What Is Catatonia (Catatonic Behavior)?

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Catatonia is a psychomotor syndrome that is characterized by unusual movement disturbances. Catatonic behavior can manifest as slow or lack of movement (retarded or akinetic type), excess and agitated movement (excited type), or dangerous physiological changes (malignant type).

It is estimated that 10% of acute psychiatric inpatients present with catatonia. This condition can be life threatening, but it is also highly treatable.

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Types of Catatonic Behavior

Over the years, psychiatrists have grouped catatonic behaviors under three main types. These types are not official, in the sense of being codified in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5).

However, the types are useful for both clinicians and patients to understand the various ways catatonic behavior can present. The types of catatonic behavior include:

  • Retarded or akinetic catatonia
  • Excited catatonia
  • Malignant or lethal catatonia

Retarded or Akinetic Catatonia Behavior

Retarded or akinetic type of catatonia is characterized by slowed down, or lack of movement.  A person with retarded catatonia may appear frozen in place. They likely will not respond to you if you ask them questions, and they won't even respond to loud noises or visual stimuli. If they do interact with you, it will likely be copying your words or movement patterns.

Behaviors characteristic of this type can include:

  • Immobility
  • Mutism
  • Staring
  • Rigidity
  • Catalepsy
  • Echolalia and echopraxia

Excited Catatonia Behavior

Excited catatonia exists on the opposite end of the spectrum from retarded or akinetic catatonia, and it is also less common. This type is characterized by fast or excess movements. Someone with the excited type of catatonia will have much more movement, but these movements will be meaningless, impulsive, and agitated.

Behaviors characteristic of this type can include:

  • Severe psychomotor agitation
  • Delirium
  • Mimicry
  • Impulsivity

Malignant or Lethal Catatonia Behavior

Malignant or lethal catatonia is often associated with the excited type. When catatonia is left untreated, it can lead to autonomic dysregulation (including drastic changes in blood pressure, heart rate, temperature, and respiratory rate), and altered levels of consciousness.

This type of catatonia can be lethal and requires immediate medical attention. Its behaviors and symptoms include:

  • Hyperthermia
  • Blood pressure changes
  • Heart rate changes
  • Respiratory rate changes
  • Delirium
  • Sweating

Symptoms

Symptoms of catatonia are broad, and will differ based on the type of catatonia being experienced. The DSM-5, however, does not categorize catatonia into its three behavioral types. Instead, the DSM-5 requires a person to experience at least three of the below symptoms in order to be diagnosed with catatonia:

  • Stupor or catalepsy
  • Mutism
  • Waxy flexibility
  • Negativism
  • Posturing
  • Mannerisms
  • Stereotypy
  • Agitation or grimacing
  • Echolalia
  • Echopraxia

People experiencing catatonia may also exhibit withdrawal and refusal to eat. This can lead to malnourishment and dehydration, as well as incontinence. These aren't necessarily symptoms of catatonia, but rather consequences of catatonic behaviors.

People with catatonia may act or appear like they aren't aware of their surroundings. However, many people who recover from catatonia report that they recall and were completely aware during their catatonic state.

Causes

The pathophysiology of catatonia is unclear. There are a few theories, however. Some scientists suspect irregularities in certain neurotransmitter systems to contribute to catatonia. These include the gamma-aminobutyric acid (GABA) and glutamate systems.

Brain imaging studies also provide clues to the biology of catatonia. Some reports have found decreased resting state activity, and decreased task activation in the motor areas of the frontal and parietal cortex.

Other reports have found increased activity in premotor areas, specifically in akinetic type catatonia. Ultimately, more research needs to be performed to make conclusions on brain activity and catatonia.

It is likely difficult to identify a single biological cause of catatonia because this syndrome has a multitude of potential causes.

Catatonia is associated with over 100 medical conditions. These conditions include:

  • Metabolic
  • Autoimmune
  • Inflammatory
  • Infectious
  • Neoplastic
  • Substance use (antipsychotics, immunosuppressants, antibiotics, illicit drugs)

One 2020 study even examined a case of catatonia in a man with COVID-19. The study posits that due to its neuroinvasive characteristics and no other medical explanation, the SARS-coV-2 caused catatonia in this patient. This is the first study to associate catatonia with the coronavirus.

Diagnosis

Historically, catatonia was classified solely as a subtype of schizophrenia. In 1994, "catatonia secondary to a medical condition" was added to the DSM, as it had become clear that people with many conditions could have catatonia.

In 2013, the new DSM-5 further changed the classification of catatonia, now listing it as an independent syndrome, as well as a specifier for 10 primary diagnoses.

The catatonia category of the DSM-5 includes these diagnoses:

  • Catatonia associated with another mental disorder (catatonia specifier) 
  • Catatonic disorder due to another medical condition 
  • Unspecified catatonia 

There is no laboratory test that can diagnose catatonia. However, if catatonia is suspected, a physician may order a complete blood count, metabolic panel, serum iron, cerebrospinal fluid analysis, and drug screens, among other tests, to rule out underlying conditions or potential causes.

If catatonia is suspected, your physician will undertake a thorough neuropsychiatric evaluation. This will include using catatonia screening tools, such as the Bush-Francis Catatonia Rating Scale, the Northoff Catatonia Rating Scale, and the Braunig Catatonia Rating Scale.

To be diagnosed with catatonia, a person must meet the criteria set forth in the DSM-5, including three of the twelve symptoms listed previously.

Potential for Misdiagnosis

There is significant potential for catatonia to be misunderstood or misdiagnosed for another disorder. Many psychiatric conditions' clinical signs overlap with catatonia. Your doctor should consider other potential conditions when diagnosing catatonia. These include:

  • Non-catatonic stupor
  • Encephalopathy
  • Stroke
  • Stiff-person syndrome
  • Parkinson's disease
  • Locked-in syndrome
  • Malignant hyperthermia
  • Status epilepticus
  • Autism
  • Severe obsessive-compulsive disorder
  • Elective mutism
  • Extrapyramidal side effects
  • Nonconvulsive status epilepticus
  • Abulia or akinetic mutism
  • Vegetative state

Treatment

It is very important to seek treatment for catatonia. Not only is this condition incredibly life limiting, but it can lead to life-threatening complications. Fortunately, catatonia is highly treatable and there is good prognosis for treatment.

Clinical evidence supports two main treatment pathways for catatonia: use of benzodiazepines, and electro-convulsive therapy.

Medication

A 2018 systematic review found that benzodiazepines are the most frequently studied treatment for catatonia. Of these studies, lorazepam was the medication most widely researched, with dosages ranging from 2 milligrams (mg) to 16 mg per day.

Remission of catatonia in these studies ranged from 66-100%. Patients with longer-term catatonia symptoms may not respond as well to treatment.

Clozapine is another prescription medication used to treat catatonia, usually as a second-line treatment when benzodiazepines are not effective or tolerated.

One 2012 study found that clozapine was effective at remitting catatonia, but requires slow titration, close monitoring by a physician, and takes approximately seven weeks to resolve symptoms of catatonia.

It is essential to note that, apart from clozapine, antipsychotic medications should be avoided among people with catatonia. Antipsychotics can actually worsen the symptoms of catatonia, which is another reason that accurate diagnosis is so important.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is effective for treating catatonia, but it is typically used as a second-line treatment after medication is attempted. ECT is typically performed bilaterally, or on both sides of the brain, and at an average rate of three times a week. Success rate at remitting catatonia range from 59-100% across the existing research.

In rarer cases, ECT may be used as a first-line treatment for people with malignant catatonia and life-threatening symptoms. This is typically administered daily for three to five days.

One reason that ECT is not preferred to medication is that there can be cognitive side effects. Many people who are treated with ECT present with memory loss or impairment after treatment. Your doctor will discuss the pros and cons of ECT, in relation to your unique situation, before recommending it.

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