Catatonia

Catatonia

Presenter: Dr Pavan Kumar K

Chairperson: Dr Manju Bhaskar

Outline

Definition Nosology Hypothesis of catatonia Causes of catatonia Primary Vs secondary catatonia Depressive Vs schizophrenia catatonia Rating scales Examination for catatonia Diagnostic evaluation of catatonia Management of catatonia Conclusion

Definition

“to stretch tightly”

SYNDROME OF MOTOR ABNORMALITIES IN ASSOCIATION WITH DISORDERS OF MOOD, BEHAVIOR AND THOUGHT.

Catatonia is a condition that can be caused by a variety of metabolic, neurological, psychiatric and toxic conditions

Nosology

Karl Ludwig Kahlbaum 1874 Coined the term ‘Catatonia’

04-10-2011 4

“Catatonia is a brain disease with a cyclic, alternating course, in which the mental symptoms are, consecutively melancholy, mania, stupor, confusion, and eventually dementia.”Monograph Die Katatonie oder das Speannungsirresein (The Tonic Mental Disorder or the Tension Insanity)

Nosology

Kraepelin and Bleuler (1919) Included catatonia in their broad definition of schizophrenia

(Dementia praecox) Strong, persistent influence on classification of catatonia

as an exclusive subtype of schizophrenia

Morrison (1974) Reawakened the profession to the association between

catatonia and mood disorders

Abrams and Taylor (1976) Reestablished link between catatonia and mood disorders

Gelenberg Documented association of catatonia with neurological and general medical disorders

Gjessing (1976) periodic catatonia

Fink and Taylor Emphasized that catatonia should not be linked exclusively

to schizophrenia – should be seen as a syndrome associated with many psychiatric, neurological and general medical illnesses

Nosology

The idea that the catatonia is tied to schizophrenia was coded in all DSM and ICD editions

DSM-IV Continues to classify catatonia as a subtype of

schizophrenia In addition, has added catatonia as a specifier in

mood disorders and as a syndrome resulting from a general medical disorder

DSM IV TR

In DSM–IV TR a diagnosis of ‘schizophrenia, catatonic type’ (295.20) is made if the clinical picture is dominated by at least two of the following:

motor immobility, excessive motor activity,

extreme negativism, peculiarities of voluntary

movements,and echolalia/echopraxia. If a physical cause is identified the diagnosis is

‘catatonic disorder due to a medical condition’ (293.89).

As in ICD–10, there is no separate diagnostic category for catatonia due to either depression or mania, but catatonia can be added as a specifier in mood disorders.

Catatonia in ICD-10

ICD – 10

ORGANIC CATATONIC DISORDER(F06.1)

CATATONIC SCHIZOPHRENIA.(F20.2)

The ICD–10

Catatonia due to physical causes is diagnosed as‘organic catatonic disorder’ (F06.1).

diagnosis of catatonic schizophrenia ( F20.2) requires at least one of the following catatonic features, stupor, excitement, posturing, negativism, rigidity,

waxy flexibility and command automatism (automatic obedience).

for at least 2 weeks

If a patient with severe depression is in a stupor, a diagnosis of ‘severe depressive episode with psychotic symptoms’ (F32.3) is made, even if there are no delusions or hallucinations.

Similarly, a patient with manic stupor will be diagnosed as having ‘mania with psychotic symptoms’ (F30.2)

For depression or mania, only stupor, which is the most extreme of catatonic signs, seems to have diagnostic implications, whereas for schizophrenia a broader range of signs are considered relevant.

Epidemiology

Organic disorders- 1/4 of catatonia 7-17% in acute psychiatric patients 13-31% occurrence in mood disorders (Caroff

et al 2004) Abraham & Taylor (1976)- significant number in

affective illness(mania)-28% Approximately 10 % are associated with

schizophrenia(incidence decreasing)

Under-recognised and under-diagnosed (Van der Heijden et al, 2005).

The introduction of antipsychotics has reduced the incidence of catatonia,it is still not uncommon (Stompe et al, 2002) and

Detection rate can be significantly improved by using a standardised rating scale (Van der Heijden et al, 2005).

India 13.5% (Chalasani, 2005)

Hypothesis of Catatonia

Northoff (2002), a ‘top-down modulation’ of basal ganglia G-aminobutyric acid (GABA) hypoactivity at the

GABAA receptor(therapeutic effect of BZDs) Glutamate hyperactivity at the n-methyl-d-

aspartate (NMDA) receptor

Osman & Khurasani (1994) caused by a sudden and massive blockade of

dopamine.(antipsychotics are not generally beneficial in catatonia)

.

Serotonin hyperactivity at the 5-HT1A receptor

and hypoactivity at the 5-HT2A receptor and

Yeh et al, 2004 cholinergic and serotonergic rebound

hyperactivity(Clozapine-withdrawal catatonia)

CATATONIA

GABA A

D2 5 HT2A 5 HT1A

GABA B

-

-- +

+

Moskowitz (2004) Catatonia- evolutionary fear response,originating

in ancestral encounters with carnivores whose predatory instincts were triggered by movement.

This response, of remaining still, is now expressed in a range of major psychiatric or medical conditions, where catatonic stupor may represent a common ‘end-state’ response to feelings of imminent doom.

PATHOPHYSIOLOGY

MOTOR SYMPTOMS dysfunction in termination of movements and

right posterior parietal cortex. AFFECTIVE SYMPTOMS

strong, intense and uncontrollable emotional symptoms may be accounted for by dysfunction in medial orbitofrontal cortex and gaba-ergic neurotransmission.

Cont… BEHAVIORAL SYMPTOMS

Bizarre behavioral abnormalities may be related to deficts in behavioral inhibition and lateral orbito frontal cortical activity. Vegetative abnormalities may be related with alteration in midbrain and brainstem nuclei.

Sub types

Catatonia appears in many guises (responses to a lorazepam challenge) Hypokinetic catatonia (Kahlbaum syndrome), Excited catatonia

(delirious mania, oneiroid state), Malignant catatonia, The neuroleptic malignant and toxic

serotonin syndromes, Periodic catatonia (rapid cycling), and Primary akinetic mutism Catatonia is also a feature in autism

Following the DSM classification model, designate three catatonia subtypes nonmalignant, delirious, and malignant

and four specifiers, secondary to: mood disorders, general medical conditions or toxic states,

neurological disorders, or psychotic disorders.

Causes of catatonia

1. Primary catatonia

2. Secondary catatonia

Causes of catatonia - primary

Psychiatric – schizophrenia, mood disorders( Taylor & Abrams, 1977), dissociative/ conversion disorder

(Galenberg,1976; Ungvari et al.,1994) OCD (Hermesh 1989), reactive psychosis, acute and transient

psychotic disorder (Banerjee & Sharma,1995;Payee et al.,1999),

postpartum/ puerperal psychiatric disorder (Bach-y-Rita & De Rainieri,1992; Ranzini et al.,1996),

PTSD (Shiloh et al.,1995), under hypnosis (Kornfeld,1985), Autistic disorder ( pervasive developmental

disorder) ( Dhossche, 1998; Zaw et al.,1999) and autistic spectrum disorder.

Secondary or organic

Neurological Medical Drugs

Organic catatonia - Neurological

Brain stem, diencephalic, basal ganglia, lesions near III ventricle, amygdala

Frontal lobe ds. (apallic syn.), SMA Parietal lobe ds. Limbic & temporal lobe ds. Head injury, dementia, MS, atrophy Encephalitis & other infections Epilepsy

Causes of catatonia - secondary Medical conditions associated with catatonia

Hepatic failure Renal failure Metabolic encephalopathy (diabetic) Endocrine dysfunction Electrolyte imbalance Alcohol intoxication Drug over dosage

Organic catatonia - Metabolic

Periodic catatonia DM, in DKA Thyroid dysfunction Hepatic failure Renal failure Porphyrias Nutritional- Wernickes, pellagra, B12 def

Organic catatonia – Drugs

Neuroleptics Alcohol Opioids Cannabis BZDs Disulfiram SSRI, TCA

Primary Vs Secondary Catatonia

In Primary catatonia Patient responds to painful stimuli Patient keeps eyes open most of the time Patient’s reflexes are normal No focal neurological deficits Patient avoids self injury (arm test) Incontinence is of retention over flow EEG pattern is that of awake test Improves with lorazepam or continues to be

same

Depressive Vs Schizophrenic catatoniaDepressive catatonia

Depressive face Athanassio’s (omega) sign Eye movements PMA retardation Mood state Past history

Schizophrenic catatonia

Vigilant face, Catatonic excitement Schnauzkrampf (snout spasm) Scanning

Rating Scales for catatonia

Bush-Francis Catatonia Rating Scale

Braunig Catatonia Rating Scale

Modified Roger’s scale

Lohr and Wisniewski scale (1987)

Northoff catatonia scale (Northoff et al.,1999b)


1. Excitement:

2. Immobility/stupor

3. Mutism

4. Staring

5. Posturing/catalepsy

6. Grimacing

7. Echopraxia/echolalia:

8. Stereotypy

9. Mannerisms

10. Verbigeration

11. Rigidity

12. Negativism

13. Waxy flexibility

14. Withdrawal

15. Impulsivity

16. Automatic obedience

17. Mitgehen

18. Gegenhalten

19. Ambitendency

20. Grasp reflex

21. Perseveration

22. Combativeness

23. Autonomic abnormality

WIRED N MIREDW

I

R

E

D

N

M

I

R

E

D

axy flexibility/catalepsy

mmobility stupor

efusal to eat or drink

xcitement

eadpan staring

egativism/negative symptoms

utism

mpulsivity

igidity

cholalia/echopraxia

irect observation

Carroll et al (2005) Current Psychiatry 4 (3) : 56 - 6404/08/2023 35


Use the presence or absence of items 1 - 14 for screening.

Use the 0 - 3 scale for items 1 -23 to rate severity

If not sure rate “0” this is for research purposes

Excitement : extreme hyperactivity, motor unrest which is apparently non-purposeful. Not to be attributed to akathesia or goal directed agitation

Immobility/stupor: extreme hypo activity, immobile, minimally responsive to stimuli.

Mutism : verbally unresponsive or minimally responsive.

Staring : fixed gaze, little or no visual scanning of environment, decreased blinking

Posturing/catalepsy : voluntary assumption and maintenance of inappropriate or bizarre posture(s)

Grimacing : maintenance of odd facial expression.

Echopraxia/echolalia: mimicking of examiner’s movement or speech.

Stereotype : repetitive non goal directed motor activity.

Mannerism : odd, purposeful movements

Verbigeration: repetition of phrases or sentences

Rigidity : maintenance of rigid position despite efforts to be moved, exclude if cog-wheeling or tremor present

Negativism : apparently motiveless resistance to instructions or attempts to move/examine patient. Contrary behavior, does exact opposite of instruction.

Waxy flexibility :maintenance of limbs and body in externally imposed positions.

Withdrawal : refusal to eat, drink and/or make eye contact.

Impulsivity : pt suddenly engages in inappropriate behavior without provocation. Afterwards can give no, or only a facile explanation

Automatic obedience: exaggerated co-operation with examiner’s request or spontaneous continuation of movement requested

Mitgehen: “Angelpose lamp” arm raising in response to light pressure of finger, despite instruction to the contrary.

Gegenhalten : resistance to passive movement which is proportional to strength of the stimulus, appears automatically rather than wilful.

Ambitendency : pt appears motorically “stuck” in indecisive, hesitant movement.

Grasp reflex

Perseveration: repeatedly returns to same topic or persists with movement.

Combativeness: usually in an undirected manner, with no, or only facile explanation

Autonomic abnormality : temp, BP, pulse, RR, diaphoresis

Examination for Catatonia

Procedure Observe

Observe patient while trying to engage in a conversation

Activity level MovementsSpeech

Examiner scratches head in exaggerated manner

Echopraxia

Attempt to reposture, instructing patient to "keep your arm loose" - move arm with alternating lighter and heavier force.

Waxy flexibility


Procedure Observe

Take the hand of the patient as if you are examining his pulse and leave his hand

Posturing

Patient does the exact opposite of what is asked to do Patient does not carry out any orders

Active negativism

Passive negativism

Extend hand and stating "DO NOT Shake my hand".

Ambitendency Forced grasping


Procedure Observe

Reach into pocket and state,"Stick out your tongue, I want to stick a pin in it".

Automatic obedience

Check for grasp reflex. Grasp reflex +

When asked to co-operate, some patients oppose all passive movements with the same degree of force as that of which is been applied by the examiner

Gegenhalten or opposition


Procedure Observe

Patients body can be put to any position without any resistance although he has been instructed to resist all movements.

Mitmachen

Ask patient to extend arm. Place one finger beneath hand and try to raise slowly after stating, "Do NOT let me raise your arm".

MitgehenAnglepoise lamp

Systematic catatonia

Insidious onset Progressive chronic course without remissions Poor response to antipsychotics Relatives at greater risk of developing

schizophrenia.

Periodic catatonia

Recurrent Typical bipolar course Prominent grimacing, stereotypes,impulsive

actions,aggressivity and negativism

alternating with

stupor,posturing,mutism and waxy flexibility Managed by BZDs, if unsuccessful by ECT

Oneroid state

Dream like state often associated with stupor or excitement

Successfully treated with ECT

Lethal Catatonia

A severe form of Catatonia. EARLY SIGNS –

Increasing mental and physical agitation.

Progresses to wild agitation and

Chorea which can alternate rigidity,

Stupor, mutism and refusal of food/fluids.

OTHERS:

Fever, hypotension and diaphoresis

(which are similar to Neuroleptic Malignant Syndrome).

SEVERE END STAGE CASES

convulsions, delirium, coma and even death.


Check chart for reports of previous 24-hour period. oral intake, I/O Chart, vital signs

Attempt to observe patient indirectly, at least for a brief period, each day.

Diagnostic evaluation of catatonia

ProcedureHistoryKirby’s

proformaPhysical examBiochemicalHaemogramCPKEEGCT or MRI of

headLumbar

punctureLorezpam inj

Reason:OrgancityNot to be forgottenLocalizing neurologic signs Metabolic disease Malaria/Nutritional statusNMSSeziuresSOLMeningitis/encephalitisFunctional improves but …

Treatment options for catatonia Treatments that have a strong evidence base

Benzodiazepines Electroconvulsive therapy

Other options (usually reserved for catatonia resistant to benzodiazepines and ECT) Mood stabilisers: especially carbamazepine Antipsychotics NMDA antagonists: amantadine and memantine Dopamine agonists (e.g. bromocriptine) and skeletal muscle relaxants (e.g.

dantrolene),especially if NMS is suspected

BZDs

Benzodiazepines are the DOC for catatonia. Lorazepam

Intravenous / intramuscularly 4 to 8 mg/day for 3to 5 days

Organic catatonia also responds well In a prospective, open study (Ungvari et al,

1994a), 18 patients with catatonia were treated with

eitheroral lorazepam or intramuscular diazepam; 16 showed significant clinical improvement within

48 h, with two showing complete remission after just one dose.

ECT

Like benzodiazepines, ECT is effective in catatonia – functional psychiatric disorders (including

schizophrenia) or organic causes (Rohland et al, 1993); hysterical catatonia(Dabholkar, 1988).

Benegal et al (1993) reported good response to ECT in their sample of 65

patientswith catatonia, which included 30 with idiopathic presentation, 19 with schizophrenia and 16 with depression.

Antipsychotics

Antipsychotics are generally not recommended during a catatonic phase even if there is an underlying psychotic illness such as schizophrenia, as the risk of precipitating NMS is considerably increased.

However, they may be effective in treatment-resistant catatonia:

Hesslinger et al (2001) reported that a patient with catatonia unresponsive to benzodiazepines showed dramatic and persistent improvement on risperidone

DIFFERENTIAL DIAGNOSIS

NEUROLEPTIC MALIGNANT SYNDROME MALIGNANT HYPERTHERMIA SERATONIN SYNDROME ANTICHOLINERGIC SYNDROME ELECTIVE MUTISM LOKED IN STATE STIFF MAN SYNDROME PARKINSONS DISEASE METABOLIC INDUCED STUPOR

NEUROLEPTIC MALIGNANT SYND

Idiopathic reaction to dopamine antagonists Develops rapidly over a few hours to days No prodrome phase Tremors and dyskinesias are early signs Leadpipe muscular rigidity, hyperthermia,

fluctuating consciousness, and autonomic instability

Cont….

Severe complications, i.e., rhabdomyolysis with elevated creatine phosphokinase, myoglobinuria, renal failure and intravasular thrombosis with pulmonary embolism and respiratory failure

Possible 20%-30% mortality with full syndrome.

SEROTONIN SYNDROME

Use of proserotonergic drugs Mild cases have tachycardia, shivering,

diaphoresis, or mydriasis. Nuerological examination reveals intermittent tremor or myoclonus, as well as hyperreflexia.

Moderate cases tachycardia, hyperthermia, and hypertension. Physical examination reveals mydriasis, hyperactive bowel sounds, diaphoresis and normal skin color, hyprereflexia greater in lower extremities

SEROTONIN SYNDROME

Mental status includes mild agitation or hyper vigilance, slightly pressured speech.

Peculiar head turning behavior characterized by repetitive rotation of the head with head held in moderate extension.

Severe cases may have severe hypertension and tachycardia that abruptly deteriorate into frank shock.

MALIGNANT HYPERTHERMIA

Autosomal dominant condition Occurs within minutes after exposure to

inhalation anesthetics and depolarizing muscle relaxants

Clinically cynotic areas contrasting with patches of bright red flushing, hypretonicity, hyporeflexia, increasing concentration of end tidal CO2

Confirmed by muscle biopsy

ANTICHOLINERGIC SYNDROME

Use of anticholinergic agents Normal reflexes Toxidrome of mydriasis, agitated delirium Dry oral mucosa, hot, dry, erythematous skin urinary retentation Absence of bowel sounds

ELECTIVE MUTISM

Preexisting personality disorder Identifiable stressor No other catatonic feature Does not respond to lorazepam challenge Neurological causes to be ruled out as mutism is

seen in number of neurological condition

STIFF MAN SYNDROME

Associated with painful spasms that are precipitated by touch, noise or emotional stimuli.

Baclofen which relive stiff man syndrome

LOKED IN SYNDROME

Associated with total immobility except for vertical eye movements and blinking

They try to communicate with these movements No other features of catatonia Does not respond to lorazepam challenge Associated with lesions in ventral pons and both

cerebellar peduncles

PARKINSON’S DISEASE Akinetic parkinsonism resemble catatonia May be mute and immobile and may posture Occurs year after illness with parkinsonian

symptoms and dementia. Anticholinergic drugs may provide some benifit

PROGNOSIS

Although the overall prognosis was excellent, a high incidence of recurrent catatonic episodes was reported for idiopathic catatonia and catatonia due to affective disorders (Barnes et al, 1986).

continuation ECT is an efficacious treatment for maintaining response for those who relapse after initially responding to ECT

the prognosis for the acute catatonic phase seems to be good, but the long-term prognosis probably depends on the underlying cause of the catatonia.

DSM V

Catatonic disorders will be treated similarly across the system. It will be a specifier associated with the specific condition and will be coded in the fifth digit (xxx.x5) 295.x5 (Schizophrenia, Schizophreniform

disorder, or Schizoaffective disorder with catatonia)

296.x5 (Major mood disorder with catatonia) 293.89 (General medical condition with catatonia) 298.99 (Catatonia NOS) 29x.x5 (Substance Induced Psychotic Disorder) 298.85 (Brief Psychotic Disorder)

Catatonia defined as three or more of the following: 1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Negativism 7. Posturing 8. Mannerisms 9. Stereotypies 10. Grimacing 11. Echolalia 12. Echopraxia

A new chapter on catatonia, discussing its etiology and clinical implications will be added. This will compile recent advances in its understanding, and discuss clinical implications.

Conclusion

A behavioral syndrome associated with several conditions – particularly mood disorders

Can be identified reliably by a cluster of clinical features

Responds to specific treatment

May warrant classification as an independent diagnostic category in psychiatric disorders

Thank u

Catatonia

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