Catatonia


Catatonia is a state of psycho-motor immobility and behavioral abnormality. It was first described in 1874 by Karl Ludwig Kahlbaum as label=none.
Though catatonia has historically been related to schizophrenia, it is now known that catatonic symptoms are nonspecific and may be observed in other mental disorders and neurological conditions. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, catatonia is not recognized as a separate disorder, but is associated with psychiatric conditions such as schizophrenia, bipolar disorder, post-traumatic stress disorder, depression, narcolepsy, drug abuse or overdose. It may also be seen in many medical disorders including infections, autoimmune disorders, meningitis, focal neurological lesions, alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions: homocystinuria, diabetic ketoacidosis, hepatic encephalopathy and hypercalcaemia.
It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available; benzodiazepines are a first-line treatment strategy. Electroconvulsive therapy is also sometimes used. There is growing evidence for the effectiveness of the NMDA receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia. Antipsychotics are sometimes employed but require caution as they can worsen symptoms and have serious adverse effects.

Signs and symptoms

Catatonia can be stuporous or excited. Stuporous catatonia is characterized by immobility during which individuals may show reduced responsiveness to the environment, rigid poses, an inability to speak, or waxy flexibility, in which they maintain positions after being placed in them by someone else. Mutism may be partial and they may repeat meaningless phrases or speak only to repeat what someone else says. People with stuporous catatonia may also show purposeless, repetitive movements. Excited catatonia is characterized by bizarre, non-goal-directed hyperactivity and impulsiveness.
Catatonia is a syndrome that can occur in various psychiatric disorders, including major depressive disorder, bipolar disorder, schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. It appears as the Kahlbaum syndrome, malignant catatonia, and excited forms. It has also been recognized as related to autism spectrum disorders.

Diagnosis

According to the DSM-5, "Catatonia Associated with Another Mental Disorder " is diagnosed if the clinical picture is dominated by at least three of the following:
Other disorders :
If catatonic symptoms are present but they do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered.

Subtypes

Although catatonia can be divided into various subtypes, the natural history of catatonia is often fluctuant and different states can exist within the same individual.
Various rating scales for catatonia have been developed. The most commonly used scale is the Bush-Francis Catatonia Rating Scale. A diagnosis can be supported by the lorazepam challenge or the zolpidem challenge. While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT.

Treatment

Initial treatment is aimed at providing symptomatic relief. Benzodiazepines are the first line of treatment, and high doses are often required. A test dose of intramuscular lorazepam will often result in marked improvement within half an hour. In France, zolpidem has also been used in diagnosis, and response may occur within the same time period. Ultimately the underlying cause needs to be treated.
Electroconvulsive therapy is an effective treatment for catatonia, however, it has been pointed out that further high quality randomized controlled trials are needed to evaluate the efficacy, tolerance, and protocols of ECT in catatonia.
Antipsychotics should be used with care as they can worsen catatonia and are the cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate discontinuation of the antipsychotic.
Excessive glutamate activity is believed to be involved in catatonia; when first-line treatment options fail, NMDA antagonists such as amantadine or memantine may be used. Amantadine may have an increased incidence of tolerance with prolonged use and can cause psychosis, due to its additional effects on the dopamine system. Memantine has a more targeted pharmacological profile for the glutamate system, reduced incidence of psychosis and may therefore be preferred for individuals who cannot tolerate amantadine. Topiramate is another treatment option for resistant catatonia; it produces its therapeutic effects by producing glutamate antagonism via modulation of AMPA receptors.