Catatonia is a psychomotor syndrome characterized by unusual behavior and movement disorders. Catatonic behavior can manifest as slow or decreased movements (slow or akinetic type), excessive or agitated movements (agitated type), or dangerous physiological changes (malignant type).
It is estimated that 10% of people hospitalized for acute psychiatric illnesses have symptoms of catatonia. This condition can be life-threatening, but it also responds well to treatment.
Types of catatonic behavior
Over the years, psychiatrists have informally grouped catatonic behavior into three main types.
Catatonia is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but the types are not. However, these annotations are helpful for both clinicians and patients to understand the various manifestations of catatonic behavior.
Informal types of catatonia include:
- Delayed or akinetic catatonia
- Excited catatonia
- Malignant or fatal catatonia
Delayed or akinetic catatonic behavior
Slow or akinetic catatonia is characterized by slow or no movement. A person with delayed catatonia may appear frozen in place and not respond to questions, loud noises, or visual stimuli.
The interaction may involve copying the words or movements of the person they are talking to.
Typical behaviors for this type of behavior may include:
- Echolalia (repetitive sounds) and echopraxia (repetitive movements)
Excited behavior of catatonia
Excited catatonia is less common than akinetic catatonia. This type is characterized by rapid or excessive movements that are often meaningless, impulsive, and agitated.
Typical behavior for this type of behavior can include:
- Strong psychomotor agitation
Malignant or fatal catatonia
Malignant or fatal catatonia is often associated with the agitated type. This can lead to autonomic dysregulation (including abrupt changes in blood pressure, heart rate, temperature, and respiratory rate) and changes in the level of consciousness.
This type of catatonia can be fatal and requires immediate medical attention. Its behavior and symptoms include:
- Changes in blood pressure
- Heart rate changes
- Changes in respiratory rate
The symptoms of catatonia are extensive and vary depending on the type.
According to DSM-5, at least three of the following 12 symptoms must be present to meet the diagnostic criteria for catatonia:
- Wax flexibility
Sometimes catatonia means refusing to eat. This can lead to malnutrition and dehydration; These are not necessarily symptoms of catatonia, but are the result of some catatonic behavior.
People with catatonia may not be aware of their surroundings. Sometimes people recovering from catatonia report that they are remembering and fully aware of their catatonic state.
Historically, catatonia has been classified as a subtype of schizophrenia . In 1994, 'secondary catatonia due to disease' was added to the DSM because it became clear that people with many conditions could have catatonia.
In 2013, in the new DSM-5, the classification of catatonia was changed, it is now included as an independent syndrome, as well as a specifier for many primary diagnoses.
Catatonia is associated with more than 100 diseases.
These conditions include:
- Medications (antipsychotics, immunosuppressants, antibiotics, illegal drugs)
A 2020 study looked at a case of catatonia in a man with COVID-19 . The study states that due to its neuroinvasive characteristics and the lack of other medical explanations, SARS-coV-2 caused catatonia in this patient. This is the first study to link catatonia to the coronavirus.
It is probably difficult to identify a single biological cause of catatonia, because this syndrome occurs in the context of so many different diseases. Scientists speculate that alterations in the neurotransmitter systems of gamma-aminobutyric acid (GABA) and glutamate may contribute to catatonia.
Brain imaging studies have shown a decrease in resting activity and a decrease in task activity in the motor areas of the frontal and parietal cortex, combined with catatonia.
Other reports have found increased activity in premotor areas, especially in akinetic-type catatonia.
Ultimately, more research is needed to draw conclusions about changes in brain activity and other causes of catatonia.
To be diagnosed with catatonia, a person must have three of the 12 symptoms listed in the DSM-5.
If you have signs of catatonia, your doctor will conduct a thorough neuropsychiatric evaluation. This could include catatonia screening tools such as the Bush-Francis Catatonia Rating Scale, the Northoff Catatonia Rating Scale, or the Braunig Catatonia Rating Scale.
There are no laboratory tests to diagnose catatonia. However, your doctor may order a complete blood count (CBC), metabolic panel, serum iron, cerebrospinal fluid analysis, and drug screening, among other tests, to rule out underlying conditions or possible causes.
A diagnosis of catatonia is classified into one of the following:
- Catatonia associated with another mental disorder (catatonia specifier)
- Catatonic disorder caused by another medical condition.
- Unspecified catatonia
Possibility of misdiagnosis
Catatonia can be misunderstood or misdiagnosed as another condition. Many mental conditions have clinical features that overlap with catatonia. Your healthcare provider may consider other possible conditions when diagnosing catatonia.
Conditions similar to catatonia include:
- Non-catatonic stupor
- Constrained person syndrome
- Parkinson's disease
- Cloistered syndrome
- Malignant hyperthermia
- Status epilepticus
- Severe obsessive compulsive disorder
- Selective mutism
- Extrapyramidal side effects
- Non-convulsive status epilepticus
- Abulia or akinetic mutism
- Vegetative state
It is very important to seek treatment for catatonia. Not only is this condition incredibly life-limiting, it can also lead to life-threatening complications. Fortunately, catatonia responds well to treatment and has a good prognosis with treatment.
Clinical evidence supports two main treatments for catatonia: benzodiazepines and electroconvulsive therapy (ECT) .
A 2018 systematic review found that benzodiazepines are the most commonly studied treatment for catatonia. And lorazepam is the most widely researched drug with doses ranging from 2 milligrams (mg) to 16 mg per day, but even higher doses are sometimes required.
The remission of catatonia in these studies ranged from 66% to 100%. Patients with long-term catatonia symptoms may not respond to treatment.
It is important to note that, in addition to clozapine, people with catatonia should avoid taking antipsychotic medications. Antipsychotics can make catatonia symptoms worse, which is another reason why an accurate diagnosis is so important.
ECT is effective in treating catatonia, but is generally used as a second-line treatment after trial medication.
Treatment with ECT requires general anesthesia. Treatment is usually done on both sides (both sides of the brain) and at a moderate dose three times a week. Success rates for ECT for catatonia remission range from 59% to 100% based on existing studies.
In rarer cases, ECT can be used as a first-line treatment for people with malignant catatonia and life-threatening symptoms. Initially, treatment is usually given on a daily basis.
ECT can cause cognitive side effects. Your healthcare provider will discuss the pros and cons of ECT in your particular situation before recommending it to you.