A syndrome of behavioral and motor disturbances,
Process typically occurs in people with an underlying psychiatric or medical illness.
Confused with other diagnoses including: primary psychiatric disorders, neuroleptic malignant syndrome, serotonin syndrome, and stroke.
Unusual underlying causes include NMDA encephalitis, metabolic disorders, focal cerebral lesions, the use of illicit drugs, especially benzodiazepine withdrawal, alcohol or opioids, delirium, postpartum psychosis, and UTI, in older patients.
Three categories of catatonia are noted in The Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition.
Catatonia associated with another mental disorder.
Catatonia due to another medical condition.
Often unrecognized as its severity ranges from subtle behavioral abnormalities, lasting only hours, to malignant, at times lethal forms.
Clinical features fluctuate over periods of time between stupor and severe agitation, or from a comfortable conversation to mutism that persists for hours.
Patients with catatonia, do not engage with their surroundings, with other people, it is difficult to obtain a history and mental status examination.
Catatonia is common in psychiatric emergency room and inpatient units with the prevalence estimates of 9 to 30%.
Its most common presentation in the ED is failure to respond to questions, that is mutism, and very little spontaneous movement, described as stupor.
These are psychomotor behaviors which are essential elements of catatonia.
A second catatonia presentation is rapidly fluctuating levels of psychomotor behavior, ranging from mutism and stupor to posturing and agitation: this type of catatonia may be due to ingested substances, or another medical condition.
A third catatonic presentation includes rigididity accompanied by repetitive, purposeless movements, such as rocking back-and-forth, and is usually encountered in persons with autism or schizophrenia spectrum disorder.
Among medical patients, its estimated prevalence is less than 10%.among medical patients.
12 Signs of catatonia are recognized as diagnostic criteria.
Three of the signs being present is sufficient for diagnosis.
Some signs found in patients: staring, stupor, mutism, and
Signs considered almost pathognomic occur in 20% of patients: echophenomena, waxy flexibility, and resistance to positioning, cataplexy with the passive induction of a posture that is held by the patient against gravity.
Catatonic signs may emerge within hours in acute catatonia, when they develop slowly over days to weeks.
Catatonic episodes may recur periodically or they may persist for years.
Most cases of acute catatonia remit promptly to therapy.
With the administration of intravenous lorazepam, within minutes a previous mute patient would start talking and immobile patients will move and resume oral intake.
Treatment effects wear off quickly, and can be reinstated with repeated ministration.
Intramuscular or oral administration is also effective, although with a slower onset of action.
Lorazepam is effective in up to 90% of acute catatonia cases.
Patients needed to be monitored for vital signs, nutrition, dehydration, and bedsores.
Severe malignant catatonia may be related to hyperthermia, tachycardia, renal failure, pneumonia, and metabolic disorders.
Patients with severe catatonia, particularly have prominent rigidity, mutism, or stupor that may result in death.
Differential diagnosis include neuroleptic malignant syndrome, and serotonin syndrome.
Catatonia in psychiatric patients may be due to a medical condition rather than underlying psychiatric disorder.
The signs of catatonia or not easily distinguish from other features of psychiatric illness.
Catatonia is a clinical diagnosis and its severity can be captured and standardized by rating scales:excitement, immobility, staring, mannerisms, and rigidity.
Assessment requires physical examination, vital signs, blood counts and metabolic panel with more specific laboratory tests of neuroimaging, and EEG, if needed to rule out underlying neurologic disorder.
Management of catatonia includes treatment of an underlying disorder and prevention of complications.
Primary treatment should be initiated as soon as possible, since the likelihood of response declines with time.
Both lorazepam administration and electroconvulsive therapy lead to response in 60 to 100% of patients.
Electroconvulsive therapy is also effective after insufficient response to benzodiazepine administration.
Second line treatments include NMDA, receptor antagonists amantadine and memantine.