What Is Catatonia (Catatonic Behavior)?

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

It is estimated that 10% of people who are hospitalized for acute psychiatric conditions have symptoms of 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 informally under three main types.

While catatonia is defined in the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), the types are not. The designations are useful, however, for both clinicians and patients to understand the various ways catatonic behavior can present.

Informal types of catatonia include:

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

Retarded or Akinetic Catatonia Behavior

Retarded or akinetic catatonia is characterized by slowed movements or a lack of movement. A person with retarded catatonia may appear frozen in place and may not respond to questions, loud noises, or visual stimuli.

Interactions may involve copying the words or movement patterns of whoever they are speaking with.

Behaviors characteristic of this type can include:

  • Immobility
  • Mutism
  • Staring
  • Rigidity
  • Catalepsy
  • Echolalia (repeating sounds) and echopraxia (repeating movements)

Excited Catatonia Behavior

Excited catatonia is less common than akinetic catatonia. This type is characterized by fast or excess movements that are usually meaningless, impulsive, and agitated.

Behaviors characteristic of this type can include:

  • Severe psychomotor agitation
  • Mimicry
  • Impulsivity

Malignant or Lethal Catatonia Behavior

Malignant or lethal catatonia is often associated with the excited type. 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.

According to the DSM-5, at least three of the 12 symptoms below should be present to meet criteria for the diagnosis of catatonia:

  • Stupor
  • Catalepsy
  • Mutism
  • Waxy flexibility
  • Negativism
  • Posturing
  • Mannerisms
  • Stereotypy
  • Agitation
  • Grimacing
  • Echolalia
  • Echopraxia

Sometimes catatonia involves a refusal to eat. This can lead to malnourishment and dehydration—these aren't necessarily symptoms of catatonia, but they are consequences of some catatonic behaviors.

People with catatonia may seem to be unaware of their surroundings. Sometimes people who recover from catatonia report that they recall and were completely aware during their catatonic state.

Causes

Historically, catatonia had been classified 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 many primary diagnoses.

Catatonia is associated with over 100 medical conditions.

These conditions include:

  • Metabolic
  • Autoimmune
  • Inflammatory
  • Infectious
  • Neoplastic
  • Drug-induced (antipsychotics, immunosuppressants, antibiotics, illicit drugs)

One 2020 study 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.

It is likely difficult to identify a single biological cause of catatonia because this syndrome occurs in the context of so many different disorders. Scientists suggest that irregularities in the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems may contribute to catatonia.

Brain imaging research studies have found decreased resting-state activity and decreased task activation in the motor areas of the frontal and parietal cortex in association with catatonia.

Other reports have found increased activity in premotor areas, specifically in akinetic type catatonia.

Ultimately, more research needs to be performed to make conclusions about brain activity changes and other causes of catatonia.

Diagnosis

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 physician will complete a thorough neuropsychiatric evaluation. This may include catatonia screening tools, such as the Bush-Francis Catatonia Rating Scale, the Northoff Catatonia Rating Scale, or the Braunig Catatonia Rating Scale.

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

Catatonia diagnosis will be classified as one of the following:

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

Potential for Misdiagnosis

There is significant potential for catatonia to be misunderstood or misdiagnosed as another disorder. Many psychiatric conditions present with clinical signs that overlap with catatonia. Your doctor may consider other potential conditions when diagnosing catatonia.

Conditions with features similar to catatonia 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 it has a good prognosis when it's treated.

Clinical evidence supports two main treatment pathways for catatonia: benzodiazepines, and Electroconvulsive therapy (ECT).

Medication

A 2018 systematic review found that benzodiazepines are the most frequently studied treatment for catatonia. And lorazepam is the medication most widely researched, with dosages ranging from 2 milligrams (mg) to 16 mg per day, but sometimes even higher doses are required.

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

It is essential to note that, apart from clozapine, antipsychotic medications should generally 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

ECT is effective for treating catatonia, but it is typically used as a second-line treatment after a trial of medication.

ECT treatment requires general anesthesia. The treatment is typically performed bilaterally (on both sides of the brain) and at an average dose of three times a week. The success rate of ECT for the remission of catatonia ranges 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. Initially, the treatment is typically administered daily.

ECT can cause cognitive side effects. Your doctor will discuss the pros and cons of ECT in relation to your unique situation before recommending it for you.

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