Catatonia

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Jesus Rosario Hernandez, M.D. [2] Luke Rusowicz-Orazem, B.S.

## Overview

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Catatonia is a syndrome of psychic and motoric disturbances. In the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (DSM-V), catatonia became recognized as a separate disorder. Catatonia is also associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression and other mental disorders, as well as drug abuse and/or overdose. It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances and abrupt or overly rapid withdrawal from benzodiazepines.[1] It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available, and depending on the case, one or more drugs may be used, including antipsychotics and benzodiazepines.

## Clinical features

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Patients with catatonia may experience an extreme loss of motor ability or constant hyperactive motor activity. Catatonic patients will sometimes hold rigid poses for hours and will ignore any external stimuli. Patients with catatonic excitement can die of exhaustion if not treated. Patients may also show stereotyped, repetitive movements. They may show specific types of movement known as "waxy flexibility" in which they maintain positions after being placed in them by someone else, or gegenhalten (lit. "counterhold"), in which they resist movement in proportion to the force applied by the examiner. They may repeat meaningless phrases or speak only to repeat what the examiner says.

### Subtypes

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Stupor is a motionless, apathetic state in which one is oblivious or does not react to external stimuli. Motor activity is nearly non-existent. Individuals in this state make little or no eye contact with others and may be mute and rigid. One might remain in one position for a long period of time, and then go directly to another position immediately after the first position.

Catatonic excitement is state of constant purposeless agitation and excitation. Individuals in this state are extremely hyperactive although the activity seems to lack purpose.

## Causes

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### Common Causes

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* Acute intermittent porphyria
* Acute stress disorder
* Addison's Disease
* Alcohol intoxication
* Anorexia nervosa
* Arachnoid cyst in right parietal region
* Astrocytoma
* Autistic disorder
* Bilateral hemorrhagic lesions of temporal lobes
* Brain cyst
* Brain disorders
* Brain trauma
* Brain tumour
* Brief psychotic disorder
* Bronchorrhea
* Catatonic schizophrenia
* Central pontine myelinolysis
* Cerebellar catalepsy
* Cerebral hemorrhage
* Cerebral infarct
* Cerebrovascular disease
* Cns bleed
* Conversion disorder
* Cortical basal ganglionic degeneration
* Cortical venous thrombosis
* Delirium
* Drug withdrawal
* Dystonia
* Emotional trauma
* Encephalitis
* Encephalopathy
* Familial fatal insomnia
* Frontal lobe brain damage
* Frontal lobotomy
* Head trauma
* Heat stroke
* Hepatic encephalopathy
* Hepatic failure
* Hereditary coproporphyria
* Homocystinuria
* Huntington's disease
* Hydrocephalus
* Hyperparathyroidism
* Hyperthyroidism
* Hyponatremia
* Hypopituitarism secondary to postpartum hemorrhage
* Hypothermia
* Idiopathic recurring stupor
* Inherited neurometabolic disorders
* Intestinal atony
* Locked-in syndrome
* Lorazepam
* Meningitis
* Meningoencephalitis
* Mental illness
* Multiple sclerosis
* Neoplasms
* Neuroleptic malignant syndrome
* Neurosyphilis
* Nonconvulsive status epilepticus
* Pallidoluysian atrophy
* Paraneoplastic encephalitis
* Parkinson's disease
* Postencephalitic parkinsonism
* Posttraumatic stress disorder
* Presenile dementia, kraepelin type \- catatonia
* Progressive multifocal leukoencephalopathy
* Progressive supranuclear palsy
* Reactive psychosis
* Schizencephaly
* Schizoaffective disorder
* Schizophrenia
* Schizophreniform disorder
* Sedative withdrawal
* Seizures
* Sibutramine
* Status epilepticus
* Stiff-man syndrome
* Stroke
* Strychnine poisoning
* Stupor
* Subarachnoid hemorrhage
* Subdural hematoma
* Subthalamic mesencephalic tumor
* Surgical removal of cerebellar tumor
* Syndrome of inappropriate antidiuretic hormone (siadh)
* Syphilis
* Systemic lupus erythematosus
* Tay-sachs disease
* Temporal lobe epilepsy
* Thrombotic thrombocytopenic purpura
* Tuberculosis
* Tuberous sclerosis
* Tumors
* Typhoid fever
* Vegetative state
* Viral encephalitis
* Wilson's disease

### Causes by Organ System

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Cardiovascular | Basilar artery thrombosis, Cortical venous thrombosis, Fibromuscular dysplasia with dissection of basilar artery, Stroke

|

Chemical/Poisoning | Carbon monoxide poisoning, Poisoning , Strychnine poisoning
Dental | No underlying causes
Dermatologic | Thrombotic thrombocytopenic purpura
Drug Side Effect | Drug withdrawal, Lorazepam, Medications, Neuroleptic malignant syndrome, Sedative withdrawal, Sibutramine
Ear Nose Throat | No underlying causes
Endocrine | Acute intermittent porphyria, Addison's disease, Homocystinuria, Hyperparathyroidism, Hyperthyroidism, Hypopituitarism secondary to postpartum hemorrhage
Environmental | No underlying causes
Gastroenterologic | Intestinal atony
Genetic | Pallidoluysian atrophy, Tay-sachs disease, Tuberous sclerosis , Wilson's disease
Hematologic | Bacterial septicemia, Hypercalcemia, Thrombotic thrombocytopenic purpura, Uremia
Iatrogenic | Frontal lobotomy
Infectious Disease | Aids, Bacterial septicemia, Fever , Malaria, Meningitis, Meningoencephalitis, Neurosyphilis, Syphilis, Tetanus, Tuberculosis, Typhoid fever, Viral encephalitis
Musculoskeletal/Orthopedic | Intestinal atony
Neurologic | Akinetic-rigid syndrome, Arachnoid cyst in right parietal region, Astrocytoma, Atrophy of left amygdala, Bilateral hemorrhagic lesions of temporal lobes, Brain cyst, Brain disorders, Brain trauma, Brain tumour, Central pontine myelinolysis, Cerebellar catalepsy, Cerebral hemorrhage, Cerebral infarct, Cerebrovascular disease, Cns bleed, Cortical basal ganglionic degeneration, Cortical venous thrombosis, Dystonia, Encephalitis , Encephalopathy , Familial fatal insomnia, Frontal lobe brain damage, Frontal lobotomy, Hepatic encephalopathy, Huntington's disease, Hydrocephalus, Idiopathic recurring stupor, Inherited neurometabolic disorders, Locked-in syndrome, Meningitis, Meningoencephalitis, Multiple sclerosis, Neuroleptic malignant syndrome, Neurosyphilis, Nonconvulsive status epilepticus, Pallidoluysian atrophy, Paraneoplastic encephalitis, Parkinson's disease, Pervasive developmental disorders, Postencephalitic parkinsonism, Presenile dementia, kraepelin type \- catatonia, Progressive multifocal leukoencephalopathy, Progressive supranuclear palsy, Seizures, Status epilepticus, Stiff-man syndrome, Stupor, Subarachnoid hemorrhage, Subdural hematoma, Subthalamic mesencephalic tumor, Surgical removal of cerebellar tumor, Syndrome of inappropriate antidiuretic hormone (siadh), Temporal lobe epilepsy, Tuberous sclerosis , Vegetative state, Viral encephalitis, Wilson's disease
Nutritional/Metabolic | Acute intermittent porphyria, Diabetic ketoacidosis, Hereditary coproporphyria, Inherited neurometabolic disorders
Obstetric/Gynecologic | No underlying causes
Oncologic | Arachnoid cyst in right parietal region, Astrocytoma, Brain cyst, Brain tumour, Carcinoid tumors, Neoplasms, Paraneoplastic encephalitis, Subthalamic mesencephalic tumor, Surgical removal of cerebellar tumor, Tumors
Ophthalmologic | Homocystinuria
Overdose/Toxicity | Alcohol intoxication, Substance intoxication
Psychiatric | Acute stress disorder, Anorexia nervosa, Autistic disorder, Brief psychotic disorder, Catatonic schizophrenia, Conversion disorder, Delirium, Depression, Emotional trauma, Huntington's disease, Hysteria, Mental illness, Mood disorders, Pervasive developmental disorders, Posttraumatic stress disorder, Reactive psychosis , Schizencephaly, Schizoaffective disorder, Schizophrenia, Schizophreniform disorder, Wilson's disease
Pulmonary | Bronchorrhea, Tuberculosis
Renal/Electrolyte | Central pontine myelinolysis, Diabetic ketoacidosis, Electrolyte imbalances, Hepatic encephalopathy, Hepatic failure, Hyponatremia, Renal failure, Uremia
Rheumatology/Immunology/Allergy | Systemic lupus erythematosus
Sexual | Aids, Syphilis
Trauma | Head trauma, Heat stroke, Hypothermia, Malignant hyperthermia, Thermal injury
Urologic | No underlying causes
Miscellaneous | No underlying causes

### Causes in Alphabetical Order

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* Acute intermittent porphyria
* Acute stress disorder
* Addison's disease
* Aids
* Akinetic-rigid syndrome
* Alcohol intoxication
* Anorexia nervosa
* Arachnoid cyst in right parietal region
* Astrocytoma
* Atrophy of left amygdala
* Autistic disorder
* Bacterial septicemia
* Basilar artery thrombosis
* Bilateral hemorrhagic lesions of temporal lobes
* Brain cyst
* Brain disorders
* Brain trauma
* Brain tumour
* Brief psychotic disorder
* Bronchorrhea
* Carbon monoxide poisoning
* Carcinoid tumors
* Catatonic schizophrenia
* Central pontine myelinolysis
* Cerebellar catalepsy
* Cerebral hemorrhage
* Cerebral infarct
* Cerebrovascular disease
* Cns bleed
* Conversion disorder
* Cortical basal ganglionic degeneration
* Cortical venous thrombosis
* Delirium
* Depression
* Diabetic ketoacidosis
* Drug withdrawal
* Dystonia
* Electrolyte imbalances
* Emotional trauma
* Encephalitis
* Encephalopathy
* Familial fatal insomnia
* Fever
* Fibromuscular dysplasia with dissection of basilar artery
* Frontal lobe brain damage
* Frontal lobotomy
* Head trauma
* Heat stroke
* Hepatic encephalopathy
* Hepatic failure
* Hereditary coproporphyria
* Homocystinuria
* Huntington's disease
* Hydrocephalus
* Hypercalcemia
* Hyperparathyroidism
* Hyperthyroidism
* Hyponatremia
* Hypopituitarism secondary to postpartum hemorrhage
* Hypothermia
* Hysteria
* Idiopathic recurring stupor
* Inherited neurometabolic disorders
* Intestinal atony
* Locked-in syndrome
* Lorazepam
* Malaria
* Malignant hyperthermia
* Medications
* Meningitis
* Meningoencephalitis
* Mental illness
* Mood disorders
* Multiple sclerosis
* Neoplasms
* Neuroleptic malignant syndrome
* Neurosyphilis
* Nonconvulsive status epilepticus
* Pallidoluysian atrophy
* Paraneoplastic encephalitis
* Parkinson's disease
* Pervasive developmental disorders
* Poisoning
* Postencephalitic parkinsonism
* Posttraumatic stress disorder
* Presenile dementia, kraepelin type \- catatonia
* Progressive multifocal leukoencephalopathy
* Progressive supranuclear palsy
* Reactive psychosis
* Renal failure
* Schizencephaly
* Schizoaffective disorder
* Schizophrenia
* Schizophreniform disorder
* Sedative withdrawal
* Seizures
* Sibutramine
* Status epilepticus
* Stiff-man syndrome
* Stroke
* Strychnine poisoning
* Stupor
* Subarachnoid hemorrhage
* Subdural hematoma
* Substance intoxication
* Subthalamic mesencephalic tumor
* Surgical removal of cerebellar tumor
* Syndrome of inappropriate antidiuretic hormone (siadh)
* Syphilis
* Systemic lupus erythematosus
* Tay-sachs disease
* Temporal lobe epilepsy
* Tetanus
* Thermal injury
* Thrombotic thrombocytopenic purpura
* Tuberculosis
* Tuberous sclerosis
* Tumors
* Typhoid fever
* Uremia
* Vegetative state
* Viral encephalitis
* Wilson's disease

## Catatonia Associated with Another Mental Disorder

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### Risk Factors

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* Bipolar disorders
* Depressive disorders
* Schizophrenia[2]

### Natural History, Complications and Prognosis

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Poor prognostic factors include:

* Bipolar disorder
* Depressive disorder
* Mental disorder
* Metabolic conditions
* Infectious conditions
* Psychotic disorder[2]

### DSM-V Diagnostic Criteria for Catatonic Disorder Due to Another Medical Condition[2]

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“  |

Catatonia associated with another mental disorder (catatonia specifier) may be used when criteria are met for catatonia during the course of a neurodevelopmental, psychotic, bipolar, depressive, or other mental disorder.

* A. The clinical picture is dominated by three (or more) of the following symptoms:

1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [Note: not applicable if there is an established aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).

| ”

|
|

## Catatonia Due to Another Medical Condition

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### Differential Diagnosis

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* Brief psychotic disorder
* Cerebrovascular disease
* Diabetic ketoacidosis
* Encephalitis
* Neoplasms
* Head trauma
* Hepatic encephalopathy
* Hypercalcemia
* Homocystinuria
* Schizoaffective disorder
* Schizophrenia
* Schizophreniform disorder
* Substance/medication-induced psychotic disorder
* Neuroleptic malignant syndrome
* Neuroleptic-induced movement disorder[2]

### DSM-V Diagnostic Criteria for Catatonia due to Another Medical Condition[2]

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“  |

* A. The clinical picture is dominated by three (or more) of the following symptoms:

1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [Note: not applicable if there is an established aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).

AND

* B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

AND

* C. The disturbance is not better explained by another mental disorder(e.g.,amanicepisode).

AND

* D. The disturbance does not occur exclusively during the course of a delirium.

AND

* E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

| ”

|
|

## Treatment

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Initial treatment is aimed at providing relief from the catatonic state. Benzodiazepines are the first line of treatment, and high doses are often required. A test dose of 1-2 mg intramuscular lorazepam will often result in marked improvement within half an hour. In France, zolpidem has also been used in diagnosis and response may occur within the same time period. Ultimately the underlying cause needs to be treated.

Electroconvulsive therapy is an effective treatment for catatonia as well as for most of the underlying causes (e.g. psychosis, mania, depression). Antipsychotics should be used with care as they can worsen catatonia and are the cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires the immediate discontinuation of the antipsychotic.

## References

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1. ↑ Rosebush PI (1996). "Catatonia after benzodiazepine withdrawal". Journal of clinical psychopharmacology. 16 (4): 315–9. PMID 883570. Unknown parameter `|coauthors=` ignored (help); Unknown parameter `|month=` ignored (help)
2. ↑ 2.0 2.1 2.2 2.3 2.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.