CATATONIA

Name: BAWDIN HERA NAAZ

Group No: 25a
CATATONIA:

• Catatonia is a state of apparent unresponsiveness to external stimuli

and apparent inability to move normally in a person who is apparently
awake.
• The term “catatonia” was given by Karl Kahlbaum who described the
motor symptoms for the first time.
These symptoms are sometimes described along with disorganization
symptoms.
• Catatonia is a clinical syndrome characterized by striking behavioral
abnormalities that may include motoric immobility or excitement,
profound negativism, or echolalia (mimicry of speech) or echopraxia
(mimicry of movement).
• A diagnosis of catatonic disorder due to a general medical condition
can be made if there is evidence that the condition is due to the
physiological effects of a general medical condition.

EPIDEMIOLOGY:

Catatonia is an uncommon condition mostly seen in advanced primary

mood or psychotic illnesses.
Among inpatients with catatonia, 25 to 50 percent are related to mood
disorders (e.g., major depressive episode, recurrent, with catatonic
features), and
approximately 10 percent are associated with schizophrenia.

• Most common cause of Catatonia is DEPRESSION.

• Second most common cause is MANIA a.k.a Excitatory Catatonia
• Third most common cause of Catatonia is Schizophrenia
 TYPES:

There are three types of catatonia:

• Akinetic catatonia.
(also called retarded catatonia) involves a lack of movement and
responsiveness; the person may stare blankly or not reply to others.
This is the most common. Someone with akinetic catatonia often
stares blankly and won’t respond when you speak to them & may only
be to repeat what you said. They’d sit in an unusual position and
won’t move.
• Excited catatonia.
This is characterised by the following features: 1. Increase in
psychomotor activity, ranging from restlessness, agitation, excitement,
aggressiveness to, at times, violent behavior (furore). 2. Increase in
speech production, with increased spontaneity, pressure of speech,
loosening of associations and frank incoherence.
The person may move around, but their movement seems pointless
and impulsive. They may seem agitated, combative, or delirious, or
they may mimic the movements of someone who’s trying to help them
The excitement has no apparent relationship with the external
environment; instead inner stimuli (e.g. thought and impulses)
influence the excited behaviour. So, it is not goal-directed.
• Malignant catatonia.
Sometimes the excitement can become very severe, and is
accompanied by rigidity, hyperthermia and dehydration, finally
culminating in death.
This type happens when the symptoms lead to other health problems,
like dangerous changes in : blood pressure, body temperature, or
heart rate.
PATHOPHYSIOLOGY

Comorbid psychiatric disorders

Deficits in fetal cortical development may result in schizophrenia and

other developmental disorders. These deficits, in turn, likely produce
dysfunction in cortical and subcortical glutamatergic pathways,
resulting in the symptoms and signs of catatonia.

Individuals with developmental disability, autism, or other

developmental disabilities may be particularly vulnerable to developing
catatonia.

Imbalances in the excitatory-to-inhibitory ratio (EIR) may play a role.

Baguley proposed that alterations in interrelated networks at the spinal
and brainstem level produce catatonia.

SIGNS AND SYMPTOMS OF CATATONIA:

It occurs in children, adolescents, and adults; is associated with a

heterogeneous group of comorbid conditions; and is characterized by
a variety of symptoms and signs of impairment of the expression of
voluntary thoughts and movements.

Psychomotor manifestations of catatonia, as analyzed by latent class

techniques, have been divided into the following 4 classes:

I. Automatic
II. Repetitive/echo
III. Withdrawal
IV. Agitated/resistive
 SIGN AND SYMPTOMS:
• Stupor: Extreme hypo-activity/ Akinesis or immobility and minimal
responsiveness to stimuli.

• Excitement: Extreme hyperactivity which is usually non goal directed

(i.e. the patient is very active but doesn’t do any meaningful work).

• Posturing/catalepsy: Spontaneous maintenance of posture for long

periods of time.

• Waxy flexibility: Parts of body can be placed in positions that will be

maintained for long periods of time, even if very uncomfortable; flexible
like wax. When examiner makes a passive movement on patient, there is
a feeling of plastic resistance which resembles bending of a soft wax
candle.

• Echolalia: Mimicking of examiner’s speech.

• Echopraxia: Mimicking of examiner’s movements.

• Negativism: Patient refuses to accept examiner’s instructions or any

attempts to move him.
• Grimacing: Maintenance of odd facial expressions.

• Stereotypy: Spontaneous repetition of odd, purposeless movements.

For example, making strange movements of fingers repeatedly.
• Automatic obedience: Excessive cooperation with examiner’s
commands despite unpleasant consequences.
For example, a patient kept on protruding his tongue in response to
examiner’s commands, despite the fact that his tongue would be
pricked by a pin everytime he protruded it.

• Gegenhalten: Resistance to passive movement, which is directly

proportional to the strength of force applied.

• Mannerisms: Spontaneous repetition of odd, purposeful movements.

For example, repeatedly saluting the passerby.

• Perseveration: It is an induced movement which is

senselessly repeated.
For example, A patient takes his tongue out and in, when asked
however then keeps on repeating the out and in movement , even when
he is no longer asked. It must be noted that perseveration occurs in
response to an instruction, whereas stereotypy and mannerisms are
spontaneous.

• Ambitendency: Inability to decide the desired motor movement.

For example, when offered a hand for handshake, patient may
repeatedly bring his hand forward and backward as he is not able to
decide whether he wants to shake the hand or not.
It is ambivalence in motor movements.
CRITERIA:

The American Psychiatric Association's Diagnostic Statistical Manual of

Mental Disorders, Fifth Edition (DSM-5), categorizes catatonia as
belonging to schizophrenia spectrum and other psychotic disorders and
divides it into the following 3 categories:

Catatonia associated with another mental disorder (catatonia specifier)

Catatonic disorder due to another medical condition
Unspecified catatonia

It can be difficult to differentiate catatonia from diffuse encephalopathy,

nonconvulsive status epilepticus, neuroleptic malignant syndrome
(NMS), acute psychosis, somatization disorder, conversion disorder,
factitious disorder, malingering, and psychogenic movement disorders.

The vast differential diagnosis for catatonia not withstanding,

identification of treatable causes (eg, nonconvulsive status epilepticus
and anti-NMDA receptor encephalitis is crucial to the administration of
the needed interventions.

Diagnostic criteria (DSM-5)

For both catatonia associated with another mental disorder (catatonia

specifier) and catatonic disorder due to another medical condition,
DSM-5 notes that the clinical picture is dominated by the presence of 3
or more of the following 12 features:
1. Stupor (no psychomotor activity; not actively relating to
environment)
2. Catalepsy (passive induction of a posture held against gravity)
3. Waxy flexibility (slight, even resistance to positioning by examiner)
4. Mutism (no, or very little, verbal response) - This is not applicable if
there is established aphasia
5. Negativism (opposition or no response to instructions or external
stimuli)
6. Posturing (spontaneous and active maintenance of a posture
against gravity)
7. Mannerism (odd, circumstantial caricature of normal actions
8. Stereotypy (repetitive, abnormally frequent, non-goal-directed
movements)
9. Agitation, not influenced by external stimuli
10. Grimacing
11. Echolalia (mimicking another's speech)
12. Echopraxia (mimicking another's movements)

Catatonia associated with another mental disorder (catatonia specifier)

is indicated when the 3 or more features are present during the course
of a neurodevelopmental, psychotic, bipolar, depressive, or other
mental disorder.
Catatonia appears in 35% of individuals with schizophrenia, but the
majority of catatonia cases are associated with depressive or bipolar
disorders.

In addition, DSM-5 lists the following criteria as specific for catatonic

disorder due to another medical condition :
I. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is the direct pathophysiologic
consequence of another medical condition
II. The disturbance is not better explained by another mental disorder.
III. The disturbance does not occur exclusively during the course of
delirium
IV. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
COURSE AND TREATMENT:

Catatonia impairs a person's ability to care for himself or her self and
therefore requires hospitalization.
In an excited state, the catatonic patient may represent a danger to
others; hence, close supervision is needed.
Fluid and nutrient intake must be maintained, often with intravenous lines
or feeding tubes.

The catatonic individual must be assisted with hygiene.

The primary treatment modality is identifying and correcting the

underlying medical or pharmacological cause.
Offending substances must be removed or minimized.

Benzodiazepines can provide temporary improvement in

symptoms, and their use may improve patients' ability to communicate
and to care for themselves.

Electroconvulsive therapy (ECT) is appropriate for catatonia due to a

general medical condition, especially if the catatonia is

It might be recommended if:

• Sedatives don’t work.

• The catatonia is severe.
• The person has had catatonia before.
• life threatening (e.g., inability to eat)
• It has developed into lethal (malignant) catatonia.