This presentation gives detailed description of symptoms of catatonia with its etiologies and differential diagnoses. It should help to differentiate catatonia in neurological and psychiatric disorders.
6. DEFINITION
• A syndrome of multiple etiologies (organic or functional)
presenting with different features.
• Features are classified as motor and behavioral.
• Motor- posturing, catalepsy, stereotypy, mannerism, rigidity,
waxy flexibility, echopraxia, echolalia.
• Behavioral- withdrawal, excitement, grimace, stupor, mutism,
staring, negativism, verbigeration, perseveration, automatic
obedience, mitgehen, gegenhalten, ambitendency,
impulsivity, combativeness.
7. HISTORICAL OVERVIEW
• Described in 1874 by Kahlbaum,
its neurological causes were also
appreciated.
• Kraepelin and Bleuler- Described
it relation to schizophrenia.
• 1976 – Abraham & Taylor – in
mania
• 1976 – Gelenberg – concept of
syndrome
8. • DSM-IV (1994) Diagnostic Criteria for Catatonic Disorder Due
to a General Medical Condition and also they classify it in
affective disorder “with catatonic symptoms” thus placing the
syndrome beyond the limits of schizophrenia.
9. HYPOTHESIS OF CATATONIA
• G-aminobuteric acid (GABA) HYPOACTIVITY at the GABAA
receptor.
• Dopamine HYPOACTIVITY at the D2 receptor.
• Glutamate HYPOACTIVITY at the N-methyl-D-aspartate
(NDMA) receptor.
• Serotonin HYPERACTIVITY at the 5-HT1A receptor and
HYPOACTIVITY at the 5-HT2A receptor.
11. PHENOMENOLOGY
• Excitement-
Extreme hyperactivity, constant motor unrest which is
apparently non purposeful. Not to be attributed to akathisia
or goal directed agitation.
• Immobility/ stupor-
Extreme hypo activity, immobile, minimally responsive to
stimuli.
12. • Mutism-
Verbally unresponsive or minimally responsive.
• Staring-
Fixed gaze, little no visual scanning of environment,
decreased blinking.
• Posturing/ catalepsy-
Spontaneous maintenance of posture(s), including mundane.
(e.g. sitting or standing for long period without reacting)
PHENOMENOLOGY
13. • Grimacing-
Maintenance of odd facial expression.
• Echopraxia/ echolalia-
Mimicking of examiner’s movement or speech.
• Stereotype-
Repetitive non goal directed motor activity (e.g. finger
play, repeatedly touching, pitting or rubbing self);
abnormality not inherent in act but in frequency.
PHENOMENOLOGY
14. • Mannerism-
Odd, purposeful movement (hopping or walking tip toe, or
exaggerated caricatures of mundane movements);
abnormality inherent in act itself.
• Verbigerations-
Repeatation of phrases or sentences (like a scratched record);
it does not require stimulus to occur.
PHENOMENOLOGY
15. • Rigidity-
Maintenance of rigid position despite of efforts to be moved,
exclude if cogwheel or tremors present.
• Negativism-
Apparently motiveless resistance to instructions or attempt to
move/ examine patient. Contrary behavior does exact
opposite of instructions.
PHENOMENOLOGY
16. • Waxy flexibility-
During reposturing of patient, patient offers initial resistance
before allowing himself to be repositioned (similar to that of
bending candle).
• Withdrawal-
Refusal to eat, drink and/ or make eye contact.
PHENOMENOLOGY
17. • Impulsivity-
Patient suddenly engages in inappropriate behavior
without provocation (e.g. runs down hallway, starts
screaming or takes off clothes). Afterwards can give no or
only facile explanation.
• Automatic obedience-
Exaggerated cooperation with examiners request or
spontaneous continuation of movement requested.
Mitgehen and mitmachen are types of automatic
obedience
PHENOMENOLOGY
18. • Mitgehen-
Arm raising in response to light pressure of finger, despite
instruction to the contrary.
• Gegenhalten-
Resistance to passive movement which is proportional to
strength of the stimulus, appears automatic rather than
willful.
PHENOMENOLOGY
19. • Ambitendancy-
Patient appears motorically “stuck” in indecisive, hesitant
movement.
• Grasp reflex-
As per neuro exam
• Perseveration-
Repeatedly returns to same topic or persists with movement.
even after stimulus is removed.
PHENOMENOLOGY
20. • Combativeness-
Usually in undirected manner with no or only facile
explanations afterwards.
• Autonomic abnormality-
Temp, BP, pulse, RR, diaphoresis.
PHENOMENOLOGY
21. DSM IV
• Mutism: refusal to speak
• Immobility: lack or paucity of movement
• Stereotypes: purposeless, repetitive movements
• Negativism: active or passive refusal to follow commands
• Mannerisms: repetitive, purposeful movements
• Posturing: maintenance of bizarre postures
• Grimacing: repetitive facial posturing
• Catalepsy or Waxy Flexibility: maintenance of posture
• Echopraxia or Echolalia: repetition of words or the imitation of
actions
• Excitement: purposeless, excessive movement
22. DSM IV
• 1 criterion needed for general medical
condition or substance induced catatonia
• 2 criteria for catatonia that is associated with
a psychiatric condition
ICD 10
• Only under psychotic disorders.
• NO ORGANIC CATATONIA DESCRIBED !!
30. PRIMARY AND SECONDARY
CATATONIA
In Primary catatonia:
1. Patient responds to painful stimuli.
2. Patient usually keeps his eyes open most of the
times.
3. Patient’s reflexes would be normal.
4. No focal neurological deficits.
5. Patient avoid self injury. (arm test)
6. Overflow incontinence seen.
7. EEG pattern is that of awake test.
8. Lorezapam injection improves or continues to be
same.
32. How to differentiate between
depressive and schizophrenic catatonia
?
Depressive catatonia:
Depressive face
Veraguth sign
Athanassio’s (omega sign)
Eye movements
PMA retardation
Mood state
Past history
Schizophrenic catatonia:
Vigilant face
Catatonic excitement
Schnauzkrampf (snout
spasm)
Scanning
Less marked
34. Bush-Francis Catatonia Rating
Scale
• Use the presence or absence of items 1 - 14
for screening.
• Use the 0 - 3 scale for items 1 -23 to rate
severity.
36. Examination for Catatonia
PROCEDURE EXAMINES
Observe patient while trying to
engage in a conversation
Activity level
Movements
Speech
Examiner scratches head in
exaggerated manner
Echopraxia
Attempt to reposture, instructing
patient to "keep your arm loose"->
moves arm with alternating
lighter and heavier force.
Waxy
flexibility
37. Examination for Catatonia
PROCEDURE EXAMINES
Take the hand of the patient as if
you are examining his pulse and
leave his hand
posturing
Patient does the exact opposite of
what is asked to do
Patient does not carry out any
orders
Active
Negativism
Passive
Negativism
Extend hand stating "DO NOT Shake
my hand".
Ambitendency
Forced
grasping
38. Examination for Catatonia
PROCEDURE EXAMINES
Reach into pocket and
state,"Stick out your tongue, I
want to stick a pin in it".
Automatic
obedience
Check for grasp reflex. Grasp reflex
Some patients oppose all passive
movements with the same degree
of force as that of which is been
applied by the examiner.
(Asked to co-operate)
Gegenhalten
39. Examination for Catatonia
PROCEDURE EXAMINES
If examiner rapidly touches the
palm and steadily withdraws his
finger the patient’s hand follows
the examiners hand like an iron
following magnet.
Magnet
reaction
Patients body can be put to any
position without any resistance
although he has been instructed
to resist all movements.
Mitmachen
Ask patient to extend arm. Place
one finger beneath hand and try to
raise slowly after stating, "Do NOT
let me raise your arm".
Mitgehen
(Anglepoise
lamp)
40. Examination for Catatonia
• Check chart for reports of previous 24-hour
period. In particular check for oral intake, I/O
Chart, vital signs, and any incidents.
• Attempt to observe patient indirectly, at least for
a brief period, each day.
• Record findings of one week in MSE.
42. Diagnostic evaluation of catatonia
Procedure
History
Physical exam
Biochemical
Haemogram
CPK
EEG
CT or MRI of head
Lumbar puncture
Lorezpam inj
Reason:
Organicity
Localizing neurologic signs
Metabolic disease
Malaria/Nutritional status
NMS
Seziures
SOL
Meningitis/encephalitis
Functional improves but
……….
44. Treatment of Catatonia
LORAZEPAM.
Intravenous/intramuscularly
4 to 8 mg/day ,
3 to 5 days,
To be tapered.
ELECTROCONVULSIVE THERAPY
ANTIPSYCHOTICS
ANTIDEPRESSANTS
THYROID EXTRACTS
45. Lethal Catatonia
• A severe form of Catatonia.
EARLY SIGNS –
• Increasing mental and physical agitation.
• Progresses to wild agitation and chorea which can
alternate with rigidity, stupor, mutism and refusal of
food / fluids.
OTHERS:
• Fever, hypotension and diaphoresis.
(which are similar to NMS)
SEVERE END STAGE CASES
• Convulsions, delirium, coma and even death.
46. DISTINCTION BETWEEN NMS & LETHAL CATATONIA
• Lethal Catatonia usually has a longer prodrome
of days to weeks.
• NMS also has the abnormal laboratory values.
• Treatment:
Supportive care.
ECT.
Restarting or increase in antipsychotic dose.
Short term use of lorazepam.
47. TAKE HOME MESSAGE
Despite low incidence,
catatonia is a serious
diagnostic and treatment
challenge.
After the main causes of
secondary catatonia
have been ruled out,
primary catatonia should
be considered.
If a trial of lorazepam
fails, ECT should be used.
