Catatonia

Background

• Catatonia is a psychomotor syndrome characterized by severe alteration of psychomotor function and responsiveness.
• Catatonia most commonly presents with stupor, but it can manifest with a variety of symptoms ranging from immobility and mutism to prolonged agitation.
• Malignant (also known as lethal) catatonia, is a rare presentation of catatonia, characterized by catatonic symptoms and life-threatening autonomic disturbances, such as fever, tachycardia, and hypertension.
• Although catatonia most commonly occurs in patients with underlying psychiatric disorders, such as bipolar disorder or schizophrenia, it may also be seen with many different underlying medical conditions, including encephalitis, metabolic abnormalities, drug reactions, and focal lesions of the brain.

Evaluation

• Suspect catatonia in any patient with marked alteration of psychomotor function and overall responsiveness, particularly if the patient is admitted to the psychiatric ward with severe major depressive disorder, bipolar disorder, psychotic disorder, or autism spectrum disorder.
• Also, suspect catatonia in any patient with immobility or mutism in the absence of another explanatory condition.
• Conduct a thorough neuropsychiatric exam to evaluate for catatonic features.
• Assess patients for any medical symptoms and changes in medication. Consider testing with complete blood count and metabolic panel, urinalysis, brain magnetic resonance imaging, lumbar puncture with cerebrospinal fluid analysis, and electroencephalogram.
• The diagnosis of catatonia can be made clinically with Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) criteria, which requires the presence of at least 3 of the following clinical features: stupor, mutism, catalepsy, waxy flexibility, negativism, posturing, mannerism, stereotypy, grimacing, echolalia, echopraxia, or agitation of unknown cause.
  • Catatonia can be categorized as a specifier to particular psychiatric disorders, including schizophrenia, brief psychotic disorder, major depressive disorder, or bipolar disorder.
  • Catatonia may also be categorized as a result of a diagnosable medical condition if one is identified, or as catatonia, not otherwise specified, if no underlying condition is immediately identified, or if other psychiatric disorders are identified, such as obsessive-compulsive disorder or autism spectrum disorder.
• Consider giving the patient a challenge test with lorazepam 1-2 mg IV, sublingually or intramuscularly, which results in marked reduction (by at least 50%) of catatonic symptoms within 10 minutes in most patients with catatonia.

Management

• Review the patient's current and previous medications. Consider discontinuing any antipsychotic medication if possible, particularly in patients with acute catatonia, as antipsychotics have been associated with the development of neuroleptic malignant syndrome (NMS).
• Use a low-dose benzodiazepine, such as lorazepam 1-2 mg IV, sublingually or intramuscularly every 4-12 hours (adjusted for response) as first-line management of catatonia in adults and children.
• For patients responsive to benzodiazepine treatment, continue the benzodiazepine until an underlying disorder is identified and treatment for it has begun.
• For patients unresponsive to benzodiazepines or if urgent treatment is required for malignant catatonia, consider electroconvulsive therapy.
• Monitor patients closely, and maintain a high level of suspicion for the development of any autonomic disturbance which may herald malignant catatonia, or other serious complications such as dehydration or pulmonary embolus.