Evidence-Based Reviews

Catatonia: How to identify and treat it

Current Psychiatry. 2018 August;17(8):16-26

References

1. Kahlbaum KL. Catatonia. Baltimore, MD: John Hopkins University Press; 1973.
2. Kahlbaum KL. Die Katatonie oder das Spannungsirresein. Berlin: Hirschwald; 1874.
3. Tang VM, Duffin J. Catatonia in the history of psychiatry: construction and deconstruction of a disease concept. Perspect Biol Med. 2014;57(4):524-537.
4. Carroll BT. Kahlbaum’s catatonia revisited. Psychiatry Clin Neurosci. 2001;55(5):431-436.
5. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160(7):1233-1241.
6. Fink M, Fricchione GL, Rummans T, et al. Catatonia is a systemic medical syndrome. Acta Psychiatr Scand. 2016;133(3):250-251.
7. Medda P, Toni C, Luchini F, et al. Catatonia in 26 patients with bipolar disorder: clinical features and response to electroconvulsive therapy. Bipolar Disord. 2015;17(8):892-901.
8. Mazzone L, Postorino V, Valeri G, et al. Catatonia in patients with autism: prevalence and management. CNS Drugs. 2014;28(3):205-215.
9. Fink M, Kellner CH, McCall WV. Optimizing ECT technique in treating catatonia. J ECT. 2016;32(3):149-150.
10. Kocha H, Moriguchi S, Mimura M. Revisiting the concept of late catatonia. Compr Psychiatry. 2014;55(7):1485-1490.
11. Lin CC, Hung YL, Tsai MC, et al. Relapses and recurrences of catatonia: 30-case analysis and literature review. Compr Psychiatry. 2016;66:157-165.
12. Saddawi-Konefka D, Berg SM, Nejad SH, et al. Catatonia in the ICU: An important and underdiagnosed cause of altered mental status. A case series and review of the literature. Crit Care Med. 2013;42(3):e234-e241.
13. Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry. 2015;86(8):825-832.
14. Grover S, Chakrabarti S, Ghormode D, et al. Catatonia in inpatients with psychiatric disorders: a comparison of schizophrenia and mood disorders. Psychiatry Res. 2015;229(3):919-925.
15. Oldham MA, Lee HB. Catatonia vis-à-vis delirium: the significance of recognizing catatonia in altered mental status. Gen Hosp Psychiatry. 2015;37(6):554-559.
16. Tuerlings JH, van Waarde JA, Verwey B. A retrospective study of 34 catatonic patients: analysis of clinical ‘care and treatment. Gen Hosp Psychiatry. 2010;32(6):631-635.
17. Ohi K, Kuwata A, Shimada T, et al. Response to benzodiazepines and the clinical course in malignant catatonia associated with schizophrenia: a case report. Medicine (Baltimore). 2017;96(16):e6566. doi: 10.1097/MD.0000000000006566.
18. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms appearing before autonomic symptoms help distinguish neuroleptic malignant syndrome from malignant catatonia. Intern Med. 2016;55(19):2893-2897.
19. Lang FU, Lang S, Becker T, et al. Neuroleptic malignant syndrome or catatonia? Trying to solve the catatonic dilemma. Psychopharmacology (Berl). 2015;232(1):1-5.
20. Beach SR, Gomez-Bernal F, Huffman JC, et al. Alternative treatment strategies for catatonia: a systematic review. Gen Hosp Psychiatry. 2017;48:1-19.
21. Kugler JL, Hauptman AJ, Collier SJ, et al. Treatment of catatonia with ultrabrief right unilateral electroconvulsive therapy: a case series. J ECT. 2015;31(3):192-196.
22. Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia. Eur Child Adolesc Psychiatry. 2015;24(4):441-449.
23. DeJong H, Bunton P, Hare DJ. A systematic review of interventions used to treat catatonic symptoms in people with autistic spectrum disorders. J Autism Dev Disord. 2014;44(9):2127-2136.
24. Wachtel L, Commins E, Park MH, et al. Neuroleptic malignant syndrome and delirious mania as malignant catatonia in autism: prompt relief with electroconvulsive therapy. Acta Psychiatr Scand. 2015;132(4):319-320.
25. Fink M, Taylor MA. Catatonia: subtype or syndrome in DSM? Am J Psychiatry. 2006;163(11):1875-1876.
26. Khan M, Pace L, Truong A, et al. Catatonia secondary to synthetic cannabinoid use in two patients with no previous psychosis. Am J Addictions. 2016;25(1):25-27.
27. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms appearing before autonomic symptoms help distinguish neuroleptic malignant syndrome from malignant catatonia. Intern Med. 2016;55(19):2893-2897.
28. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
29. Wilson JE, Niu K, Nicolson SE, et al. The diagnostic criteria and structure of catatonia. Schizophr Res. 2015;164(1-3):256-262.
30. Ducharme S, Dickerson BC, Larvie M, et al. Differentiating frontotemporal dementia from catatonia: a complex neuropsychiatric challenge. J Neuropsychiatry Clin Neurosci. 2015;27(2):e174-e176.
31. Narayanaswamy JC, Tibrewal P, Zutshi A, et al. Clinical predictors of response to treatment in catatonia. Gen Hosp Psychiatry. 2012;34(3):312-316.
32. Thamizh JS, Harshini M, Selvakumar N, et al. Maintenance lorazepam for treatment of recurrent catatonic states: a case series and implications. Asian J Psychiatr. 2016;22:147-149
33. Ungvari GS, Chiu HF, Chow LY, et al. Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study. Psychopharmacology (Berl). 1999;142(4):393-398.
34. Flamarique I, Baeza I, de la Serna E, et al. Long-term effectiveness of electroconvulsive therapy in adolescents with schizophrenia spectrum disorders. Eur Child Adolesc Psychiatry. 2015;24(5):517-524.

DSM-5 criteria for the diagnosis of catatonia are more restrictive than DSM-IV criteria. As a result, they exclude a significant number of patients who would be considered catatonic in other systems.²⁹ For example, DSM-5 criteria do not include common features noted in Table 1,^8,12,13 such as rigidity and staring.^14,29 If the diagnosis is not obvious, it might be suspected in the presence of >1 of posturing, automatic obedience, or waxy flexibility, or >2 of echopraxia/echolalia, gegenhalten, negativism, mitgehen, or stereotypy/vergiberation.¹² Clues to catatonia that are not included in formal diagnostic systems and are easily confused with features of psychosis include whispered or robotic speech, uncharacteristic foreign accent, tiptoe walking, hopping, rituals, and odd mannerisms.⁵

There are several catatonia rating scales containing between 14 and 40 items that are useful in diagnosing and following treatment response in catatonia (Table 5^8,13,15,29). Of these, the Kanner Scale is primarily applied in neuropsychiatric settings, while the Bush-Francis Catatonia Rating Scale (BFCRS) has had the most widespread use. The BFCRS consists of 23 items, the first 14 of which are used as a screening instrument. It requires 2 of its first 14 items to diagnose catatonia, while DSM-5 requires 3 of 12 signs.²⁹ If the diagnosis remains in doubt, a benzodiazepine agonist test can be instructive.^9,12 The presence of catatonia is suggested by significant improvement, ideally assessed prospectively by improvement of BFCRS scores, shortly after administration of a single dose of 1 to 2 mg lorazepam or 5 mg diazepam IV, or 10 mg zolpidem orally. Further evaluation generally consists of a careful medical and psychiatric histories of patient and family, review of all medications, history of substance use with toxicology as indicated, physical examination focusing on autonomic dysregulation, examination for delirium, and laboratory tests as suggested by the history and examination that may include complete blood count, creatine kinase, serum iron, blood urea nitrogen, electrolytes, creatinine, prolactin, anti-NMDA antibodies, thyroid function tests, serology, metabolic panel, human immunodeficiency virus testing, EEG, and neuroimaging.^8,15,16

A complex differential diagnosis

Manifestations of numerous psychiatric and neurologic disorders can mimic or be identical to those of catatonia. The differential diagnosis is complicated by the fact that some of these disorders can cause catatonia, which is then masked by the primary disorder; some disorders (eg, NMS) are forms of catatonia. Table 6^{5,8,12,19,26,30} lists conditions to consider.

Some of these conditions warrant discussion. ASD may have catatonia-like features such as echolalia, echopraxia, excitement, combativeness, grimacing, mutism, logorrhea, verbigeration, catalepsy, mannerisms, rigidity, staring and withdrawal.⁸ Catatonia may also be a stage of deterioration of autism, in which case it is characterized by increases in slowness of movement and speech, reliance on physical or verbal prompting from others, passivity, and lack of motivation.²³ At the same time, catatonic features such as mutism, stereotypic speech, repetitive behavior, echolalia, posturing, mannerisms, purposeless agitation, and rigidity in catatonia can be misinterpreted as signs of ASD.⁸ Catatonia should be suspected as a complication of longstanding ASD in the presence of a consistent, marked change in motor behavior, such as immobility, decreased speech, stupor, excitement, or mixtures or alternations of stupor and excitement.⁸ Freezing while doing something, difficulty crossing lines, or uncharacteristic persistence of a particular behavior may also herald the presence of catatonia with ASD.⁸

Catatonia caused by a neurologic or metabolic factor or a substance can be difficult to distinguish from delirium complicated by catatonia. Delirium may be identified in patients with catatonia by the presence of a waxing and waning level of consciousness (vs fluctuating behavior in catatonia) and slowing of the EEG.^12,15 Antipsychotic medications can improve delirium but worsen catatonia, while benzodiazepines can improve catatonia but worsen delirium.

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Catatonia: How to identify and treat it

References

A complex differential diagnosis

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