Catatonia

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
• 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

• Ischemic Stroke
• Hemorrhagic Stroke
• Meningitis
• Encephalitis
• Neuroleptic Malignant Syndrome
• Serotonin Syndrome
• Delirium

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
  • 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

• "Benzodiazepine challenge" (first-line treatment)
  • Lorazepam IV 2mg; repeat prn
  • 60-70% of patients will achieve remission with benzodiazepine monotherapy
• Second line treatment is electro-convulsive therapy (ECT)
  • 80-100% effective
• Consult psychiatry

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