Approach Considerations
Treatment modalities include pharmacotherapy and electroconvulsive treatment (ECT). Prompt treatment in the early phases of catatonic states is crucial to obtaining a lasting abatement of symptoms.
Treatable conditions must be identified immediately. Specifically, neuroleptic malignant syndrome (NMS), encephalitis, including anti-NMDA receptor encephalitis, nonconvulsive status epilepticus, and acute psychosis must be diagnosed and treated. The first 3 constitute neurologic emergencies that merit admission to a neurologic or medical intensive care unit (ICU); acute psychosis merits admission for intensive psychiatric inpatient evaluation and treatment.
Refusal to eat necessitates the institution of parenteral nutrition. Supervised activity is indicated. Prompt intervention may be needed to prevent collapse from exhaustion.
The need to administer parenteral nutrition and fluids and to monitor vital signs may require a patient to be transferred from a psychiatric unit to a neurologic or medical unit. If the patient poses a risk of injury to himself or herself or to staff members, then the use of a 1-on-1 psychiatric attendant at all times is indicated.
Regular outpatient follow-up visits are advisable to check for the recurrence of catatonia. In some patients, catatonia remits only in response to ECT. Some patients may require weekly ECT on an outpatient basis.
Pharmacologic Therapy
The following medications have been used in the treatment of patients suffering from catatonia [91] :
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Benzodiazepines (eg, clonazepam, lorazepam, and midazolam)
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Carbamazepine
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Zolpidem
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Tricyclic antidepressants
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Muscle relaxants
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Amobarbital
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Reserpine
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Thyroid hormone
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Lithium carbonate
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Bromocriptine
Because of the possible development of NMS, the use of traditional neuroleptics is avoided; second-generation (atypical) antipsychotics may be helpful in some cases but should still be used with caution. [92, 93] Because catatonia was reported in a 47-year-old woman treated with levofloxacin, prudent clinicians exercise caution when treating patients with fluoroquinolones. [67]
In particular, successful treatment of catatonia has been reported with carbamazepine, [94] clonazepam, [94] olanzapine, [95] and dantrolene, [91] as well as for lorazepam and diazepam. [96, 97] Cyclooxygenase (COX) inhibitors have been reported to protect against the development of perphenazine-induced catatonia in rats. [98]
Krivoy et al recommended the addition of benzodiazepines to antipsychotics in the treatment of catatonia. [99] Lorazepam has been reported to reduce the serum levels of brain-derived neurotrophic factor and to ameliorate the symptoms and signs of catatonia in patients with schizophrenia. [100] A 38-year-old woman with idiopathic catatonia required maintenance treatment with 6 mg lorazepam orally daily. [101]
If a patient fully recovers from catatonia, the gradual reduction and discontinuance of medications, one drug at a time, is reasonable. A return of symptoms and signs of catatonia may necessitate maintenance of pharmacologic interventions.
Electroconvulsive Treatment
When nonconvulsive status epilepticus, diffuse encephalopathy, and other neurologic disorders are ruled out, ECT is indicated for patients who do not respond to pharmacotherapy within 5 days or who manifest malignant catatonia. ECT is effective for many patients with catatonia, [102, 103, 91] including those with catatonia secondary to mood disorders, autistic disorder, [104] or another pervasive developmental disorder. [33, 34] Efficacy may be hindered by coexisting alcohol or drug abuse. [105]
ECT is beneficial for adolescents with catatonic schizophrenia. [106, 91] Slooter et al reported improvement in an adolescent with malignant catatonia (apparently due to viral encephalitis) after ECT. [107] One study found right unilateral ultrabrief ECT to be an effective treatment for catatonia in adolescents and adults. [108]
Indications for Hospitalization and ICU Admission
Because of the risk of serious complications of catatonia, admission to an ICU is the treatment of choice for a patient with this condition. Although placement in an ICU may itself precipitate the development of catatonia, [69] an ICU is nevertheless the appropriate location for monitoring a patient with catatonia until the symptoms have improved sufficiently to allow transfer to a less restrictive setting.
The onset of catatonia merits hospitalization to accomplish the workup and provide intervention for assaultiveness; refusal to eat necessitates parenteral nutrition. Vitamin K deficiency may result from inadequate nutrition. [109] Vitamin K deficiency must be identified and treated in people with catatonia. [109] Autonomic instability requires intravenous (IV) administration of fluids and monitoring of vital signs.
Because catatonia is often periodic, a patient who has recovered from one episode of catatonia is at risk for further episodes. A recurrence of catatonia is an indication for hospitalization to perform a diagnostic workup and initiate therapeutic interventions.
Consultations
Medical consultation is recommended to rule out treatable medical disorders. The following consultations may be required:
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Consultation with a neurologist is recommended to rule out treatable neurologic conditions; specifically, neuroleptic malignant syndrome (NMS), encephalitis, and focal status epilepticus must be ruled out
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Ophthalmologic consultation is recommended to rule out Kayser-Fleischer rings (pigmented rings at the edge of the cornea that are characteristic of Wilson disease)
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Hematologic consultation is appropriate to prevent thromboembolic disease if people with catatonia demonstrate evidence of early coagulation activation [63]
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Consultation with a psychiatrist is indicated to rule out acute psychosis
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Consultation with a movement disorders specialist may help to clarify the diagnosis and treatment; information about locating movement disorder experts is available from the Movement Disorder Society
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Genetic consultation may identify an underlying disorder. The identification of a genetic disorder may facilitate the administration of effective interventions and genetic counseling for relatives of the proband.
Complications
Moving an immobile patients from side to side, mattresses with air cushions, and vigilant nursing care may prevent development of pressure ulcers.
Diet
A regular diet may be adminstered as tolerated. Patients may require assistance with feeding. Refusal to consume food may require the utilization of a nasogastric tube to feed the patient.
Activity
Physical therapy, occupational therapy, and speech pathology may facilitate the development of appropriate actions.
Since excitement may lead to collapse from exhaustion, measures may be required to sedate an agitated patient.
Prevention
Avoid the administration of agents known to precipitate the development of catatonia in individuals.
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Serotonin syndrome checklist.
Tables
Category |
Causes |
Neurologic conditions |
Neuroleptic malignant syndrome [28] Administration of agents that block postsynaptic dopamine receptors* Administration of sibutramine [29] (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 [30] Autistic disorder [17, 10, 11, 31, 32, 33, 34, 35, 36, 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 [37] 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, 35] Pallidoluysian atrophy Paraneoplastic encephalitis [40] 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 [28] 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 [28] 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
- Antidepressants, TCAs
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- Tables
- References
