What Is Catatonia?

Catatonia is a psychological syndrome where the individual, although awake, does not respond to the environment around him. Different symptoms can present, affecting speech, motion and behaviour. Catatonia can occur as a result of existing psychological and neurological conditions.

Catatonia can be broadly classified asretarded, which is the more common type characterised by immobility, rigidity and staring into space, or  excited. The latter is a rare type of catatonia that causes individuals to exhibit excess movements, which may prove fatal if not addressed. Hence, it is also referred to as malignant catatonia if other organ systems also become affected. Catatonia is noticed alongside disorders like:

• Schizophrenia
• Bipolar disorders 
• Depression
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Psychosis
• Dissociative disorders 

Overview

Catatonia is a disorder where one's brain does not properly function in response to  environmental stimuli. Most times, patients with catatonia do not adequately react or react inappropriately. Abnormal movements, or lack of them, no communication or excess communication and aberrant behaviour are the most common symptoms of catatonia.

Karl Kahlbaum identified catatonia as a special entity in 1874. Kraepelin thought of catatonia as a key sign of a subtype of amnesiacs. It was first associated with schizophrenia. Catatonia is found in up to 20% of all acute psychiatric patients. Catatonia is also linked with neurological and developmental disorders as well as brain damage.¹

Causes of catatonia

Catatonia is caused by an imbalance in the transmission of electrical nerve signals and disruption to brain circulation. Gama amino butyric acid (GABA), dopamine, glutamate and serotonin are neurotransmitters that help in the proper functioning of the brain and in the accurate expression of emotions in response to the environment. An imbalance in these neurotransmitters can similarly cause catatonia.²

Neurological conditions that can co-occur with catatonia include:

• Autism -a developmental disability resulting from divergent brain function
• Epilepsy - a disease caused by abnormal brain activity which presents with seizures
• Stroke - a medical emergency that can result in the death of brain tissue due to a lack of blood supply to certain parts of the brain
• Tourette syndrome - a disorder of the nervous system that causes individuals to experience tics, which are involuntary movements or sounds that are recurring and which cannot be controlled

Medical conditions that can cause catatonia:  

• Encephalitis - inflammation of the brain caused by infection (bacterial or viral) and autoimmune conditions Down syndrome - a genetic disorder that occurs when a baby has an extra chromosome. It is also known as trisomy 21 and it can affect how the baby develops and responds to various environmental challenges
• Autoimmune conditions - conditions, such as lupus and multiple sclerosis, where the immune system fights against one’s own body
• Hydrocephalus - an accumulation of cerebrospinal fluid within the cavities in the brain that hampers brain function
• Drug-related conditions - drug allergies or interactions between multiple drugs can cause adverse reactions

Psychological conditions with symptoms of catatonia:

1. Depression - a serious medical condition that negatively affects the way you act, think and behave.
2. Mood disorders - disorders that affect one’s emotional state. They can cause persistent and intense sadness, excitement or anger
3. Schizophrenia - a mental health condition that can present with auditory and visual hallucinations due to disruptions in how the brain functions 
4. Bipolar disorder -  a mental health issue that causes mood changes from one extreme (extreme happiness) to the other (extreme sadness

Signs and symptoms of catatonia

Catatonia is an uncertain and random syndrome that encompasses a wide range of symptoms. These greatly vary but in most cases, motor signs that hinder a person’s autonomy are observed. There are 12 officially accepted symptoms of catatonia, according to the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

• Agitation - impatience in regard to everyone and everything 
• Catalepsy -when a person retains the body position set by others without losing balance or trying to change it, even when it is an uncomfortable posture
• Echolalia - when a person echoes and continuously repeats sounds, words or phrases that they have just heard
• Echopraxia - when a person repeatedly mimics or mirrors someone else’s movements
• Grimacing - this is where a person holds the same facial expression because of tense facial muscles 
• Mannerisms - this is when gestures and movements, that are typically considered to be normal, are overdone or exaggerated by an individual  
• Mutism - this is when a person is totally mute, meaning they are unable to talk 
• Negativism - this is when a person does not react to anything happening around them or acts with resistance
• Posturing - this is when a person spontaneosly takes on and maintains an uncomfortable body position
• Stereotypy - repeating movements that do not seem to have a purpose, such as making futile finger movements 
• Stupor - This is when a person does not respond to painful stimuli
• Waxy flexibility - this is when a person resists any changes to their position, keeping their muscles flexed³ 

Catatonia can lead to severe complications. The mental health of affected individuals can deteriorate, leading to violent pscychotic breaks and self-destructive behaviour, which can include refusing to eat or inflicting self-trauma. Other body systems and organs can become affected, causing the development of pneumonia, pressure ulcers, deep vein thrombosis (DVT) and pulmonary embolism.³

Management and treatment for catatonia

Catatonia is a treatable syndrome but it often goes unnoticed, leading to underdiagnosis. To avoid the development of malignant catatonia, it is important to begin treatment early. Various treatment modalities have been found to help manage catatonic symptoms.⁴ 

Benzodiazepines   

These are a class of drugs that act as the first-line treatment for catatonia. They help replenish an important neurotransmitter, known as GABA, to assist in the proper functioning of the brain.

• Advantages - it can be administered orally or intramuscularly. When a patient can not take medication orally, the parenteral route can also be utilised
• Limitations - although effective at treating acute symptoms, long-term use of benzodiazepines for the treatment of chronic cataconia has not been found useful

Electroconvulsive therapy (ECT)

This is an invasive procedure, which is usually done under general anesthesia, where the brain is electrically stimulated to generate brief seizure-like symptoms in the affected patient.ECT should be administered three times a week. In most cases, it is used as supplemental therapy rather than a primary treatment option. ECT is most useful when catatonia is severe and needs immediate attention.

• Advantages - ECT has been found to be effective when drug therapy did not help manage symptoms Limitations - surrogate consent or consent from a family member needs to be taken before the initiation of ECT as a catatonic patient is not seen fit to give consent. Some patients have also reported side-effects from the treatment, such as memory loss and headaches during the treatment

Antipsychotic drugs

Antipsychotics are a group of drugs, including olanzapine and clozapine, that play a role in altering the action of certain neurotransmitters in the brain. This, in turn, helps improve the mental health of patients with catatonia, especially reducing the incidence of catatonic depression. 

• Limitations - antipsychotic drugs need to be replaced after every six months of use  as they progressively become ineffective. Adverse effects can also be observed, such as the worsening of catatonic symptoms and increased confusion, agitation and restleness.

Anti convulsants 

Drugs like carbamazepine and topiramate, which are typically used to manage seizures in epileptic patients, have been found to effectively resolve some symptoms of catatonia.

• Advantages - anti-convulsants have been found to manage symptoms of catatonia in those who had been refractory to treatment with benzodiazapines and anti-psychotics⁵

FAQs

How is catatonia diagnosed?

Catatonia can be diagnosed using diagnostic lab tests, imaging procedures and brain activity tests, with specific examples listed below:

• Diagnostic tests - blood, urine and cerebrospinal fluid can be tested forinfections
• Imaging procedures - computerised tomography (CT) and magnetic resonance imaging (MRI) techniques are used to detect changes in the brain structure and function
• Brain activity tests - an electroencephalogram analyses and records the brain’s electrical signalsand helps to rule out seizures² 

How can I prevent catatonia?

Catatonia is a treatable condition. When the underlying condition is treated, catatonia can be prevented. Medications, such as benzodiazepine and anti-psychotics, as well as invasive therapies, like electro convulsive therapy, have been shown to help with the management and prevention of catatonia. 

Who is at risk of developing catatonia?

People with psychological conditions are more prone to have symptoms of catatonia. If one is using anti-psychotic medication, or has abruptly discontinued their medication, they have a higher chance of developing catatonia.

How common is catatonia?

The rate of incidence of catatonia is higher among patients with mood disorders. tIt occurs in 13-27% of psychiatric patients. In schizophrenic patients, the incidence rate can be as high as 50%.⁵

When should I see a doctor?

Catatonia is a very unpredictable syndrome that needs medical attention as soon as possible. When you notice yourself, or any of your loved ones, displaying symptoms of catatonia, immediately reach out to your health provider for medical advice.

Summary

Catatonia is one of the most poorly diagnosed psychological conditions. Catatonia can be akinetic, excited and malignant. It usually develops alongside an existing psychological, medical or neurological disorder.  It is important to recognise the symptoms of catatonia early as it can be fatal. Thankfully, catatonia can be prevented and managed with different drug types and electro convulsant therapy. Everyone should be aware of this condition and the treatment options that can help in saving the life of an affected individual.