What Is Catatonic Behavior in Schizophrenia?

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Catatonia is a psychomotor condition in which a person has significant motor disturbances. This can manifest as a lack of movement (retarded type), fast and irregular movement (excited type), or life-threatening autonomic changes (malignant type).

Schizophrenia is a psychiatric condition characterized by hallucinations, delusions, disorganized speech, and more. Some people may experience what used to be called catatonic schizophrenia when these two conditions overlap.

Historically, catatonic schizophrenia was considered a subtype of schizophrenia. As of 2013 and the advent of the newest "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), catatonia became an independent syndrome, separate from schizophrenia.

Although catatonia is no longer considered a subtype of schizophrenia, it is now a specifier for schizophrenia, along with other mental health conditions.

It's currently estimated that about 20% of people with catatonia have schizophrenia., and studies show that of people with schizophrenia, between 7.6% to 20% have catatonia.

It is more common to have catatonia associated with a mood disorder, such as bipolar disorder, than it is to have catatonic schizophrenia. Approximately 43% of people with catatonia also have bipolar disorder.

Mature white woman in gray sweater stands by and leans on window and looks down

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Symptoms

Someone with catatonic schizophrenia will have symptoms of both catatonia and schizophrenia. In addition to the hallucinations and delusions that a person with schizophrenia experiences, they may also present with unusual movement patterns, such as being frozen in place, mimicking other people's movements, or not communicating.

Catatonia Symptoms

The symptoms of catatonia vary across four domains: motor, behavioral, autonomic instability, and inability to suppress motor functions. According to the DSM-5, a person must have a minimum of three of the following symptoms for a catatonia diagnosis:

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

There are three behavioral types of catatonia, based on symptoms that are frequently grouped together. These include:

  • Retarded or akinetic catatonia: This type is characterized by lack of movement, mutism, and appearing "frozen."
  • Excited catatonia: This type is characterized by irregular and agitated movement, delirium, and "copycat" movement patterns.
  • Malignant or lethal catatonia: This life-threatening type of catatonia includes hyperthermia, and drastic changes in blood pressure, heart rate, and respiration rate. Requires immediate medical attention.

Schizophrenia Symptoms

According to the DSM-5, someone with schizophrenia will have two or more of the following symptoms, with at least one of the first three symptoms listed:

  • Hallucinations
  • Delusions
  • Disorganized speech patterns
  • Disorganized or catatonic behavior
  • Negative symptoms (diminished emotional expression)
  • Marked decrease in level of functioning at work, academically, interpersonally, or in self-care

Notably, someone with schizophrenia often lacks insight into their condition.

Causes

There is not conclusive evidence on the exact cause of catatonia in schizophrenia or in other conditions. Scientists do have theories and there is developing research on the causes of the independent conditions.

Catatonia

It is believed that catatonia is caused, in part, by dysregulation of certain neurotransmitters.

The most studied neurotransmitter in relation to catatonia is gamma-aminobutyric acid (GABA). Positron emission tomography (PET) imaging shows decreased GABAergic brain activity, and drugs that are GABAergic are effective at treating catatonia.

Other neurotransmitter abnormalities, including dopamine and glutamate, have also been associated with catatonia. Although the role of neurotransmitters, including GABA, have been well established, the exact cause of catatonia, and this neurotransmitter dysfunction, is still unclear.

Catatonia has been associated with over 100 medical conditions, including infectious diseases and autoimmune conditions. It is likely that the cause of catatonia is multifactorial.

Schizophrenia

Research has shown there is a genetic connection to schizophrenia. The heritability of schizophrenia is estimated between 65% to 80%, but not everyone with schizophrenia has a relative with the condition.

There are also many nongenetic risk factors for schizophrenia. These include childhood trauma, social isolation, substance use, pregnancy and birth complications, urbanicity, and more.

It is likely that there is no single cause to schizophrenia, but rather that the condition is caused by a complex interplay of both genetic and environmental factors.

The cause of catatonic schizophrenia, or the intersection of these two conditions, is under-researched. Studies on schizophrenia often feature diverse samples of presentation, which limits conclusions that can be made on the cause of catatonic schizophrenia in particular.

Diagnosis

To be diagnosed with catatonic schizophrenia, a person must be separately diagnosed with both catatonia and schizophrenia. This is because catatonia is an independent condition within the DSM-5, and no longer considered a subtype of schizophrenia.

Catatonia can now, however, be used as a specifier for 10 psychiatric conditions, including schizophrenia. "Specifiers" are ways for psychiatrists and physicians to add dimension to a diagnosis.

Catatonia Diagnosis

For a catatonia diagnosis, a person must exhibit three of the 12 symptoms listed previously. A physician or psychiatrist may use specific screening tools, such as the Northoff Catatonia Rating Scale or Bush-Francis Catatonia Rating Scale, to identify catatonia.

An important part of the catatonia diagnosis process is eliminating other potential diagnoses from consideration. Catatonia has a history of being misdiagnosed, as conditions such as autism, encephalopathy, stroke, Parkinson's disease, and more can have similar symptoms.

For a catatonic schizophrenia diagnosis in particular, it is essential for physicians to differentiate between negative symptoms of schizophrenia (such as lack of emotional expression or flat affect), and true catatonic symptoms.

Schizophrenia Diagnosis

To be diagnosed with schizophrenia, a person must have the symptoms listed previously. These include at least one of the primary three symptoms: hallucinations, delusions, or disorganized speech, accompanied by a period of functional decline.

There is no physiological test for schizophrenia, but your physician may ask you to undergo magnetic resonance imaging (MRI), computerized tomography (CT), urine, or blood tests to rule out other conditions, such as brain tumors, lesions, or certain drugs.

A person who meets diagnostic criteria for both schizophrenia and catatonia can be diagnosed with schizophrenia with a catatonic specifier.

Treatment

Treatment for catatonic schizophrenia will be comprehensive, and should address both the schizophrenic and catatonic symptoms separately and in combination.

Treatment of catatonia is generally the priority due to its symptomatic impact and potential to progress to a more life-threatening type.

Schizophrenia itself has no cure, but can be treated through a multipronged approach that includes medication, hospitalization, occupational therapy, counseling, and more.

Medication

The first-line treatment for catatonia is prescription medication. Benzodiazepines are the most commonly prescribed medication, with Ativan (lorazepam) being prescribed in relatively high dosages, sometimes up to over 20 milligrams (mg) a day. A reduction of symptoms can typically be seen rapidly, but a fuller response may take between three to seven days.

In the acute treatment of catatonia, antipsychotics are generally avoided as they can potentially worsen the condition. As the catatonia resolves, antipsychotic medications can be cautiously reintroduced to treat the underlying schizophrenia.

Other Treatment

Electroconvulsive therapy (ECT) is another well-studied treatment for catatonia that is typically tried if prescription medication is not tolerated or unsuccessful. ECT is considered the first line treatment for malignant catatonia.

Repetitive transcranial magnetic stimulation (rTMS) is being studied regarding its potential use in catatonia.

Prognosis

Catatonia is a severe condition that can be life-threatening. It is, however, highly treatable. The prognosis for both catatonia and schizophrenia improves the earlier it is treated.

Retarded or excited catatonia associated with underlying bipolar, depressive, or medical disorders tend to resolve with the treatment of the catatonia in addition to the underlying psychiatric or medical condition.

Catatonia in patients with schizophrenia may be more persistent, although this doesn't mean remission is impossible.

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