What is catatonia?

Catatonia: A Neuropsychiatric Syndrome

Catatonia is a neuropsychiatric syndrome characterized primarily by psychomotor disturbances including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia. 1

Clinical Features and Diagnosis

Catatonia presents with distinctive clinical features that form the basis of diagnosis:

• Key diagnostic features:
  • Stupor (marked decrease in reactivity)
  • Catalepsy (passive induction of posture)
  • Waxy flexibility (slight resistance to positioning)
  • Mutism (little or no verbal response)
  • Negativism (opposition or no response to instructions)
  • Posturing (spontaneous maintenance of posture)
  • Mannerisms and stereotypies (repetitive movements)
  • Psychomotor agitation
  • Grimacing
  • Echolalia (mimicking speech)
  • Echopraxia (mimicking movements) 1

Diagnosis is primarily clinical and can be challenging, particularly when differentiating between medication side effects (like Parkinson's symptoms) and catatonic features 1. Validated rating scales are recommended to measure severity and treatment response 2.

Epidemiology

Catatonia is more common than generally recognized:

• Present in 9.2% of patients according to recent epidemiological studies 2
• Found in 5-18% of psychiatric inpatients and 3.3% of medical inpatients 3
• Often remains undiagnosed, putting patients at risk of life-threatening complications 3

Etiology and Risk Factors

Catatonia can occur in various contexts:

• Psychiatric disorders:

  • Mood disorders (particularly bipolar disorder and severe depression)
  • Schizophrenia
  • Autism spectrum disorders 1, 4

• Medical conditions:

  • Neurological disorders (dementia, neurodegenerative diseases, multiple sclerosis, demyelinating diseases)
  • Cerebrovascular events
  • Traumatic brain injury
  • Viral infections affecting the central nervous system (encephalitis)
  • Post-viral syndromes 1

• Other risk factors:

  • Severe psychological stress
  • Significant adverse life events
  • Genetic vulnerabilities affecting GABA and glutamate systems
  • Lower stress resilience 1

Pathophysiology

Current evidence suggests catatonia involves:

• Imbalance in neurotransmission, particularly in GABA and dopamine receptors
• Altered glutamatergic activity
• Dysfunction in cortico-cortical and cortico-subcortical pathways
• Involvement of structures such as the orbitofrontal and temporal cortex, basal ganglia, and brainstem 4

Treatment

The treatment of catatonia is well-established:

1. First-line treatment:

   • Benzodiazepines (particularly lorazepam) 1, 2, 5, 3, 4
   • Midazolam may be an alternative when IV lorazepam is unavailable, though more research is needed 6

2. Second-line treatment:

   • Electroconvulsive therapy (ECT) - particularly effective for severe or malignant catatonia or when benzodiazepines fail 1, 2, 5, 3

3. Alternative treatments:

   • NMDA antagonists (amantadine, memantine) for benzodiazepine-refractory cases 5, 3
   • Dopamine-modulating second-generation antipsychotics (clozapine, aripiprazole) in certain populations 3
   • Transcranial magnetic stimulation (emerging therapy) 2, 4

Clinical Pearls and Pitfalls

• Early recognition is crucial - unrecognized catatonia can lead to life-threatening complications 3
• Diagnostic challenge - catatonia can be mistaken for medication side effects, particularly Parkinson's-like symptoms 1
• Dual approach needed - both the catatonic symptoms and the underlying condition must be addressed 5
• High-risk populations require vigilant monitoring:
  • Patients with bipolar disorder or schizophrenia experiencing acute exacerbation
  • Patients recently started on or with dosage changes in antipsychotic medications
  • Patients with autoimmune disorders affecting the central nervous system
  • Patients experiencing abrupt discontinuation of benzodiazepines or clozapine 1

With appropriate and early treatment, the prognosis for catatonia is generally favorable 2, 3.