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[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

Primary CNS disease or trauma

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)
    • Lorazepam IV 2mg; repeat prn
    • 60-70% of patients will achieve remission with benzodiazepine monotherapy[2]
  • 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

References

  1. Fink M. The catatonia syndrome: forgotten but not gone. Arch Gen Psychiatry. 2009. 66:1173
  2. 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