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Catatonia Clinical Presentation

  • Author: James Robert Brasic, MD, MPH; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Jul 09, 2015
 

History

Catatonia is a syndrome—typically episodic, with periods of remission—characterized by the presence of a variety of behavioral and motoric traits. Accurate, prompt diagnosis of catatonia is crucial for preventing morbidity and death in a variety of settings (including emergency medical, psychiatric, neurologic, medical, obstetric, and surgical ones) and for instituting effective interventions.

Individuals with catatonia often cannot provide a coherent history; however, collateral sources can often relate relevant historical information. Family members can confirm the presence of typical primary features of catatonia, including immobility, stupor, posturing, rigidity, staring, grimacing, and withdrawal.

A history of behavioral responses to others usually includes the presence of the following:

  • Mutism
  • Negativism
  • Echopraxia
  • Echolalia
  • Waxy flexibility
  • Withdrawal

A history of stereotypies, mannerisms, and verbigeration is often elicited from people who are close to the patient. Priapism was reported in a 20-year-old man with paranoid schizophrenia and catatonia.[48]

The alternative presentation of catatonia is an excited state, possibly with impulsivity, combativeness, and autonomic instability. A history of an excited state should be sought from the family of a person with catatonia, but it is often denied by the family. When excited episodes are present, they are typically short-lived and may precipitate collapse with exhaustion. An excited state of catatonia is usually associated with bipolar disorder.

The history-taking process should include the following:

  • During the initial interview of the patient and the family, ask about possible precipitating events, including infection, trauma, and exposure to toxins and other substances
  • Inquire about any previous similar episodes of catatonia; determine whether the precipitating events of the earlier episode are present in the current episode, and record any interventions that relieved catatonia previously
  • Question the patient and family regarding exposure to neuroleptics and other substances associated with catatonia; catatonia and neuroleptic malignant syndrome (NMS) [15] may follow the administration of neuroleptic medications
  • Identify any comorbid disorders, including schizophrenia, mood disorders, psychological stressors, medical conditions, and obstetric conditions

Catatonia has occurred in patients after treatment with levetiracetam[49] and levofloxacin.[50] Catatonia developed in a 55-year-old woman with schizophrenia who was treated with rimonabant, a cannabinoid receptor (CB1) antagonist.[51]

Emergency settings

In an emergency setting, treatable common causes of catatonia must be rapidly considered and ruled out. The emergency physician must quickly consider the presence of NMS,[15] encephalitis, nonconvulsive status epilepticus, and acute psychosis. Catatonia has occurred in intensive care units (ICUs).[52] Given that the patients all had serious disorders leading to ICU placement, it is possible that the underlying disorders contributed to the development of catatonia in the units.

A history of exposure to traditional and atypical neuroleptic agents must be sought. Although NMS often follows the initiation of neuroleptic therapy or an increase in the neuroleptic dosage, exposure to neuroleptics may be minimal in some susceptible individuals. For example, Nielsen and Nielsen report the occurrence of NMS after a single dose of neuroleptic medication.[28]

In addition, the patient’s history must be evaluated for the following conditions:

  • Encephalitis - Determine whether the patient has had sudden onset of headache, fever, and deterioration in mental functioning
  • Nonconvulsive status epilepticus - Determine whether the patient has a history of seizures and whether the patient has been prescribed antiepileptic drugs; determine whether electroencephalography (EEG) has been performed, and if it has, review the findings
  • Acute psychosis - Determine whether the patient has exhibited evidence of delusions and hallucinations and whether he or she has exhibited suicidal or homicidal threats or actions; record any history of prior psychiatric hospitalization and treatment
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Physical Examination

Assessment of a person with possible catatonia should include unstructured, indirect observation, as well as a direct interview. Patients with catatonia exhibit the same general behaviors whether or not the examiner is present. If a patient demonstrates behaviors consistent with catatonia only in the presence of the examiner, then catatonia is unlikely.

Because patients with catatonia may be unable to cooperate with the requests of the examiner, specific neurologic signs characteristic of catatonia must be quickly elicited, especially in emergency settings. In particular, rigidity, gegenhalten, and a grasp reflex are readily apparent signs of catatonia in such settings. During the physical examination, it is also important to test for the presence of a grasp reflex, a secondary feature of catatonia.

Excited and immobile states

The predominant activity level is either markedly slow or extremely high, and the patient’s behavior may shift suddenly and unpredictably from one state to the other.

In the excited state, people with catatonia may injure themselves and assault others. They may also experience autonomic instability manifested by hyperthermia, tachycardia, and hypertension. Individuals in the excited state are at risk for collapse from exhaustion.

In the immobile state, the individual may not move. Akinesia and stupor are synonyms for this state. The patient may appear unresponsive to external stimuli. He or she may be unable to eat and therefore may die unless parenteral nutrition and fluids are administered. People with catatonia may exhibit catalepsy, the persistent maintenance of spontaneous or imposed postures.

Negativistic phenomena

Negativistic phenomena (eg, gegenhalten [“to hold against” in German; the apparent resistance of the movement of the extremities by the examiner], and mitgehen [“to go along with” in German; movement in the direction of a slight push from the examiner in spite of the command to remain still]) are typically observed in catatonia.

Examination should include checking for cogwheeling at the wrist and elbow. Patients should be instructed to keep their arms loose and limp (like a dead fish), and the arms should be moved with varying degrees of force. Rigidity is commonly elicited in the extremities of patients with catatonia.

The particular phenomenon of gegenhalten is characteristic. Patients with gegenhalten demonstrate increasing resistance to passive movement of the limbs. The patient appears to be deliberately opposing the movements of the examiner. Mitgehen is characterized by the patient moving in the direction of a slight push from the examiner in spite of the command to remain still. The physical examination should include tests for these.

Motor persistence (ie, maintenance of a posture when commanded not to maintain it) is a manifestation of catatonia that is associated with right hemispheric strokes. Other negativistic phenomena are withdrawal from all usual activities and refusal to eat.

Automatic obedience

In addition to negativistic phenomena, individuals with catatonia may display other behaviors, indicating inability to appropriately modulate the inhibition of impulses. For example, patients with catatonia may demonstrate automatic obedience, meaning the performance of tasks at the command of the examiner even though the tasks are inappropriate or dangerous.

Stereotypies

Peculiarities of movement are common in catatonia. Stereotypies, in which the patient repetitively performs apparently meaningless activities, are common. These may take the form of repetitive actions or sounds. Verbigeration (verbal stereotypies) refers to the presence of repetitive, apparently meaningless utterances, such as sniffing, clicking, snorting, and nonmeaningful sounds.

Common motor stereotypies include the following:

  • Nose wrinkling
  • Repetitive movements of the mouth and the jaw
  • Repetitive eye movements
  • Repetitive tapping of the foot, the finger, or the hand
  • Repetitive abdomen patting, shoulder shrugging, or body rocking

Other movements associated with catatonia include mannerisms, postures, gaze fixation, and choreoathetoid movements of the trunk and extremities.

Preservation

Patients with catatonia may also display preservation (ie, the inappropriate repetition of acts).

Echophenomena

Echophenomena are typical in catatonia. Echolalia (repetition of the words spoken by the examiner) and echopraxia (repetition of the motor acts performed by the examiner) are common.

Verbal findings

In France, the inappropriately formal use of vous (the formal form of “you”) by the patient to address his or her spouse has been identified as a finding in catatonia. Normally, tu (the informal form of “you”) is used by an individual to address a spouse.

Comorbid conditions

Clinicians must identify comorbid disorders, including schizophrenia, mood disorders, and neurologic and medical conditions. Neuroleptic-induced parkinsonism may also be associated with catatonia. Headache, fever, and a stiff neck in an acutely ill patient suggest encephalitis. The presence of severe muscle rigidity, autonomic dysregulation, and hyperthermia suggests NMS. Acute psychosis is suggested by the presence of hallucinations, delusions, and suicidal and homicidal threats and behaviors.

Psychogenic movement disorders

Patients with catatonia exhibit the same general behaviors whether or not the examiner is present. If a patient demonstrates behaviors consistent with catatonia only in the presence of the examiner, then catatonia is unlikely, and conditions characterized by the presence of medical symptoms and signs without physical illness must be considered.

More specifically, catatonia that occurs only when the patient is directly observed by the examiner suggests the presence of somatoform disorders, factitious disorders, or malingering. In the movement disorders literature, somatoform disorders, factitious disorders, and malingering in patients exhibiting abnormal movements are commonly classified as psychogenic movement disorders.

Patients with somatoform disorders (eg, somatization disorder, conversion disorder, and hypochondriasis) report symptoms and signs that they truly believe they have, despite the absence of confirmation on physical examination. Patients with factitious disorders and malingering deliberately report symptoms and signs that they know to be false.

Patients with Munchausen syndrome and other factitious disorders fabricate symptoms and signs because they want to be patients. In Munchausen syndrome by proxy, the parents of the patient (who is typically an infant unable to communicate) fabricate symptoms and signs in the patient.

Unlike patients with factitious disorders, patients with malingering deliberately report false symptoms and signs for specific gain—for example, to obtain disability benefits and to be excused from work.

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Complications

The following complications are associated with catatonia:

  • Trauma - During an excited state, patients with catatonia may cause serious, even fatal, injuries to themselves and others; they may cause marked destruction of property
  • Refusal to eat - Patients with catatonia may refuse to eat; death may result unless parenteral nutrition and fluids are administered on an involuntary basis
  • Autonomic instability - Patients with catatonia may experience autonomic instability manifested by hyperthermia, hypertension, and tachycardia; medical intervention is required
  • NMS - If this condition occurs, medical consultation is appropriate
  • Pulmonary embolism – The risk of fatal pulmonary embolism is increased in catatonia; to prevent thromboembolic disease, fibrin D-dimer levels should be checked; if evidence of early coagulation activation is found, hematologic consultation is appropriate [46]
  • Other - Patients with catatonia are at risk of complications from the underlying neurologic, psychiatric, medical, and obstetric causes of catatonia
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Contributor Information and Disclosures
Author

James Robert Brasic, MD, MPH Assistant Professor, Russell H Morgan Department of Radiology and Radiological Science, Division of Nuclear Medicine, Johns Hopkins University School of Medicine; Active Staff, Department of Radiology and Radiological Science, Division of Nuclear Medicine, Johns Hopkins Hospital; Courtesy Staff, Department of Radiology, Johns Hopkins Bayview Medical Center

James Robert Brasic, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Received royalty from Medscape for other; Received royalty from Neuroscience-Net, LLC for other; Received grant/research funds from National Institutes of Health for other.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Acknowledgements

Nestor Galvez-Jimenez, MD, MSc, MHA Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida

Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The research for this article was supported by the Essel Foundation; the National Alliance for Research on Schizophrenia and Depression (NARSAD); the Tourette Syndrome Association, Inc; the National Institutes of Health; and the Department of Psychiatry of Bellevue Hospital Center and the New York University School of Medicine, New York, New York. The cooperation of the Health and Hospitals Corporation of the City of New York is gratefully acknowledged.

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  85. Rhoads JC, Votolato NA, Young JL, Gilchrist RH. The successful use of right unilateral ultra-brief pulse electroconvulsive therapy in an adolescent with catatonia. Brain Stimulation. 2009.

  86. Nomoto H, Hatta K, Usui C, Ito M, Kita Y, Arai H. Vitamin K deficiency due to prolongation of antibiotic treatment and decrease in food intake in a catatonia patient. Psychosomatics. 2011 Sep-Oct. 52(5):486-7. [Medline].

 
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Table. Causes of Catatonia by Category
Category Causes
Neurologic conditions Neuroleptic malignant syndrome[15]



Administration of agents that block postsynaptic dopamine receptors*



Administration of sibutramine[16] (withdrawn from US market October 8, 2010)



Withdrawal of lorazepam and other sedatives



Akinetic-rigid syndrome



Arachnoid cyst in right parietal region



Astrocytoma



Atrophy of left amygdala[17]



Autistic disorder[6, 7, 8, 18, 19, 20, 21, 22, 23]



Basilar artery thrombosis



Bilateral hemorrhagic lesions of temporal lobes



Cerebellar catalepsy



Cerebral hemorrhage



Cerebral infarct



Cerebrovascular disease



Cortical venous thrombosis



Central pontine myelinolysis



Cortical basal ganglionic degeneration



Dystonia



Encephalitis (herpesvirus, Trypanosoma cruzi)



Encephalopathy (Borrelia burgdorferi, HIV infection, Wernicke encephalopathy)



Familial fatal insomnia[24]



Fibromuscular dysplasia with dissection of basilar artery



Frontal lobotomy



Head injury



Huntington disease



Hydrocephalus



Hypopituitarism secondary to postpartum hemorrhage



Idiopathic recurring stupor



Inherited neurometabolic disorders



Locked-in syndrome



Meningitis, tuberculous



Meningoencephalitis



Multiple sclerosis[25, 26]



Neurosyphilis



Nonconvulsive status epilepticus



Pervasive developmental disorders[7, 8, 22]



Pallidoluysian atrophy



Paraneoplastic encephalitis[27]



Parkinsonism



Postencephalitic parkinsonism



Progressive multifocal leukoencephalopathy



Progressive supranuclear palsy



Schizencephaly



Seizures (complex with partial symptomatology)



Stiff-man syndrome



Stroke



Stupor



Subarachnoid hemorrhage



Subdural hematoma



Substance intoxication (alcohol, disulfiram, organic fluorides, phencyclidine)



Subthalamic mesencephalic tumor



Surgical removal of cerebellar tumor



Tay-Sachs disease



Temporal lobe epilepsy



Tuberous sclerosis



Tumors (corpus callosum, glioma of third ventricle, supraventricular diffuse pinealoma)



Vegetative state



Von Economo (lethargic) encephalitis



Wilson disease



Psychiatric conditions Acute stress disorder



Anorexia nervosa



Autistic disorder[6]



Brief reactive psychosis with catatonia



Conversion disorder



Hysteria



Major depression, single episode with catatonic features



Mood disorders



Neuroleptic malignant syndrome[15]



Posttraumatic stress disorder



Schizophrenia



Substance intoxication (3,4-methylenedioxymethamphetamine [“ecstasy”], alcohol, amphetamine, phencyclidine, substance withdrawal, hypnotic-sedative, lorazepam)



Psychological factors Immigration



Experiencing rejection of an expression of love



Feelings of alienation in an unfamiliar country



Medical conditions AIDS



Acute intermittent porphyria



Addison disease



Bacterial septicemia



Bronchorrhea



Carcinoid tumors



Diabetic ketoacidosis



Encephalopathy (hepatic, HIV infection, Wernicke encephalopathy)



Fever of unknown cause



Heat stroke



Hepatic failure



Hereditary coproporphyria



Homocystinuria



Hypercalcemia



Hyperparathyroidism



Hyperthyroidism



Hyponatremia



Hypothermia



Intestinal atony



Malaria



Neuroleptic malignant syndrome[15]



Poisoning (carbon monoxide, tetraethyl lead)



Renal failure



Substance intoxication (alcohol, cyclosporine, disulfiram, organic fluorides, phencyclidine)



Syndrome of inappropriate antidiuretic hormone (SIADH)



Syphilis



Systemic lupus erythematosus



Thermal injury



Thrombotic thrombocytopenic purpura



Tuberculosis



Typhoid fever



Uremia



Von Economo (lethargic) encephalitis



Obstetric conditions Hypopituitarism secondary to postpartum hemorrhage
*Administration of agents that block postsynaptic dopamine receptors is associated with the onset of catatonia in some individuals.
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