Catatonic

What is Catatonic?

The catatonic state in which a person suffers is called catatonia.

The sufferer is ostensibly awake, but cannot respond to stimuli in word or deed. It is believed to be a psychomotor disturbance characterized by neurotransmitter inconsistencies in the dopamine, glutamate and gamma-aminobutyric neurotransmitter systems of the brain. It’s also believed that psychiatric, physical or neurological problems underlie the catatonia.

Catatonia manifests itself in many ways, among them silent staring, convulsions, mild to severe agitation and holding a gravity-defying posture not natural to the individual.

Catatonia Symptoms

The Diagnostic and Statistical Manual or DSM5 identifies the following as symptoms of catatonia. The presence of three among the 12 symptoms constitutes catatonia:

  • Stupor
  • Catalepsy (trance or seizure with loss of consciousness and bodily rigidity)
  • Waxy flexibility (symptom of a mental disorder in which the body is immobile and does not respond to stimuli)
  • Mutism (inability to speak)
  • Negativism (capacity to do the opposite of what is requested)
  • Posturing
  • Gestures
  • Stereotypy (seemingly pointless and persistent repetition of an act)
  • Agitation
  • Making faces
  • Echolalia (mindless repetition of someone’s spoken words)
  • Echopraxia (mindless repetition of someone’s gestures)

Catatonic schizophrenia manifests in body rigidity, agitated posturing, excitement, stupor or pointless movements. Depressive catatonia, being a mood problem, manifests in immobility and looks much like schizophrenic catatonia. Catatonia with a medical problem, though, looks totally different. For one thing, the patient is aware and may intelligently discuss the occurrence with medical professionals. In each type of catatonia, the symptoms are the same. It’s the patient’s ability to respond that makes or breaks the case.

Alternatively, the excitable kind of catatonia is characterized by an excited state of being with impulsiveness, combativeness, and all around instability.

Certain diseases or mental disorders feature catatonia as a symptom of the disease or disorder, such as Schizophrenia Types 1 through 14, Presenile dementia and Neuroleptic Malignant Syndrome.

Catatonia Causes

Pinpointing an exact cause for catatonia hasn’t happened yet. However, the list of things believed to cause catatonia is daunting. It is believed that there are three causes of catatonia: catatonic schizophrenia, depression with catatonia, and catatonia with a medical condition.

Catatonic schizophrenia

The exact cause of schizophrenia is not known, either. However, recent research has shown that the limbic system, the frontal cortex, and the basal ganglia are hooked together. An abnormality in one will necessarily mean an interrupted structure in another. The limbic system appears to be the beginning point of pathology.

Catatonic depression

Neurotransmitters conduct messages from the body’s nerves to the nerve center in the brain. When the brain’s neurotransmitters get a short in the wiring, depression results. The three most important neurotransmitters in the brain are norepinephrine, serotonin, and dopamine. These have a part to play in the development of depressive disorders.

Catatonic medical condition

Almost any medical condition can cause psychiatric distress. Neurological, metabolic and infectious diseases head the list. In patients with earlier encephalitic disorders or Parkinson’s Disease, there might be a manifestation of catatonic behavior. However, the majority of post-encephalitic patients are not psychotic, although the catatonia might mirror the condition suffered by catatonic schizophrenic people.

The list of underlying health problems or medical conditions that might cause catatonia is too long to include here, but a few are:

Also associated with catatonia are:

  • A severe shortage of Vitamin B12
  • Toxin exposure
  • Psychotic disorders
  • Infection
  • Mood disorders
  • Autism
  • Severe trauma

The link between catatonia and general medical conditions is often ignored because such symptoms frequently mirror something else. However, when they are recognized for what they truly are, the usual catatonia treatments produce excellent results.

Treatment of Catatonia

Effective treatment begins with correctly diagnosing the cause of the catatonia. Patients showing obvious deterioration of psychomotor abilities such as repetition of words and movements or excitable movements unnatural to the patient should be examined with an eye toward catatonia. The same is true of patients showing signs of psychiatric distress.

Tests to help diagnose the base problem:

  • A total blood count and metabolic test
  • Erythrocyte sedimentation rate
  • Blood urea nitrogen
  • Creatinine
  • Serum iron
  • Creatinine-phosphokinase
  • Antinuclear antibodies
  • Urinalysis
  • MRI
  • EEG
  • Cerebrospinal fluid analysis

The NIH further instructs us that complications from catatonia should be treated immediately. Dehydration, malnutrition, the resulting weight loss, muscle spasms, ulcers and pneumonia among more are complications best taken care of in the ICU. Some patients with severe catatonia will require round-the-clock supervision using IV fluids to prevent the dehydration and resulting death of the patient. Immobile patients will need blood thinners.

Those suffering catatonia from a medical problem should be treated immediately.

Medical Conditions with Catatonia

Anti-NMDA-receptor Encephalitis (ANRE) was studied in a control group, the majority of which were young females approximately aged 23. Although ovarian tumors are largely associated with ANRE, only about 59 percent of the females in the study showed tumors. In these cases, corticosteroids, IV immunoglobulin, plasma exchange, cyclophosphamide or rituximab have proven effective treatments. Whether or not a tumor was found and extracted, recovery time is still weeks to months, with the possibility of relapse in later years.

Stroke, Dementia and Brain Irregularities

Frontotemporal atrophy and Lewy body dementia have been successfully treated with high doses of lorazepam or electroconvulsive therapy or ECT. Donepezil has been shown to both aid in improving psychiatric symptoms in those with Lewy body disease as well as exacerbating the problem with abrupt withdrawal from the treatment.

Multiple Sclerosis

Catatonia is a rare association with multiple sclerosis, but may be the first indication of the disease. Such patients have shown a good response to benzodiazepines and ECT therapy.

Electrolyte Inconsistencies

A few studies have shown a correlation between catatonia and hyponatremia, or electrolyte inconsistency. All but one case improved with the use of benzodiazepines. The one that didn’t required lorazepam and ECT to correct the problem.

Catatonia and Drug Withdrawal

Oddly, what are considered recreational drugs are not considered catatonia inducers. Only “Ecstasy” and “Cocaine” have been shown in studies to cause catatonia. In the Ecstasy case, serotonin hyperactivity was considered to be the trigger. In the Cocaine case, the catatonia happened following a withdrawal using lorazepam in a binge-type setting. Things like steroids and antibiotics tend to have more catatonic episodes.

Currently, only the fluoroquinolone class of antibiotics are responsible for catatonic episodes. This class includes ciprofloxacin and levofloxacin. The macrolide class of antibiotics has manifested in psychotic episodes, mania, and depression, but not catatonia. This class includes clarithromycin and erythromycin.

No evidence exists that catatonia resulting from medical illness is any different from catatonia resulting from mental illness or brain irregularities. The same therapies and medications, however, are used to treat both.

Benzodiazepines

Benzodiazepines are the first line of defense against catatonia-inducing illnesses. The NIH describes them as “positive allosteric modulators of the GABA-A receptors and will regulate deficient GABA function in the orbitofrontal cortex”¬Ě. Several studies show that between 70 and 100 percent of patients begun on low dosages (one to two mg) of lorazepam showed marked (70 to 83 percent) resolution of catatonic phenomena. Studies have not shown, however, how long to use lorazepam, only that tapering off the use sometimes shows a relapse of symptoms. The general consensus is to continue use until remission is good and solid.

Zolpidem

Also a positive allosteric modulator, zolpidem is often used when ECT and benzodiazepines fail. In the majority of cases, remission begins within two to five hours following on one half hour of ingestion. Medical professionals have used it in doses of 7.5 to 40 mg per day with no unfavorable side effects.

Glutamate Antagonists

Of special use and of satisfying results in the treatment of catatonia with schizophrenia, amantadine and its off-spring memantine have proven satisfactory N-methyl-D-aspartic acid (NMDA) property. Studies have shown that psychiatric patients using amantadine were vastly improved within seven days.

Antipsychotics

There is some concern that the use of antipsychotics can take a catatonic patient right into malignant catatonia/neuroleptic-induced catatonia. No studies exist testing antipsychotics alone for treatment, but several exist describing their use with other treatments such as ECT or benzodiazepines.

ECT

The only time ECT should be used is when a patient is in danger of sustaining a life-threatening condition such as the volatile blood pressure changes and high fevers of malignant catatonia. ECT is usually given when patients fail to respond to benzodiazepines and antipsychotic drugs. No controlled studies exist, but ECT’s efficacy is largely documented.

Catatonia Prevention

Considering no one has yet figured out what causes catatonia, it stands to reason no one has yet figured out how to prevent it. The best anyone can do is to prevent the symptoms of catatonia. While it is true that some brain structure and cognitive features are involved, they haven’t been pinpointed as the cause of catatonia.

Catatonia is often connected to schizophrenia, although only about 20 percent of schizophrenics have catatonia. Mood disorders are more frequently connected with catatonia. One thing is certain: avoid using antipsychotic drugs, as they help to set off catatonic symptoms. A regime to follow in order to prevent symptom manifestation is to take the prescribed medications in the proper dosages. Do not take other medications except on a doctor’s advice. Attend therapy sessions and go to the hospital when asked.

The patient will know when an outbreak of symptoms is imminent. The patient can and should tell family, friends, workmates and his doctor when he feels an outbreak of symptoms coming on. Additionally, staying away from recreational drugs and alcohol may prevent the onset of catatonic symptoms.

Preventing the symptoms of many medical conditions is as simple as seeing a doctor on a regular basis. There, the medical professionals will take blood pressure readings, check blood sugar, blood oxygen saturation, take blood tests for cholesterol, triglycerides and blood lipids. These will tell the doctor whether the patient is in danger of stroke, heart attack, whether or not diabetes is present, and dozens of other things. Keeping up with these is key to avoiding catatonia from medical issues.

Taking prescribed medications as directed by a doctor is so important that we cannot stress it enough. Forgetting to take it, not taking it so money can be saved or other reasons for not taking medications as prescribed can land a patient in the hospital in a catatonic state. Mixing prescription drugs with recreational drugs or someone else’s pill bottles when it’s not clear how the body will react is also a bad idea, and could lead to catatonia. Maintaining a medication schedule is also key to avoiding catatonia from medical issues.

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Last Reviewed:
September 25, 2017
Last Updated:
November 29, 2017
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