catatonia

catatonia, psychomotor syndrome in which an affected individual is unresponsive and immobile or occasionally hyperactive, agitated, or restless. Catatonia is most often seen in adults, though it sometimes occurs in children. The syndrome commonly is associated with mood disorders, toxic neural conditions (such as those caused by medications), and infections; in some instances, it appears to develop on its own, in the absence of known risk factors.

Characteristics

Catatonia is associated with more than 40 motor-related behaviours, which generally are categorized into two groups: those slowing a person toward immobility and inaction and those agitating a person with hyperactivity. The immobilizing form of catatonia, which is more common, can include mutism, stupor (no reactivity), staring, waxy flexibility (slight resistance to repositioning), negativism (refusing all instructions), posturing (striking odd poses), stereotyped movements or expressions, automatic obedience, echolalia (repeating the words of others), echopraxia (repeating the movements of others), and various odd mannerisms. These movements have been described as especially relating to the patient’s mood, thoughts, or vigilance. The agitating form of catatonia includes hyperactive movements and behaviours that can sometimes lead to dangerous complications, such as hyperthermia or autonomic dysfunction, which causes sweating and impacts heart rate and blood pressure. This condition can be fatal if left untreated. The symptoms of catatonia often mean that patients will refuse to eat or drink, which eventually can cause further health complications.

Some psychologists have categorized subtypes of catatonia according to not only symptom clusters but also temporal patterns and family history. Distinguishing between types of catatonia and similar but different syndromes can be difficult, although it is essential because in some cases the treatment differs. Recognized subtypes of catatonia include: periodic catatonia (symptoms come and go), malignant catatonia (affecting the entire body in a potentially lethal way), neuroleptic malignant syndrome (a response to antipsychotic drugs), toxic serotonin syndrome (a response to a mood-disorder drug), excited catatonia (a rapid onset of delirium, mania, and psychosis), benign stupor, and oneirophrenia (a dreamlike state of consciousness with associative disturbances and difficulty assessing the reality of sensory perceptions).

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Causes

Catatonia may occur with autism and is observed in psychiatric patients at a relatively high frequency, with between 7 and 38 percent of hospitalized psychiatric patients exhibiting catatonia. These associations contribute to the idea that catatonia stems from abnormalities in neurotransmitter signaling, specifically within the basal ganglia and cortical regions of the brain. However, the neural underpinnings of catatonia remain unclear and may in fact differ according to other health problems that co-occur with the condition. In children catatonia may be associated with the presence of a developmental disorder, including intellectual disability or pervasive developmental disorder. Some aspects of catatonia may be due to a heritable genetic trait, although this may be the result of correlations with associated genetic conditions, such as bipolar disorder.

Diagnosis and treatment

The guidelines for diagnosing catatonia have changed over time and can differ between organizations and psychological practices. Some psychologists have defined catatonia as occurring when at least 2 of 40 associated behaviours last for an hour or longer. Others look for 4 of 11 specific behaviours. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; 2013) adopted a system in which 3 of 12 specific behaviours must be present to diagnose catatonia. These behaviours include catalepsy (postures held against gravity), waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerism, stereotypes, grimacing, echolalia, and echopraxia. Many psychologists consider immobility and mutism to be the core, most common, behaviours of catatonia.

Successful treatment for catatonia is well established. Lorazepam, which is a benzodiazepine drug, and electroconvulsive therapy (ECT) are effective treatments for catatonia. Lorazepam is often administered by intramuscular injection, since catatonic patients may refuse to eat or drink. The drug is effective in the majority of cases, although catatonia associated with schizophrenia is thought to be less responsive to lorazepam. Since ECT requires consent, which is difficult to obtain from catatonic patients, it is used less often; in potentially lethal cases of catatonia, however, it is used with surrogate consent. If left untreated, catatonia can lead to lethal complications.

History

Catatonia was first described in the late 1800s as a suite of psychomotor behaviours associated with schizophrenia. By the 1970s, psychologists had observed that catatonia typically occurs with other psychological conditions beyond schizophrenia; in the 2010s it was officially recognized as a distinct disorder, primarily associated with affective mood disorders. There is ongoing debate about how to categorize catatonia in the field of psychology. TheDSM-IV listed it as either a specific qualifier of other mental disorders or a disorder that complicates medical conditions not associated with mental illness. The DSM-5 treats catatonia as a specific qualifier of other disorders but also allows it to be diagnosed on its own when the associated problems are difficult to identify.

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