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

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
  • Hypothermia
  • Hyperthermia
• 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
  • Intraparenchymal hemorrhage
• SAH
• Stroke
  • Hemispheric, brainstem
• CNS infections
  • Encephalitis
  • Anti-NMDA receptor encephalitis
  • Meningitis
• Neoplasms
  • Paraneoplastic Limbic encephalitis
  • Malignant Meningitis
  • Pancreatic Insulinoma
• Seizures
  • Nonconvulsive status epilepticus
  • Postictal state
• Dementia
  • Alzheimer's
  • Lewy Body Dementia
  • Frontotemporal Dementia

Psychiatric

• Acute psychosis
• Catatonia
• Excited delirium
• Malingering
• Steroid induced psychosis

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)
  • 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

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

• Altered mental status
• Neuroleptic Malignant Syndrome
• Schizophrenia
• Bipolar disorder

External Links

• Brown Emergency Medicine - Catatonia

Videos

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