Catatonia is a neuropsychiatric syndrome characterized by marked inhibition or excitation of motor behavior, often occurring in the context of psychotic, mood, or medical disorders. The condition manifests along a spectrum, with catatonic stupor representing extreme inhibition of spontaneous activity, and catatonic excitement representing extreme psychomotor agitation.

Pathophysiology

The exact mechanism of catatonia is not fully understood but is believed to involve dysfunction in GABAergic, dopaminergic, and glutamatergic pathways within the basal ganglia, thalamus, and frontal cortex. Neuroimaging and neurochemical studies suggest:

• GABA hypoactivity leading to impaired inhibition of motor circuits.

• Dopamine dysregulation, particularly hypodopaminergia in frontal-subcortical loops.

• Glutamate hyperactivity contributing to excitatory motor and behavioral symptoms.

These alterations result in abnormal motor behaviors, ranging from stupor and immobility to purposeless agitation. Catatonia can occur in schizophrenia, bipolar disorder, severe depression, or as a secondary phenomenon in medical conditions (e.g., encephalitis, metabolic disturbances).

Examination Technique

Patient Observation

• Observe spontaneous motor activity in various positions (sitting, standing, walking).

• Assess for posturing, waxy flexibility, negativism, stereotypies, echolalia, or echopraxia.

• Record duration, frequency, and triggers of motor abnormalities.

Structured Assessment

• Use validated scales such as the Bush-Francis Catatonia Rating Scale (BFCRS) or the Northoff Catatonia Scale.

• Evaluate response to external stimuli, including verbal commands or gentle physical prompts.

Clinical features

Differential Diagnosis

Diagnostic approach

• Clinical evaluation remains the cornerstone; scales such as BFCRS quantify severity.

• Laboratory workup: CBC, electrolytes, liver and kidney function, thyroid studies.

• Neuroimaging: MRI or CT if structural brain pathology is suspected.

• Electroencephalography (EEG): May help rule out nonconvulsive status epilepticus.

Management

First-line Treatment

• Benzodiazepines (e.g., lorazepam) are highly effective in both stuporous and excited catatonia.

Adjunctive interventions

• Electroconvulsive therapy (ECT) for refractory cases or life-threatening features.

• Supportive care: hydration, nutrition, prevention of pressure sores, and monitoring for complications like deep vein thrombosis or aspiration pneumonia.

• Review and adjust psychiatric medications, avoiding agents that may exacerbate catatonia (e.g., high-dose antipsychotics).

Pediatric considerations

• Rare but can occur in autism spectrum disorders, mood disorders, or post-infectious encephalitis.

• Early recognition and treatment are crucial to prevent physical complications and developmental regression.

Geriatric considerations

• Older adults are at higher risk due to medical comorbidities or polypharmacy.

• Catatonia may be misdiagnosed as depression, delirium, or dementia, delaying treatment.

Patient counseling

• Explain the nature of catatonia as a treatable motor and behavioral syndrome.

• Emphasize the importance of prompt medical attention for stupor or agitation.

• Discuss treatment options, including benzodiazepines and ECT, and the need for supportive care.

Conclusion

Catatonia is a potentially severe neuropsychiatric syndrome with distinct motor manifestations. Early recognition and treatment are essential to prevent physical complications and progression to life-threatening conditions. Awareness of the different subtypes, underlying causes, and effective interventions enhances patient outcomes.

References

1. Fink M, Taylor MA. Catatonia: A Clinician’s Guide to Diagnosis and Treatment. 2nd ed. Cambridge: Cambridge University Press; 2003.

2. Carroll BT, et al. Catatonia: From Psychopathology to Neurobiology. Prog Neuropsychopharmacol Biol Psychiatry. 2005;29(3):343–352.

3. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2):129–136.

4. Northoff G. Catatonia and the Motor System: Towards an Integrative Neurobiological Model. Berlin: Springer; 2002.

5. American Psychiatric Association. DSM-5: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.