, according to a guide called the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). However, in 2013, the American Psychiatric Association (APA) decided to group all these types together under the general label of schizophrenia. “Catatonia” has been defined in various ways over time, and generally refers to abnormal behaviors or movements.
Medical professionals like Kahlbaum and Kraepelin first identified features of catatonia, such as confusion and stiff, unresponsive behavior, in the 1800s. They realized that these symptoms were part of a bigger set of unusual mental and physical behaviors, which they labeled as “catatonia”. Catatonia can even be part of other mental conditions, like schizophrenia and bipolar disorder, or physical illnesses.
In 2013, with the introduction of a new version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), catatonia was recognized as a condition separate from schizophrenia, with three different types: akinetic (unresponsive), hyperkinetic (overactive), and malignant (dangerous) catatonia.
What Causes Catatonic Schizophrenia?
Catatonia, a disorder characterized by abnormal movements and behaviors, can be caused by a number of factors. One theory suggests that when specific messengers in the brain – known as GABA (gamma-aminobutyric acid) neurotransmitters – that regulate our emotional and cognitive functions get disrupted, it can lead to symptoms of catatonia. GABA neurotransmitters help our brain function properly, and any disruption can affect our emotions and cognition.
According to this theory, strong negative emotions can lead to what’s called “tonic immobility,” resulting in a lack of control in a part of the brain called the orbitofrontal cortex (OFC). This can affect the balance between two other parts of the brain: the ventromedial prefrontal cortex (VMPFC) and the dorsolateral prefrontal cortex (DLPFC), which in turn may lead to symptoms of catatonia. To put it simply, these parts of the brain help us process and understand negative emotions, and any imbalance can lead to symptoms of catatonia.
Risk Factors and Frequency for Catatonic Schizophrenia
Catatonic schizophrenia is a complex mental illness and can show up in different ways. Roughly 10% of people in mental health care facilities exhibit catatonic symptoms. Years ago, the medical field strongly linked schizophrenia with catatonia, but modern studies tell a slightly different story. They indicate that only 20% of patients with catatonia have schizophrenia. Many, about 45%, actually have symptoms of mood disorders and other medical illnesses.
- About 10% of people being treated at mental health hospitals show signs of catatonia.
- Previously, schizophrenia was closely linked with catatonia.
- Modern research shows that only 20% of patients with catatonia also have schizophrenia.
- Around 45% of catatonic patients have symptoms tied to mood disorders and other medical conditions.
- One recent study showed that 7.6% of people diagnosed with schizophrenia also display catatonic symptoms.
- Other research indicates 10% to 25% of inpatient schizophrenia patients can be classified as catatonic schizophrenia, especially when specific diagnostic tools are used.
- This can be present in any stage of schizophrenia – from first diagnosis to those with lifelong schizophrenia history and multiple episodes.
Signs and Symptoms of Catatonic Schizophrenia
Catatonia is a condition that impacts a person’s ability to move in a normal way and also affects their mood and thoughts. People with this condition can have many different symptoms. The official guide used for diagnosing mental disorders, the Diagnostic and Statistical Manual V, says that coping with catatonia, a person should show at least three of the following symptoms:
- Catalepsy – a condition where a person holds a posture against gravity
- Waxy flexibility – a person resists attempts to change their position
- Stupor – lack of activity and lack of response to the environment
- Agitation – restlessness that’s not related to external triggers
- Mutism – little or no verbal response (not applicable if the person has a known speech issue)
- Negativism – a person resists or does not respond to external stimuli
- Posturing – a person maintains a position against gravity
- Mannerisms – a person displays strange exaggerations of normal actions
- Stereotypies – a person shows repetitive, strangely frequent, non-purposeful movements
- Grimacing
- Echolalia – a person mimics another’s speech
- Echopraxia – a person copies another’s movements
A researcher named Walter classified these symptoms into four main types: immobility, negativism, instability in automatic body processes like heart rate or body temperature, and inability to stop certain motor functions like repetitive movements or echoing speech.
To diagnose catatonia in someone with schizophrenia, healthcare providers should take a full mental health history, seek information from people who know the person well, and do a detailed examination of the person’s nervous system. They should pay careful attention to when symptoms started and how long they’ve been present.
Testing for Catatonic Schizophrenia
If doctors suspect you have catatonia (a condition that affects your ability to move and behave normally), they may use neuroimaging. Neuroimaging is a technique that allows doctors to look at how the brain is working. The focus is specifically on the motor regions in the front (frontal cortex) and side (parietal cortex) parts of the brain. These areas are involved in movement and have been shown to function less effectively in patients with catatonia.
Additionally, doctors might need to run some blood tests, such as blood count and serum iron tests. Sometimes, if your catatonia is severe, they might even need to perform a lumbar puncture (a procedure where a needle is used to extract fluid from the lower part of your spine) to check for autoimmune antibodies.
A tool called the Bush Francis Catatonia Rating Scale (BCFRS) is often used to check for catatonia symptoms. This scale has 23 items. The first 14 are used for screening, and you need to show at least two of these 14 items for a positive diagnosis. These items cover a range of behaviors, like excitement, immobility, staring, strange postures, repeatable movements, mimicking other people’s words or actions, withdrawal, and rigidity, among others.
In some cases, a “benzodiazepine challenge” may be used to confirm a catatonia diagnosis. A benzodiazepine is a type of medicine which can rapidly relieve catatonia symptoms in some patients. Doctors often give a dose of a benzodiazepine called lorazepam to the patient, and then see if there’s a significant reduction in their symptoms. This test can lead to a 60% change in symptom display, making it easier to reach a diagnosis.
Treatment Options for Catatonic Schizophrenia
The first step in managing catatonia in patients with schizophrenia involves ensuring their basic needs are met. This can include providing IV fluids to keep them hydrated and potentially inserting nasogastric tubes to help with their nutrition. Why? Because people suffering from catatonia can become dehydrated or malnourished, and are susceptible to conditions such as pneumonia.
If a patient is already taking medications for psychosis, these should be stopped because they may be contributing to their catatonia.
The core treatment of catatonia in schizophrenia involves benzodiazepines, which are a type of tranquilizer. Studies have shown that these medications can reduce catatonia symptoms significantly. For example, one study found a 60% reduction in catatonia symptoms after treatment with a benzodiazepine called lorazepam.
Another study involving 107 people found that two-thirds of the participants responded well to treatment with lorazepam, although only a third achieved remission. In other words, although their symptoms improved, they weren’t completely free of catatonia.
When benzodiazepines don’t work or aren’t enough, the next step is Electroconvulsive Therapy (ECT). This is a procedure in which small electric currents are passed through the brain to trigger a brief seizure. This is also the preferred treatment for severe or rapidly progressing catatonia, which can seriously disrupt bodily functions.
Lastly, various other types of medications have also been studied for treating catatonia in schizophrenia. Although they might show some promising results, more research is needed to determine their effectiveness. For example, a group of medications called anti-NMDA agents and the mood-stabilizing drug lithium have shown some effect in particular cases, yet further clinical studies are required to verify their efficacy specifically for catatonic schizophrenia.
What else can Catatonic Schizophrenia be?
The following conditions may be similar and potentially misdiagnosed. They include:
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Malignant hyperthermia
- Akinetic mutism
- Epilepsy, specifically nonconvulsive status epilepticus
- Locked-in syndrome
- Stiff-person syndrome
- Parkinson’s disease
- Stroke
- Delirium
- Dementia
- Elective mutism
- Encephalitis
What to expect with Catatonic Schizophrenia
Catatonia, a complex syndrome that affects movement and behavior, can have a good prognosis if caught and treated early. It can have a better outlook if it’s linked to mood or anxiety disorders rather than schizophrenia.
Schizophrenia that presents with catatonia tends to have a less favorable prognosis. Research conducted on using lorazepam, a medication commonly used to treat anxiety, has shown limited success when used specifically for catatonic schizophrenia.
A particular study observed the effects of lorazepam on patients with catatonic schizophrenia and others with catatonia due to other conditions. This research showed that those with catatonic schizophrenia only partially improved, while others showed full improvement.
Electroconvulsive therapy (ECT) is often suggested when catatonia doesn’t react to medicines like benzodiazepines (drugs used to treat anxiety and insomnia). However, to date, research suggests that catatonic schizophrenia responds less effectively to ECT compared to catatonia related to mood disorders. Several theories argue that catatonic schizophrenia behaves differently, leading to it not responding as well to benzodiazepines and ECT.
A group led by Gabor S.Ungvari has been studying the physical symptoms, including repetitive behaviors and changes in posture, seen in patients with long-term schizophrenia. They noticed that these symptoms are often undiagnosed and untreated. Patients with these symptoms tend to have a poorer outlook.
This group has explored catatonic schizophrenia through four main types of motor symptoms: negative/withdrawn phenomena (lack of emotional expression), automatic phenomena (unconscious, automatic movements), repetitive phenomena (repetitive, involuntary movements), and agitated phenomena (restlessness). They found links between sex, younger age, Parkinson-like symptoms, and negative symptoms of schizophrenia with catatonia.
The group emphasizes recognizing catatonia within both acute (short-term) and chronic (long-term) schizophrenia, focusing particularly on the presence of physical symptoms.
Possible Complications When Diagnosed with Catatonic Schizophrenia
Acute catatonia is a condition that can be caused by medical or neurological illnesses. As such, it requires immediate monitoring and treatment. This could include noting vital signs and administering treatments like intravenous fluids and using a nasogastric tube, which goes through the nose into the stomach. If not managed properly, there can be significant issues like aspiration pneumonia (a lung infection), dehydration, embolisms (a blocked blood vessel), pressure ulcers (bed sores), and malnutrition, all of which can be life-threatening.
Potential Risks of Acute Catatonia:
- Aspiration Pneumonia
- Dehydration
- Embolisms
- Pressure Ulcers
- Malnutrition
- Potentially life-threatening outcomes
Preventing Catatonic Schizophrenia
The key to managing schizophrenia effectively is to catch it early and start treatment as soon as possible. When we talk about schizophrenia, we usually focus more on the clearly visible symptoms, like hallucinations, and less on the less obvious ones. There’s a type of schizophrenia called catatonic schizophrenia, which only affects a small number of people with the condition. But this form is often more severe, making it critical for individuals and their families to be aware of it.
Catatonic schizophrenia can be identified by repetitive, purposeless movements, known as stereotypy; strange, mechanical-like behavior called automated mannerisms; and periods where the individual doesn’t move or speak at all, known as immobility. Being able to identify the signs of catatonic schizophrenia can help patients and their families better respond to the disorder and help patients get the treatment they need as soon as possible.
