Catatonia: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{AMS DDX}} | |||
==Evaluation== | |||
===Physical Exam=== | |||
* Neurological Exam | |||
* Evaluate for rigidity/waxy flexibility (move arm with alternating light/heavy force) | |||
===Labs=== | |||
*CBC | |||
*BMP | |||
*D-Dimer | |||
**Patients w/ catatonia typically have levels >500 ng/mL. | |||
*Creatinine Kinase | |||
**r/o neuroleptic malignant syndrome | |||
*Liver Function Tests | |||
**r/o neuroleptic malignant syndrome | |||
*(+/-) CSF studies | |||
**r/o CNS infections | |||
== | ===Imaging=== | ||
*Head CT/MRI | |||
**r/o treatable mass lesions | |||
===Diagnosis=== | ===Diagnosis=== | ||
*To meet DSM-V criteria for diagnosis of catatonia, patient must present with at least 3 of the following features: | |||
**''Stupor, Catalepsy, Waxy flexibility, Mutism, Negativism, Posturing, Mannerism, Stereotypy, Agitation, Grimacing, Echolalia, Echopraxia'' | |||
==Management== | ==Management== | ||
*Consult psychiatry | |||
*"Benzodiazepine challenge" (first-line treatment) | *"Benzodiazepine challenge" (first-line treatment) | ||
**[[Lorazepam]] IV 2mg; repeat prn | **[[Lorazepam]] IV 2mg; repeat prn | ||
| Line 31: | Line 52: | ||
==Disposition== | ==Disposition== | ||
===Admission=== | |||
*Admission is recommended for all patients with catatonia due to the high risk of complications | |||
*Patients with autonomic instability or hyperthermia should be admitted to ICU | |||
===Discharge=== | |||
*Discharge from the ED is not recommended for these patients | |||
==See Also== | ==See Also== | ||
*[[Altered mental status]] | |||
*[[Neuroleptic Malignant Syndrome]] | |||
*[[Schizophrenia]] | |||
*[[Bipolar disorder]] | |||
==External Links== | ==External Links== | ||
*[http://brownemblog.com/blog-1/2019/1/30/catatonia Brown Emergency Medicine - Catatonia] | |||
===Videos=== | |||
{{#widget:YouTube|id=/e7tlPlzRvTQ}} | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Neurology]] | |||
Latest revision as of 14:57, 26 November 2021
Background
- Catatonia is a syndrome characterized by psychomotor abnormalities, often presenting as a state of apparent unresponsiveness to external stimuli or inability to move normally in a person who is awake[1]
- Classically associated with schizophrenia, but may also present in bipolar, PTSD, autism, encephalitis, and other neurologic disorders
- If left untreated, can progress into malignant catatonia (20% mortality)
Clinical Features
- Stupor - Overall decreased activity and interaction with environment
- Catalepsy - Body remains in position that examiner places it in ("pretzel-shaping")
- Waxy Flexibility - Resistance to positioning, like bending a candle
- Mannerisms - odd movements
- Echolalia - mimicking speech
- Echopraxia - mimicking movements
Differential Diagnosis
Altered mental status
Diffuse brain dysfunction
- Hypoxic encephalopathy
- Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
- Hypertensive Encephalopathy
- Toxins
- TTP / Thrombotic thrombocytopenic purpura
- Alcohol withdrawal
- Drug reactions (NMS, Serotonin Syndrome)
- Environmental causes
- Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
- Sepsis
- Osmotic demyelination syndrome (central pontine myelinolysis)
- Limbic encephalitis
Primary CNS disease or trauma
- Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
- Vascular disease
- SAH
- Stroke
- Hemispheric, brainstem
- CNS infections
- Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
- Seizures
- Nonconvulsive status epilepticus
- Postictal state
- Dementia
Psychiatric
Evaluation
Physical Exam
- Neurological Exam
- Evaluate for rigidity/waxy flexibility (move arm with alternating light/heavy force)
Labs
- CBC
- BMP
- D-Dimer
- Patients w/ catatonia typically have levels >500 ng/mL.
- Creatinine Kinase
- r/o neuroleptic malignant syndrome
- Liver Function Tests
- r/o neuroleptic malignant syndrome
- (+/-) CSF studies
- r/o CNS infections
Imaging
- Head CT/MRI
- r/o treatable mass lesions
Diagnosis
- To meet DSM-V criteria for diagnosis of catatonia, patient must present with at least 3 of the following features:
- Stupor, Catalepsy, Waxy flexibility, Mutism, Negativism, Posturing, Mannerism, Stereotypy, Agitation, Grimacing, Echolalia, Echopraxia
Management
- Consult psychiatry
- "Benzodiazepine challenge" (first-line treatment)
- Second line treatment is electro-convulsive therapy (ECT)
- 80-100% effective
Avoid antipsychotic medications, as they may worsen symptoms
Disposition
Admission
- Admission is recommended for all patients with catatonia due to the high risk of complications
- Patients with autonomic instability or hyperthermia should be admitted to ICU
Discharge
- Discharge from the ED is not recommended for these patients
See Also
External Links
Videos
{{#widget:YouTube|id=/e7tlPlzRvTQ}}
References
- ↑ Fink M. The catatonia syndrome: forgotten but not gone. Arch Gen Psychiatry. 2009. 66:1173
- ↑ Luchini F, Medda P, Mariani MG, Mauri M, Toni C, Perugi G. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry. 2015;5(2):182-192. doi:10.5498/wjp.v5.i2.182