From the Guidelines
Catatonia is a neuropsychiatric syndrome characterized by abnormal movements, behaviors, and withdrawal that results from dysregulation in multiple neurotransmitter systems, particularly GABA and glutamate, and it responds to benzodiazepines due to their ability to enhance GABA neurotransmission. The pathophysiology of catatonia involves hyperactivity in the glutamatergic system (excitatory) and hypoactivity in the GABAergic system (inhibitory), creating an imbalance that leads to the characteristic symptoms 1. This dysregulation affects brain regions controlling motor function, particularly the basal ganglia, supplementary motor areas, and orbitofrontal cortex.
Key Points
- The imbalance between excitatory and inhibitory neurotransmission is key to the development of catatonia
- Benzodiazepines, such as lorazepam, effectively treat catatonia by enhancing GABA neurotransmission and restoring the balance between excitatory and inhibitory neurotransmission
- The dose of lorazepam typically starts at 1-2mg every 4-6 hours, with adjustments based on response, and most patients respond within 48 hours
- For patients who don't respond adequately to benzodiazepines, electroconvulsive therapy is considered the next treatment option, as indicated by the practice parameter for the use of electroconvulsive therapy with adolescents 1
Treatment Approach
The treatment approach for catatonia should prioritize the use of benzodiazepines as the first-line treatment, given their effectiveness in restoring the balance between excitatory and inhibitory neurotransmission. The use of benzodiazepines, such as lorazepam, is the most effective treatment for catatonia, and it should be considered as the initial treatment option. In cases where patients do not respond to benzodiazepines, electroconvulsive therapy may be considered as the next treatment option, as it has been shown to be effective in treating catatonia, particularly in adolescents with severe and treatment-resistant conditions 1.
From the Research
Pathophysiology of Catatonia
- Catatonia is a syndrome associated with several mental illness disorders and medical conditions, including schizophrenia, mania, depression, hyponatremia, cerebral venous sinus thrombosis, and liver transplantation 2
- The pathophysiology of catatonia is proposed to involve aberrant neuronal activity in different motor pathways, defective neurotransmitter regulation, and impaired oligodendrocyte function 2
- Prolonged use of benzodiazepines or clozapine may increase gamma-aminobutyric acid (GABA) activity, and discontinuation may increase excitatory neurotransmission, leading to catatonia 2
Response to Benzodiazepines
- Benzodiazepines, such as lorazepam, are often used in combination therapy with antipsychotics to treat catatonia 2
- The lorazepam-diazepam protocol has been shown to rapidly relieve catatonia in schizophrenia within a day 3
- Benzodiazepines may work by enhancing GABA transmission in certain brain areas, which may contribute to their efficacy in treating catatonic symptoms 4
- However, some patients may not respond to benzodiazepines, and alternative treatment strategies, such as electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS), may be necessary 5, 6
Alternative Treatment Strategies
- rTMS and transcranial direct current stimulation (tDCS) may be promising alternative treatment strategies for patients who do not respond to benzodiazepines or in case ECT is not available or contraindicated 5
- Aripiprazole, an antipsychotic with a unique receptor profile, has been shown to rapidly resolve catatonic symptoms in some cases, and may be considered as a viable alternative to ECT and benzodiazepines 4