catatonia

Introduction

A syndrome of psychomotor disturbances, first described in 1874 by Ludwig Karl Kahlbaum.

Etiology

(associated disorders)

• schizophrenia
• mood disorders, including major depression
• organic mental disorders, including dementia

Genetics

• missense mutation in WKL1 on chromosome 22q13.33, encoding a non-selective cation channel is associated with autosomal dominant form of catatonic schizophrenia

Clinical manifestations

• acute onset
• natural course of catatonia
  • single episode with recovery
  • chronic, deteriorating, dementia
  • episodic
  • death, infections, institutionalization
  • episodic, to chronic, dementia
• hypomobility
  • waxy flexibility
    • limbs maintain position imposed by examiner
  • negativism, resistance to examiner's efforts to move the patient
  • generally no true rigidity, except that of voluntary resistance
• resembling, but generally different from stupor
  • patients may appear awake, with eyes open, but make no voluntary or responsive movements
  • they make blink spontaneously
  • patients may have some memory of events during episodes of catatonic stupor
• fever may accompany a lethal form of catatonia
• also see -> motor features of catatonia, DSM IV & ICD-10
• forms of catatonia (classification)
  • excited catatonia:
    • excited, impulsive, hyperactive, combative
  • periodic catatonia:
    • regularly recurring episodes of excited catatonia
  • stuporous catatonia:
    • subdued, mute, negativistic, staring, rigidity, cataplexy

Complications

• pulmonary embolism
• physical restraint
• pneumonia
• labeling as advanced dementia
• inappropriate Do Not Resuscitate Orders
• death

Differential diagnosis

• akinetic mutism
• abulia
• neuroleptic malignant syndrome (febrile catatonia)
• schizophrenia
• advanced dementia -> paratonia
• Parkinson's disease

Management

• electroconvulsive therapy (ECT)
  • improves immediate signs of catatonia
  • improves underlying depression or psychosis
  • may be no better than other treatments after onset of negative symptoms
• pharmaceutical agents
  • benzodiazepines
    • improves immediate signs of catatonia
    • may not relieve underlying psychosis
    • lorazepam 6-16 mg/day for 3-5 days
  • clozapine, may be used in conjunction with ECT
  • carbamazepine is suggested to be useful
  • valproic acid
    • 4 g/day IV (initially)
    • taper & maintain on oral dose of 1 g/day
  • risperidone, acute & maintenance therapy [7, 9]
  • barbiturates (amobarbital)
• prognosis:
  • response is favorable, unless associated with disorganized schizophrenia

More general terms

• sign/symptom
• syndrome

Additional terms

• motor features of catatonia, DSM IV & ICD-10