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:
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Mutism (absence of speech)
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Negativism (performing actions contrary to the commands of the examiner)
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Echopraxia (repeating the movements of others)
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Echolalia (repeating the words of others)
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Waxy flexibility (maintaining the physical positions placed on the body of patient by the examiner)
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Withdrawal (absence of responses to the environment)
A history of stereotypies, mannerisms, and verbigeration (uttering gibberish) 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. [63]
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:
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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
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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
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Question the patient and family regarding exposure to neuroleptics and other substances associated with catatonia; catatonia and neuroleptic malignant syndrome (NMS) [27] may follow the administration of neuroleptic medications
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Identify any comorbid disorders, including schizophrenia, mood disorders, psychological stressors, medical conditions, and obstetric conditions
Catatonia has occurred in patients after treatment with levetiracetam [64] and levofloxacin. [65] Catatonia developed in a 55-year-old woman with schizophrenia who was treated with rimonabant, a cannabinoid receptor (CB1) antagonist. [66]
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 neuroleptic malignant syndrome (NMS), [27] encephalitis, including anti-NMDA receptor encephalitis, [4] nonconvulsive status epilepticus, and acute psychosis. Catatonia has occurred in intensive care units (ICUs). [67] 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. [40]
In addition, the patient’s history must be evaluated for the following conditions:
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Encephalitis - Determine whether the patient has had sudden onset of headache, fever, and deterioration in mental functioning
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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
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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
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 (passive resistance of the patient to the active movement of the patient's extremities by the examiner [5] ), 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.
Commonly observed signs in catatonia include the following:
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Immobility (hypokinesis or akinesis)
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Mutism (absence of speech)
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Stupor (decreased alertness and response to stimuli)
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Negativism (resistance to all instructions or all attempts to be moved)
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Waxy flexibility (slight, even resistance to positioning by examiner)
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Posturing
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Excitement (excessive, purposeless motor activity)
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Staring
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:
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Nose wrinkling
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Repetitive movements of the mouth and the jaw
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Repetitive eye movements
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Repetitive tapping of the foot, the finger, or the hand
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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.
Perseveration
Patients with catatonia may also display perseveration (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 neuroleptic malignant syndrome (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.
Complications
The following complications are associated with catatonia:
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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
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Refusal to eat - Patients with catatonia may refuse to eat; death may result unless parenteral nutrition and fluids are administered on an involuntary basis
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Autonomic instability - Patients with catatonia may experience autonomic instability manifested by hyperthermia, hypertension, and tachycardia; medical intervention is required
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Neuroleptic malignant syndrome (NMS) - If this condition occurs, medical consultation is appropriate
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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 [61]
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Other - Patients with catatonia are at risk of complications from the underlying neurologic, psychiatric, medical, and obstetric causes of catatonia
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Serotonin syndrome checklist.
Tables
Category |
Causes |
Neurologic conditions |
Neuroleptic malignant syndrome [27] Administration of agents that block postsynaptic dopamine receptors* Administration of sibutramine [28] (withdrawn from US market October 8, 2010) Withdrawal of lorazepam and other sedatives Akinetic-rigid syndrome Anti-NMDA receptor encephalitis [4] Arachnoid cyst in right parietal region Astrocytoma Atrophy of left amygdala [29] Autistic disorder [17, 10, 11, 30, 31, 32, 33, 34, 35, 12, 13] 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 [36] 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 Neurosyphilis Nonconvulsive status epilepticus Pervasive developmental disorders [10, 11, 34] Pallidoluysian atrophy Paraneoplastic encephalitis [39] 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 [17] Brief reactive psychosis with catatonia Conversion disorder Hysteria Major depression, single episode with catatonic features Mood disorders Neuroleptic malignant syndrome [27] 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 [27] 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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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Medication
- Medication Summary
- Anxiolytics, Benzodiazepines
- Anticonvulsants, Other
- Anticonvulsants, Barbiturates
- Anxiolytics, Nonbenzodiazepine
- Skeletal Muscle Relaxants
- Central Monoamine-Depleting Agents
- Thyroid Products
- Antipsychotics, Other
- Antipsychotics, 2nd Generation
- Ergot Derivatives
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