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Catatonia

Practice Essentials

Catatonia is a state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake.
There are 3 types: (1) catatonia associated with another mental disorder (catatonia specifier), (2) catatonic disorder due to another medical condition, and (3) unspecified catatonia.

Signs and symptoms

Catatonia can be acute and occur in severely ill patients with underlying psychiatric or other medical disorders.
Individuals with catatonia often cannot provide a coherent history; however, collateral sources are crucial sources of relevant historical information. Thorough review of old records is needed to figure out possible causes of the behaviors of people with catatonia. A history of behavioral responses to others usually includes the presence of the following:

Mutism (absence of speech)

Negativism (performing actions contrary to the commands of the examiner)

Echopraxia (repeating the movements of others)

Echolalia (repeating the words of others)

Waxy flexibility (slight, even resistance to positioning by examiner)

Withdrawal (absence of responses to the environment)

The alternative presentation of catatonia is an excited state, possibly with impulsivity, combativeness, and autonomic instability.

The history should inquire into the following:

Possible precipitating events, including infection, trauma, and exposure to toxins and other substances

Previous similar episodes of catatonia

Exposure to neuroleptics and other substances associated with catatonia

Comorbid disorders, including schizophrenia, mood disorders, psychological stressors, medical conditions, and obstetric conditions

In an emergency setting, treatable common causes of catatonia must be rapidly considered and ruled out. In addition, the following must be considered:

Neuroleptic malignant syndrome (NMS)

Encephalitis

Nonconvulsive status epilepticus

Acute psychosis

Anti-NMDA receptor encephalitis

The physical examination should include evaluation of the patient for the following:

Excited and immobile states

Negativistic phenomena, such as gegenhalten (passive resistance of the patient to the active movement of the patient’s extremities by the examiner
) and mitgehen (the patient moves an extremity in the direction of a minimal push by the examiner despite the instruction to remain still and to not move
)

Automatic obedience (following all commands of the examiner including inflicting harm on self and others)

Stereotypies (eg, nose wrinkling; repetitive movements of the mouth and the jaw; repetitive eye movements; repetitive tapping of the foot, the finger, or the hand; and repetitive abdomen patting, shoulder shrugging, or body rocking)

Perseveration (the inappropriate repetition of acts)

Echophenomena (echolalia [repeating the words of others] and echopraxia [repeating the movements of others])

Inappropriate verbal usage (eg, in French, inappropriate use of vous, the formal word for “you” in place of tu, the informal word for “you.”)

Comorbid conditions (eg, schizophrenia, mood disorders, and neurologic and medical conditions)

Psychogenic movement disorders (eg, somatoform disorders, factitious disorders, and malingering)

See Presentation for more detail.

Diagnosis

Laboratory studies that may be useful include the following:

Complete blood count (CBC)

Electrolyte concentrations

Chemical analyses of blood

Fibrin D-dimer

Serum creatine kinase level

Liver function tests

Serum ceruloplasmin level

Imaging is mainly useful for ruling out other treatable disorders. Modalities that may be helpful include the following:

Magnetic resonance imaging (MRI)

Computed tomography (CT)

Single-photon emission CT (SPECT)

Positron emission tomography (PET) with fluorodeoxyglucose (FDG)

Electroencephalography (EEG) is indicated to rule out a seizure disorder, a space-occupying lesion, and generalized abnormalities.

See Workup for more detail.

Management

Prompt treatment in the early phases of catatonic states is crucial to obtaining a lasting abatement of symptoms. Treatable conditions must be identified immediately.

Medications that have been used to treatment catatonia include the following:

Benzodiazepines (eg, clonazepam, lorazepam, and midazolam)

Carbamazepine

Zolpidem

Tricyclic antidepressants

Muscle relaxants

Amobarbital

Reserpine

Thyroid hormone

Lithium carbonate

Bromocriptine

Neuroleptics – Traditional neuroleptics are generally avoided; second-generation (atypical) antipsychotics should be used with caution

When nonconvulsive status epilepticus, diffuse encephalopathy, and other neurologic disorders are ruled out, electroconvulsive treatment (ECT) is indicated for patients who do not respond to pharmacotherapy within 5 days or who manifest malignant catatonia.

See Treatment and Medication for more detail.

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