Catatonia

Catatonia is a neuropsychiatric syndrome characterized by abnormalities of movement, behaviour, speech, and responsiveness. It is associated with several psychiatric disorders, particularly schizophrenia, severe depressive disorder, and bipolar disorder, but may also occur secondary to medical and neurological conditions. Catatonia is a potentially life-threatening condition requiring prompt recognition, investigation for underlying causes, and timely treatment to prevent complications.

Epidemiology

Catatonia occurs in patients with both psychiatric and medical illnesses. It is most commonly associated with schizophrenia, mood disorders, and acute medical or neurological disorders. Early recognition is essential, as delayed treatment increases the risk of morbidity and mortality.

Risk factors

Psychiatric disorders

• Schizophrenia

• Severe depressive disorder

• Bipolar disorder

Neurological disorders

• Central nervous system infections

• Brain tumours

• Cerebrovascular accidents

• Epilepsy

Medical conditions

• Metabolic disturbances

• Autoimmune disorders

• Severe systemic infections

Toxicological causes

• Severe intoxication with recreational drugs

• Heavy metal poisoning

• Drug withdrawal

Other causes

• Lethal (malignant) catatonia

Pathophysiology

The exact pathophysiology of catatonia remains incompletely understood. Proposed mechanisms include dysfunction of gamma-aminobutyric acid (GABA), dopamine, and glutamate neurotransmission within cortical-subcortical circuits involved in motor regulation and behaviour. Catatonia may also result from acute neurological injury, inflammatory processes, metabolic abnormalities, or severe psychiatric illness.

Clinical presentation

Catatonia presents with a combination of motor, behavioural, speech, and autonomic abnormalities. Symptoms may develop gradually or abruptly and can range from mild immobility to life-threatening malignant catatonia.

Symptoms

• Reduced speech or mutism.

• Decreased interaction with the environment.

• Refusal to eat or drink.

• Reduced spontaneous movement.

• Immobility.

• Abnormal repetitive movements.

• Social withdrawal.

Clinical signs

• Ambitendency.

• Automatic obedience.

• Waxy flexibility (catalepsy).

• Negativism.

• Stereotypy.

• Mannerisms.

• Echolalia.

• Echopraxia.

• Mutism.

• Stupor.

• Posturing.

• Rigidity.

• Reduced response to external stimuli.

Differential diagnosis

• Schizophrenia.

• Severe depressive disorder.

• Bipolar disorder.

• Delirium.

• Neuroleptic malignant syndrome.

• Parkinson disease.

• Non-convulsive status epilepticus.

• Encephalitis.

• Central nervous system tumours.

• Stroke.

• Drug intoxication.

• Drug withdrawal.

Diagnostic criteria

Diagnosis is clinical and is based on the presence of characteristic catatonic signs in the appropriate clinical setting.

The diagnosis should be supported by:

• Characteristic motor and behavioural abnormalities.

• Exclusion of alternative neurological and medical conditions.

• Identification of an underlying psychiatric, neurological, or medical cause where possible.

Investigations

Laboratory investigations

• Full blood picture (FBP).

• Renal function tests (RFT).

• Liver function tests (LFT).

• Thyroid function tests (TFT).

• Blood glucose.

• Creatine kinase (CK).

• Urine drug screen.

• Syphilis screen.

• HIV testing.

• Heavy metal screen.

• Autoantibody screen.

• Blood culture.

• Urine culture.

Imaging and other investigations

• Electrocardiogram (ECG).

• CT scan of the brain.

• MRI of the brain.

• Electroencephalography (EEG).

• Lumbar puncture where clinically indicated.

Management

Management aims to stabilize the patient, identify and treat the underlying cause, prevent complications, and relieve catatonic symptoms.

Initial management includes:

• Assess airway, breathing, and circulation.

• Evaluate for underlying medical or neurological disorders.

• Correct metabolic abnormalities.

• Monitor hydration, nutrition, and vital signs.

• Prevent complications related to prolonged immobility.

Non-pharmacological treatment

• Maintain adequate hydration.

• Encourage early mobilization where possible.

• Closely monitor vital signs and neurological status.

• Prevent pressure ulcers and venous thromboembolism.

• Provide nutritional support.

• Transfer to the intensive care unit (ICU) if the patient's condition deteriorates.

Pharmacological treatment

• Diazepam – 10–20 mg – IV/IM – every 24 hours.

OR

• Lorazepam – 1–4 mg – IM – every 24 hours.

Management according to underlying cause

Schizophrenia

• Treat according to the schizophrenia guideline after stabilization of catatonia.

Severe depressive disorder

• Initiate appropriate antidepressant treatment after resolution of catatonia where indicated.

Bipolar disorder

• Manage according to bipolar disorder treatment guidelines.

Organic neurological disorders

• Treat central nervous system infections, stroke, tumours, epilepsy, or other neurological conditions appropriately.

Drug intoxication or withdrawal

• Discontinue offending agents where appropriate and provide supportive management.

Malignant (lethal) catatonia

• Urgent intensive care management.

• Prompt benzodiazepine therapy.

• Early consideration of electroconvulsive therapy.

Referral

Urgently refer patients to psychiatry, neurology, or internal medicine as appropriate.

Immediate referral is indicated for:

• Suspected malignant catatonia.

• Severe autonomic instability.

• Respiratory compromise.

• Failure to respond to benzodiazepine therapy.

• Suspected underlying neurological disease.

• Requirement for electroconvulsive therapy.

• Need for intensive care management.

Complications

• Dehydration.

• Malnutrition.

• Pressure ulcers.

• Venous thromboembolism.

• Aspiration pneumonia.

• Rhabdomyolysis.

• Acute kidney injury.

• Autonomic instability.

• Respiratory failure.

• Death if untreated.

Prognosis

The prognosis is generally favourable when catatonia is recognized early and treated promptly. Delayed diagnosis or failure to treat the underlying cause increases the risk of serious complications and mortality. Malignant catatonia carries a particularly poor prognosis if treatment is delayed.

Prevention

Early recognition and treatment of psychiatric and medical disorders associated with catatonia can reduce its occurrence. Regular monitoring of high-risk patients, prompt investigation of new behavioural or motor abnormalities, and timely intervention may prevent progression to severe or malignant catatonia.