Introduction
Abnormal movements, behavioral issues, and communication characterize catatonia. It is often the precipitation of an underlying medical condition, brain disorder, or psychotic disorder. Previously, schizophrenia diagnosis was based on the symptoms of catatonia. However, recently catatonia has been designated an independent disorder. About 10 % of psychiatric patients suffer from catatonia. Various studies in India have reported a prevalence of approximately 5 to 20 %.
How Does Catatonia Occur?
Catatonia is a common disorder, however, the pathogenesis is not clear. The defective functioning of the brain’s cerebral cortex and impaired neurotransmitters (chemicals carrying nerve impulses) such as dopamine and gamma amino butyric acid (GABA) are involved in catatonia progression. Catatonia has also been stated as a response to fear and emotional stress.
What Are the Causes of Catatonia?
The causes of catatonia are linked to a primary medical disease occurring in the body. They are listed below:
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Psychiatric and Mood Disorders: Catatonia symptoms are apparent in bipolar disorder, schizophrenia, autism, depression, and post-traumatic stress disorder (PTSD).
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Metabolic Conditions: Kidney problems, uncontrolled Diabetes Mellitus, and thyroid diseases are connected to catatonia. Hyperparathyroidism, hyponatremia, and hypercalcemia are other causes.
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Brain Disorders: Brain tumors, stroke, dementia, or Parkinson’s disease can lead to catatonia.
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Drug-Induced: Various psychotropic drugs have been implicated in causing catatonia, namely, Haloperidol, Clozapine, and Risperidone; and others such as steroids, benzodiazepines (BZDs), and Ciprofloxacin. Addictive drugs such as Cannabis, Ecstasy, and Cocaine also can increase the risk of catatonia.
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Infections: AIDS, syphilis, bacterial infections, typhoid, tuberculosis, and malaria are infections associated with catatonia.
What Are the Types of Catatonia?
Three clinical types of catatonia are known:
- Retarded: In this type, patients mostly stare and are mute. They are non-reactive to any verbal input.
- Excited: These types of catatonia patients are impulsive. They might exhibit repeated and pointless movements which can harm themselves or others.
- Malignant: It is a life-threatening condition that indicates a deadly underlying cause. It develops very rapidly. As a result, it is important to intervene in such cases.
- Periodic Catatonia: This is a rare type of catatonia in which symptoms occur in phases. Patients experience numerous catatonic episodes.
What Are the Signs and Symptoms of Catatonia?
Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) has set twelve symptoms for the diagnosis. The clinical presentation for each patient is different. Therefore, it can be only one symptom or an amalgamation of all twelve. To arrive at a diagnosis of catatonia, three out of the twelve symptoms should be present:
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Stupor: Although the person is awake, they do not respond to anything. The person is immobile, and there is no activity.
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Mutism: The person gives no or very little verbal response. If a person cannot speak (aphasia), that should be excluded.
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Negativism: The person actively opposes instructions or does not respond for no valid reason.
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Agitation: The person is simply anxious or in a state of distress.
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Echolalia: The person impersonates another, such as copying another person’s words.
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Echopraxia: The person copies another’s movements meaninglessly.
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Posturing: The person spontaneously and voluntarily takes up a new position.
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Wavy flexibility: There is resistance to any change in position.
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Stereotyping: These are incomprehensible, repetitive, and frequent meaningless movements.
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Catalepsy: The person maintains a position to which they have been held or subjected.
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Mannerism: Normal gestures and movements are made exaggeratedly.
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Grimacing: The person expresses negative emotions through constant facial expressions.
The Bush Francis Catatonia Rating Scale (BFCRS) is another scale of twenty-three criteria that is useful along with DSM-5.
What Are the Complications of Catatonia?
The complications include;
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Patients refuse to eat or drink, leading to dehydration and malnourishment.
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Patients may engage in a conflict or fight in an excited catatonic stage.
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Patients can develop muscle contractures or instability due to repeated movements.
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Suicidal thoughts or tendencies are worsened if the patient has concomitant schizophrenia.
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Due to prolonged immobilization, patients are at a high risk of developing pressure ulcers, bed sores, deep vein thrombosis (DVT), and lung embolism. If left untreated, it can progress to death.
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Some cases of periodic catatonia can progress to Neuroleptic Malignant Syndrome (NMS) after treatment with antipsychotics.
How Is Catatonia Diagnosed?
Apart from recording a detailed case history, drug usage, and patient examination, a series of investigations are done:
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Neurological Examination: Eye movements, light reflex, pain reaction, and blink response, among other reflexes, should be checked for proper brain function.
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Brain Imaging: Computed tomography (CT) and magnetic resonance imaging (MRI) are done to rule out any brain or neurological disorders.
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Electroencephalograph (EEG): This test detects brain activity. The EEG in catatonia patients is normal unless there is a simultaneous condition. Slow wave rhythm or fast activity can both indicate various types of catatonia.
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Laboratory Tests: A blood, urine, and metabolic workup are important to rule out any medical condition, including complete blood count, blood urea nitrogen, creatinine, thyroid function tests, and renal function tests. Cerebrospinal fluid (CSF) evaluation through lumbar puncture is advised to evaluate any brain infection.
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Lorazepam Challenge Test: In this test, 2 mg of Lorazepam, a BZD (benzodiazepine), is injected into the vein (intravenously) of a catatonic patient. Symptom resolution within half an hour clinches the diagnosis of catatonia.
What Is the Treatment of Catatonia?
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Benzodiazepines (BZD) - BZDs, such as Diazepam, and Lorazepam, are used as a first-line treatment in catatonia. After a positive response from the challenge test, the concerned doctor should start the treatment. The initial dose of Lorazepam is 2 mg (milligram) twice daily intravenously or intramuscularly (into the muscle), which can be increased up to 16 mg. The dose is tapered once there is a reduction in symptoms.
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Electroconvulsive Therapy (ECT): Brief brain stimulation under anesthesia is done. It is thought to improve blood circulation to the cerebral cortex and neurotransmitter function. ECT is given for at least six sessions and stopped when clinical improvement occurs. BZDs are safe and easy to administer. However, if the patient does not respond to BZDs, ECT should be used. ECT is also used in malignant catatonia.
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Repetitive Transcranial Magnetic Stimulation (rMTS): This is similar to ECT, but patients do not require anesthesia. It is an emerging treatment modality with promising results.
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Other Medications: After all the treatment options have failed, medications such as memantine or amantadine are given twice daily. Clozapine and Olanzapine, antipsychotic drugs, are effective in catatonic patients with schizophrenia. Anti-epileptic drugs, namely Carbamazepine and Valproic acid, are also beneficial.
Conclusion
Catatonia is a condition that affects the patient’s overall perception of the world. As a result, many catatonic patients inadvertently pose a threat to themselves and society. Therefore, it is important to provide emergency medical care to avoid serious complications and promote their well-being. The earlier the condition is diagnosed, prompt treatment can improve the patient's condition and reduce complications. Hence, in most cases, the outcome and prognosis of catatonia are positive.
