Professional Documents
Culture Documents
Dr Sudip Aryal
Resident
Dept of Psychiatry & Mental Health
TUTH, IOM
Overview
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Introduction ●
Rating Scales
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History ●
Neurobiology
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Epidemiology ●
Management
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Clinical Features ●
Prognosis
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Examination ●
DSM-5 and ICD-10
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Common Causes ●
Summary
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Differential Diagnosis ●
References
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Subtypes
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Laboratory Findings
Introduction
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Catatonia is a neuropsychiatric syndrome with a
unique combination of mental, motor, vegetative,
and behavioral signs.
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Catatonia or Tension Insanity
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Cerebral disorder accompanied by mental,
physical , and behavioral symptoms
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Catatonia considered a distinct disease entity
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Catatonia : mitis, gravis, protracta
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Overall good prognosis
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Derived from 19th century concept: Unitary
psychosis
Emil Kraepelin (1899)
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Supported Kahlbaum’s comprehensive
nosological approach, Challenged unitary
concept of catatonia
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20% dementia precox : Catatonia
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Kraeplin vs Kahlbaum
– Unitary concept challenged
– Volitional symptoms emphasised (vs motor)
– Chronic course, poor prognosis
– Catatonia and hebephrenia: subtypes, same dz
Eugen Bleuler (1911)
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Same motor and behaviour symptoms as above
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50% hospitalised schizophrenic : catatonia
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Rejected pathophysiological explanation, gave
psychoanalytic explanation
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Manifestations of subconscious Freudian
complexes
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Accessory symptoms, less important
Epidemiology
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7-17% : Hospitalised patient, acute psychotic
episodes
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13-31% : Mood disorders
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<5% : Schizophrenia , last quarter century
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Catatonic Schizophrenia: Average 57% decline
over the course of 20th century, same site study
Clinical Features
Excitement
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Extreme Hyperactivity, constant motor unrest,
which is apparently non-purposeful.
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Not to be attributed to akathisia or goal directed
agitation
Immobility/ Stupor
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Extreme hypoactivity, immobile, minimally
responsive to stimuli
Mutism
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Verbally unresponsive or minimally responsive
Staring
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Fixed gaze, little or no visual scanning of
environment, decreased blinking
Posturing/ catalepsy
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Spontaneous maintenance of posture(s),
including mundane (e.g. sitting or standing for
long periods without reacting)
Grimacing
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Maintenance of odd facial expressions
Echopraxia/ Echolalia
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Mimicking of examiner’s movements/ speech
Stereotypy
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Repetitive, non-goal-directed motor activity (e.g.
finger-play- repeatedly touching, patting or
rubbing self)- abnormality not inherent in act but
in frequency
Mannerism
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Odd, purposeful movements (hopping or walking
tiptoe, saluting passersby or exaggerated
caricatures of mundane movements)-
abnormality inherent in act itself
Verbigeration
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Repetition of phrases or sentences (like a
scratched record)
Rigidity
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Maintenance of a rigid position despite efforts to
be moved, exclude if cogwheeling or tremors
present.
Negativism
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Apparently motiveless resistance to instructions
or attempts to move/ examine the patient.
Contrary behaviour, does exact opposite of
instructions.
Waxy Flexibility
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During reposturing of patient, patient offers
initial resistance before allowing himself to be
repositioned, similar to that of a bending candle.
Withdrawal
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Refusal to eat, drink, and/or make eye contact
Impulsivity
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Patient suddenly engages in inappropriate
behaviour (e.g. runs down hallway, starts
screaming or takes off clothes) without
provocation. Afterward can give no, or only a
facile expression
Automatic obedience
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Exaggerated cooperation with examiner’s
request or spontaneous continuation of
movement requested.
Mitgehen
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“Anglepoise lamp” arm raising in response to
light pressure of finger, despite instruction to
contrary.
Gengenhalten
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Resistance to passive movement which is
proportional to strength of the stimulus, appears
automatic rather than wilful.
Ambitendency
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Patient appears motorically “stuck” in indecisive,
hesistant movement.
Grasp refex
Perseveration
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Repeatedly returns to same topics or persists
with movement
Combativeness
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Usually in an undirected manner, with no, or only
a facile expression afterwards
Autonomic abnormality
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Temperature, Pulse, Respiratory Rate,
Diaphoresis
Examination of the patient
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“Only a comprehensive and intensive application of
the clinical method can enable psychiatry to progress
and to increase the understanding of
psychopathological processes”
-Kahlbaum, 1874
Procedure Examines
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Mood disorders
– Mania > Depression. Upto 50% in mania
– Referred to as manic (or depressive) stupor (or
excitement)
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Schizophrenia (upto 10-15%)
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General medical disorders
– Metabolic/ Endocrine disturbances
– Viral infections (including HIV)
– Typhoid fever
– Heat strokes
– Autoimmune disorders
– Drug related ( antipsychotic, dopaminergic
drugs, recreational drugs, BZD withdrawal,
opiate intoxication)
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Neurological disorders
– Postencephalitic states
– Parkinsonism
– Seizure d/o (non convulsive status epilepticus)
– B/L globus pallidus disease
– Lesions of thalamus/ parietal lobe
– Frontal lobe disease
– General paresis
Diferential Diagnosis
Non-catatonic stupor Precipitating cause (e.g. cranial
trauma, anoxia, drug intoxication)
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Mutism, inhibited movement, posturing,
negativism, and staring
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Postures : mundane or unusual
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Decreased response to voice and noxious stimuli
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Speech, spontaneous movement reduced
– Some pt: alert, aware of environment
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Severe cases: no eating/drinking- stupor-
incontinence
Excited catatonia
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Hyperkinesis, restlessness, stereotypy,
impulsivity, frenzy, and combativeness
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Severe cases : Delirium, self harm, harm to
others
Malignant catatonia
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Also known as lethal catatonia
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Life threatening condition
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Fever, autonomic instability, delirium, rigidity
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Typically fulminant, rapidly progressive
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Signs of MC overlap with that of NMS
Other forms
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Periodic catatonia
– waxing and waning of catatonic signs
– periods of retarded catatonia alternating with
excited catatonia
Laboratory Findings in
catatonia
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Increased CPK
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Low serum iron
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Increased CSF homovanillic acid
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Frontal slowing on EEG that may be
intermittent-features wax and wane
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Increased size of lateral ventricle or cerebellar
atrophy on brain imaging
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Decreased sensory motor cortex functioning and
altered laterality on functional MRI and SPECT
Rating Scales
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Bush-Francis Catatonia Rating Scale
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Rogers Catatonia Scale
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Modified Rogers Scale
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Northoff Catatonia Scale
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Catatonia Rating Scale (Bräunig et al). (2000)
Neurobiology
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Studies : Better understanding of neurological
mechanisms
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Current knowledge still insufcient to formulate
an exhaustive pathophysiological description
Neuroanatomical Studies
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Brain lesions associated with catatonia
– frontal and parietal lobes, basal ganglia,
pons, Cerebellum, corpus callosum
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Focal isolated brain lesions: catatonia rare
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Dysfunction of neural circuits with involvement
of multiple structures rather than focal
alterations
Neurochemical studies
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Hypotheses
– Dysfunction of GABAergic system
BZD
– Dysfunction of glutamatergic system
Amantadine
– Dysfunction of dopaminergic system
controversial
Neuroimaging Studies
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Lower levels of blood fow in the right
prefrontal lateral cortex and right posterior
parietal region
– Motor manifestations
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Functional alterations in the medial
orbitofrontal cortex
– Affective component
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Dysfunction of lateral section of orbitofrontal
cortex
– Behavioural manifestations
Genetic studies
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Association between the long arm of
chromosome 15q15 and periodic catatonia
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Association of catatonia with Prader Willi
Syndrome 15q11-13
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Genes coding for subunits of GABA-A localised
in chromosomal regions associated with PWS
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Periodic catatonia : 27% risk in first degree
relatives
Management
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Identification and treatment of any underlying
medical conditions
– Internal, neurologic, toxicological
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Measures to reduce morbidity and mortality
associated with immobility and malnutrition
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Prevent complications :
– Pressure ulcers, deep vein thrombosis with
pulmonary embolism, fever, infections, urine
retention and aspiration pneumonia
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Integrated multi-disciplinary specialist
approach
– psychiatric, internist, nutritionist,
infectologist,,paramedical support
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Measures to prevent medical complications
– Anticoagulant therapy with subcutaneous
heparin
– Placement of a urinary catheter
– Adequate nursing care
– Adequate parenteral and/or enteral hydration
and alimentation through a nasogastric tube
or PEG (percutaneous endoscopic
gastrostomy).
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Benzodiazepines and ECT are most commonly
used and most effective treatment modalities.
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IV Lorazepam : 70% remission rate
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ECT : 85%
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Malignant catatonia
– ECT : 89%, Lorazepam : 40%
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Lorazepam challenge test
– 1 mg intravenous lorazepam
– If no response after 5 min, administer another
1 mg
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If positive
– Treat with lorazepam increasing the dose up
to 24 mg/day
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If negative
– Bilateral electroconvulsive therapy
(modifed from Dhossche and Watchel 2008)
Benzodiazepine and Zolpidem
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GABA-A Agonist action
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Better response in acute cases, associated with
mood disorders : 70%
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Low response in schizophrenia , long term
symptoms : 20-30%
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Lorazepam : most commonly used
– Diazepam, Oxazepam, Clonazepam also
successfully used
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Initial dose : 1-2 mg parenterally every 4-10 hrs
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Increased upto 24 mg/day until resolution
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Continue till complete remission
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Synergistic action with ECT
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Zolpidem : Rapid action but short duration, more
frequent administration
Electroconvulsive Therapy
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Most effective, irrespective of etiology
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High success in all forms, including MC and NMS
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Better response : Younger age, longer seizure,
more severe vegetative impairment, early
initiation
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Negative response : Delay in initiation
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No standardized ECT t/t protocol
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B/L electrode, brief pulse recommended
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Continue atleast 6 cycles even if rapid response :
relapse prevention
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MC,NMS : consider daily ECT
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Avoid rapid interruption of BZD with ECT
initiation
– Exacerbation of catatonic manifestation
– Synergistic action : ECT + BZD
Other treatment modalities
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Repeated transcranial magnetic stimulation
(rTMS)
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NMDA antagonists
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Antiepileptics
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Atypical antipsychotics
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BZD,ECT resistance, C/I, adjunct
Prognosis
Catatonia: DSM-5 & ICD-10
DSM- 5
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Catatonia Associated With Another Mental
Disorder (Catatonia Specifier) (293.89)
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Catatonic Disorder Due to Another Medical
Condition (293.89)
– 3 or more of 12 symptoms
Stupor Catalepsy Waxy Mutism
Flexibility
Negativism Posturing Mannerism Stereotypy
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Catatonia is a syndrome
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Catatonia is common
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Catatonia has different faces
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Many dz conditions cause catatonia
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Rating Scales
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Benzodiazepine and ECT
References
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Catatonia : From psychopathology to neurobiology, Stanley N.
Caroff et al- 1st ed.- 2008
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Catatonia: A Clinician’s Guide to Diagnosis and Treatment, Max
Fink et al- 2003
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The ICD-10 Classification of Mental and Behavioural Disorders-
Clinical descriptions and diagnostic guidelines- WHO- 1992
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DSM-5- American Psychiatric Association- 2013
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Sempler D. et al- Oxford Handbook of Psychiatry, 3rd ed.- 2015
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N. Bartolommei et al- Catatonia: a critical review and
therapeutic recommendations- Journal of Psychopathology
2012