Electroconvulsive Therapy For Catatonia

  • Helen McLachlanMSc Molecular Biology & Pathology of Viruses, Imperial College London

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Overview

Catatonia is a serious condition which affects the brain and is characterised by abnormal movements. It affects individuals across all age groups. Associated with severe mental illnesses, its precise cause is unknown, but it can be fatal if left untreated. Symptoms range from heightened or slowed movements, altered mental states, hindered communication, and autonomic effects on heart rate and breathing rate. Electroconvulsive therapy (ECT), while intense, is potentially the most effective and reliable treatment for catatonia. It is used to induce controlled seizures which alleviate symptoms. It requires an accurate diagnosis and a very specific, tailored treatment plan by a trained practitioner. Despite some adverse effects, ethical concerns, and stigmas, this treatment is lifesaving and often necessary for the recovery of catatonia sufferers.

Understanding catatonia

Catatonia is classified as a psychomotor syndrome, meaning it is a psychological state that affects movement.1,2,3 It manifests as abnormal movements, which can be debilitating and long-lasting. If left untreated, it can develop into malignant catatonia, which may be fatal.1,2,4,5 Catatonia may manifest across all age groups, spanning from childhood through to the elderly population.3,5 It is associated with a number of medical conditions, like encephalitis (swelling on the brain), epilepsy (seizures), and other neurological disorders.1,3 It is also associated with severe mental illness: psychiatric disorders such as schizophrenia, anxiety, depression, bipolar, and post-traumatic stress, usually only in severe cases.1,3,4,6  In older people, catatonia has been associated with Parkinson's disease, stroke, dementia, and Alzheimer's disease.3

The cause of catatonia is poorly understood; however, it occurs due to a dysfunction of a network of neural pathways in the brain called the cerebral motor network.1,7 There is less activation of the neural pathways and lower blood flow than normal in this area, leading to symptoms of catatonia. The reason this area of the brain does not function correctly in people with catatonia is unknown, but some studies suggest the disorder may be hereditary, so further research is required.1

Signs and symptoms of catatonia

The effects of catatonia are described as abnormal movements, excessively increased movements, or extremely slow movements.1,2 Although there are around 50 signs of catatonia, some of the most commonly described signs, specific to movement,4,5 include:

  • Excitement or agitation: expressed as agitated or jerky movements that may or may not have the intention to cause harm1,4
  • Ambitendency: when two opposing actions are trying to occur simultaneously1,2
  • Waxy flexibility: where there is seemingly involuntary resistance to the person being moved by an examiner or doctor1,4
  • Grimacing: unusual facial expressions1
  • Immobility: rigidity or freezing in place1,2,4

Other, more physiological, signs and symptoms include heart palpitations and abnormal blood pressure, temperature, heart rate, or respiratory rate.1,4,5

Catatonia can affect one's state of mind. Patients who experience catatonia express that during episodes they are often in an intense and uncontrollable emotional state and experience contradicting ideas and emotions. Some report feeling intense anxiety, fear, and depression or experiencing altered realities, believing they are going to die or even that they are already dead. Catatonia can also cause confusion and disorientation, as well as a phenomenon called stupor, which is a near unconscious state.1,2,4,5

Communication with people who are having a catatonic episode is often very difficult or impossible due to the effect on their speech. The movement and state of mind experienced by people with catatonia can be so debilitating that they inhibit speech.2,5 Others may experience withdrawn behaviour involving a lack of eye contact or refusing treatment, food, or water.1,4 Patients with catatonia also sometimes speak nonsense phrases, words, or just syllables and sounds.1

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) is a treatment involving sending electrical currents through the brain that will induce controlled seizures.5,8 The seizures are non-convulsive, meaning physical symptoms like shaking and jerky movements will not occur. ECT can be applied to either one or both sides of the brain, called unilateral or bilateral treatment.5

When receiving ECT, you are placed under a general anaesthetic and dosed with medication to maintain normal activity of your heart and other vitals. Electrical currents are used to stimulate your brain via multiple electrodes placed on your scalp. The duration of the electrical brain stimulations varies, generally between 0.2 and 0.5 milliseconds. The electrical currents cause electrical activity in your brain, inducing a seizure that lasts between 15 and 80 seconds.8,9 Seizures of 15 seconds and under are not sufficient to treat catatonia or other conditions, so ideally, they should be 30 seconds or longer to be deemed effective.8

ECT for catatonia

ECT has been well researched, and many studies have found that it is an effective and often better treatment than others commonly used for catatonia.5 Often, the first course of action for catatonia is a short-term prescription of benzodiazepine for suitable cases.3 Benzodiazepine and similar drugs can produce results for catatonia within days or even hours.3 For cases of catatonia when benzodiazepines are not suitable for a patient or their condition is life-threatening, ECT is used as a first response.3,5 The two can also be used together for catatonia treatment.4 Sometimes, withdrawals of benzodiazepine, antidepressant, antianxiety, or antipsychotic drugs are the cause of catatonia, so ECT is the main treatment option.5,6

ECT is often effective for people who experience schizophrenia, mood disorders, and psychosis alongside their catatonia.3,4,7 Overall, studies have found that 60–100% of cases are responsive to the ECT treatment, with more recent studies finding 80–100% responsive. In cases where people have recurring or chronic catatonia, ECT is often beneficial.5,6 ECT is used for malignant catatonia, the most severe and fatal type of the condition, and is more effective than other treatments at preventing death.5,7 However, the therapy must begin within 5 days of the onset of malignant catatonia, or recovery is likely impossible.5

When people receive ECT, they are usually treated 2–3 times per week, sometimes even daily or twice daily for severe cases, e.g.malignant catatonia. On average, people receive 9 treatments; however, this number can be between 3 and 35 or more, depending on the individual case. The number of treatments can depend on the response after the first treatment, such as any side effects experienced or potential risks foreseen by practitioners.5

Potential risks and ethical considerations

Some professionals believe that ECT is underused due to stigmas surrounding it, a lack of understanding behind the action of ECT, and concerns for safety.7,8 The stigmas surrounding it stem from its use in the 1930s, when anaesthesia was insufficient so the procedure was extremely painful.5,8 During this time, the intensity of the electrical current was often too high, and the therapy caused severe memory loss.8 Research is ongoing to better understand the exact mechanism of ECT and catatonia, but the effect of ECT is well understood.5

There are often delays when trying to administer ECT to someone with catatonia, potentially allowing their condition to worsen while waiting for treatment. Delays can be due to the availability of professionals and accessibility of the equipment. There may also be legal issues when trying to obtain consent from a mute or incoherent patient, establishing a more ethical dilemma. In the UK, there are requirements which must be met and a procedure to adhere to when someone cannot consent to an ECT.5

There are many types of catatonia, and courses of treatment vary depending on the patient.4,5 In many cases, ECT will be the recommended action, while at other times it will be drugs like benzodiazepine. Therefore it is imperative that a specific and accurate diagnosis be made, as ECT can potentially worsen a patient's condition or delay them from receiving the proper treatment.5,6 

There are adverse effects that sometimes occur after ECT. Some people experience headaches during the treatment., which subside afterwards. Other times, more serious adverse effects such as declined cognitive function and memory loss can occur. These kinds of impairments are associated with the intensity of the electrical currents, so physicians are trained to find the balance between the intensity of therapy and its necessity for a positive outcome of a patient’s condition.6 It should also be noted that ECT often has a longer recovery time spent in hospital than other treatments; however, this may be necessary for the best possible outcome.4

Summary

Overall, ECT has an abundance of research backing up its efficacy to treat catatonia. It is a crucial treatment that induces controlled seizures in the brain and improves the condition of people with catatonia. ECT alleviates symptoms like abnormal and sporadic movements, impaired speech, and disorientation. While it does cause some adverse reactions like headaches, cognitive impairment, and memory loss, it is arguably the most effective treatment for catatonia. ECT is undertaken with a careful diagnosis, a specific treatment plan, and close monitoring by a trained practitioner.

References

  1. Walther S, Stegmayer K, Wilson JE, Heckers S. Structure and neural mechanisms of catatonia. Lancet Psychiatry 2019;6:610–9. Available from: https://doi.org/10.1016/S2215-0366(18)30474-7.
  2. Zingela Z, Stroud L, Cronje J, Fink M, van Wyk S. The psychological and subjective experience of catatonia: a qualitative study. BMC Psychol 2022;10:173. Available from: https://doi.org/10.1186/s40359-022-00885-7.
  3. Jaimes-Albornoz W, Ruiz de Pellon-Santamaria A, Nizama-Vía A, Isetta M, Albajar I, Serra-Mestres J. Catatonia in older adults: A systematic review. World J Psychiatry 2022;12:348–67. Available from: https://doi.org/10.5498/wjp.v12.i2.348.
  4. Worku B, Fekadu A. Symptom profile and short term outcome of catatonia: an exploratory clinical study. BMC Psychiatry 2015;15:164. Available from: https://doi.org/10.1186/s12888-015-0554-2.
  5. Rogers JP, Oldham MA, Fricchione G, Northoff G, Ellen Wilson J, Mann SC, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2023;37:327–69. Available from: https://doi.org/10.1177/02698811231158232.
  6. Pelzer AC, van der Heijden FM, den Boer E. Systematic review of catatonia treatment. Neuropsychiatr Dis Treat 2018;14:317–26. Available from: https://doi.org/10.2147/NDT.S147897.
  7. Gazdag G, Ungvari GS. Electroconvulsive therapy: 80 years old and still going strong. World J Psychiatry 2019;9:1–6. Available from: https://doi.org/10.5498/wjp.v9.i1.1.
  8. Lloyd JR, Silverman ER, Kugler JL, Cooper JJ. Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives. Neuropsychiatr Dis Treat 2020;16:2191–208. Available from: https://doi.org/10.2147/NDT.S231573.
  9. Salik I, Marwaha R. Electroconvulsive Therapy. StatPearls, Treasure Island (FL): StatPearls Publishing; 2024.

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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