How is catatonia identified clinically?

Clinical Identification of Catatonia

Catatonia is identified clinically as a syndrome of primarily psychomotor disturbances characterized by the occurrence of several different symptoms including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia. 1

Diagnostic Criteria

The most empirically validated approach to diagnosing catatonia requires the presence of three or more of the following 11 signs:

1. Immobility/stupor - Extreme passivity, marked hypokinesia
2. Mutism - Includes inaudible whisper
3. Negativism - Resistance to instructions, contrary behavior
4. Oppositionism/gegenhalten - Resistance to passive movement that increases with force
5. Posturing - Spontaneous adoption of odd postures
6. Catalepsy - Passive maintenance of imposed limb positions (waxy flexibility)
7. Automatic obedience - Exaggerated cooperation with instructed movements
8. Echo phenomena - Copying examiner's movements, mimicry or speech
9. Rigidity - Increased muscular tone
10. Verbigeration - Continuous, directionless repetition of words/phrases
11. Withdrawal/refusal to eat or drink - Turning away, no eye contact, refusal of food/drink

This diagnostic threshold of three or more signs has been validated with 100% sensitivity and 99% specificity 2, 3.

Clinical Subtypes

Catatonia presents in two main subtypes:

• Retarded catatonia - Characterized by immobility, mutism, staring, rigidity
• Excited catatonia - Less common, characterized by prolonged psychomotor agitation 4

Additionally, malignant catatonia is a severe, potentially life-threatening form that includes autonomic instability with labile blood pressure, hyperthermia, and diaphoresis 2.

Differential Diagnosis

When evaluating a patient with suspected catatonia, it's crucial to differentiate from:

1. Neuroleptic Malignant Syndrome (NMS) - Features exposure to dopamine antagonist or withdrawal of dopamine agonist within 3 days, hyperthermia, muscle rigidity, mental status alteration, elevated creatine kinase, autonomic instability, and leukocytosis 5

2. Serotonin Syndrome - Requires recent serotonergic drug use and specific symptoms per Hunter criteria including muscle rigidity, hyperthermia, ocular clonus, inducible clonus, tremor, and hyperreflexia 5

3. Parkinsonism - May be difficult to differentiate from catatonic symptoms, particularly negative symptoms or severe cases 1

4. Delirium - Features inattention, fluctuating course, and disturbances in consciousness 1

Clinical Evaluation

When assessing a patient with suspected catatonia:

1. Observe for psychomotor abnormalities - Look specifically for the 11 diagnostic signs listed above

2. Assess for underlying causes - Catatonia occurs with various medical and psychiatric conditions:

   • Mood disorders (most common psychiatric association)
   • Schizophrenia
   • Medical conditions (approximately 14% of cases) 2
   • Neurological disorders (particularly frontal lobe dysfunction) 6

3. Rule out medical emergencies - Particularly malignant catatonia which requires immediate intervention 2

4. Medication review - Assess for medications that may cause or exacerbate catatonia, particularly antipsychotics 1

Key Clinical Pitfalls

1. Misdiagnosis as schizophrenia - While historically considered a subtype of schizophrenia, catatonia is now recognized to occur more commonly with mood disorders 2

2. Overlooking medical causes - Always investigate for underlying medical conditions before attributing to psychiatric causes

3. Inappropriate antipsychotic use - Neuroleptics can worsen catatonia and are potentially lethal when catatonic symptoms are present 2

4. Delayed treatment - Catatonia requires prompt recognition and treatment to prevent complications

5. Missing malignant catatonia - This life-threatening variant requires emergency intervention with ECT if autonomic instability or hyperthermia develops 2

Catatonia is a complex neuropsychiatric syndrome that requires careful clinical assessment. The presence of three or more characteristic motor signs in the appropriate clinical context should prompt diagnosis and immediate treatment, as catatonia is highly treatable but associated with significant morbidity and mortality if left untreated 4.