What are the different types of catatonia?

Types of Catatonia

Catatonia is classified into three main types: retarded (stuporous) catatonia, excited catatonia, and malignant catatonia, each with distinct clinical presentations and management considerations. 1, 2

Main Types of Catatonia

1. Retarded (Stuporous) Catatonia

• Most common presentation
• Characterized by:
  • Immobility/stupor
  • Mutism
  • Negativism
  • Catalepsy (waxy flexibility)
  • Posturing
  • Automatic obedience
  • Withdrawal/refusal to eat or drink 1, 3

2. Excited Catatonia

• Less common presentation
• Characterized by:
  • Prolonged psychomotor agitation
  • Combativeness
  • Purposeless hyperactivity
  • Stereotypies
  • Grimacing
  • Verbigeration (repetitive speech)
  • Echo phenomena (echolalia and echopraxia) 3, 2

3. Malignant Catatonia

• Life-threatening form with significant autonomic instability
• Characterized by:
  • Features of either retarded or excited catatonia
  • Hyperthermia
  • Autonomic instability (fluctuations in blood pressure, heart rate)
  • Respiratory abnormalities
  • Can progress to delirium, coma, and death if untreated 4, 5

Special Variants of Catatonia

1. Periodic Catatonia

• Recurrent episodes of catatonia with relatively symptom-free intervals
• May have familial patterns

2. Medication-Induced Catatonia

• Can occur with:
  • Neuroleptic medications (particularly high-potency antipsychotics)
  • Abrupt withdrawal of medications (including clozapine) 6

3. Neuroleptic Malignant Syndrome (NMS)

• Considered by some experts to be a medication-induced variant of malignant catatonia
• Features exposure to dopamine antagonist or withdrawal of dopamine agonist
• Presents with hyperthermia, muscle rigidity, altered mental status, and autonomic instability 1

Diagnostic Considerations

The diagnosis of catatonia requires the presence of three or more of the following 11 signs:

1. Immobility/stupor
2. Mutism
3. Negativism
4. Oppositionism/gegenhalten
5. Posturing
6. Catalepsy
7. Automatic obedience
8. Echo phenomena
9. Rigidity
10. Verbigeration
11. Withdrawal/refusal to eat or drink 1

Important Clinical Pitfalls

• Catatonia can be misdiagnosed as Parkinsonism, particularly when presenting with negative symptoms or in severe cases 7
• Failure to recognize malignant catatonia can lead to life-threatening complications
• Treating catatonia with antipsychotics may worsen the condition, particularly in malignant forms
• Catatonia often requires treatment before underlying conditions can be accurately diagnosed 3
• Catatonia is not exclusive to psychiatric disorders and can occur in various medical conditions, requiring thorough evaluation for underlying causes 2

Understanding these distinct types of catatonia is crucial for early recognition and appropriate management to reduce morbidity and mortality associated with this complex neuropsychiatric syndrome.