Catatonia

Presenter: Dr Pavan Kumar K Chairperson: Dr Manju Bhaskar

Outline
Definition Nosology Hypothesis of catatonia Causes of catatonia Primary Vs secondary catatonia Depressive Vs schizophrenia catatonia Rating scales Examination for catatonia Diagnostic evaluation of catatonia Management of catatonia Conclusion

Definition
to stretch tightly SYNDROME OF MOTOR ABNORMALITIES IN

ASSOCIATION WITH DISORDERS OF MOOD, BEHAVIOR AND THOUGHT.

Catatonia is a condition that can be caused by a

variety of metabolic, neurological, psychiatric and toxic conditions

Nosology
Karl Ludwig Kahlbaum 1874

Coined the term Catatonia

Catatonia is a brain disease with a cyclic, alternating course, in which the mental symptoms are, consecutively melancholy, mania, stupor, confusion, and eventually dementia. Monograph Die Katatonie oder das Speannungsirresein (The Tonic Mental Disorder or the Tension Insanity)

04-10-2011

Nosology
Kraepelin and Bleuler (1919) Included catatonia in their broad definition of schizophrenia (Dementia praecox) Strong, persistent influence on classification of catatonia as an exclusive subtype of schizophrenia

Morrison (1974) Reawakened the profession to the association between catatonia and mood disorders
Abrams and Taylor (1976) Reestablished link between catatonia and mood disorders

 Gelenberg Documented association of catatonia with neurological and general medical disorders Gjessing (1976) periodic catatonia Fink and Taylor Emphasized that catatonia should not be linked exclusively to schizophrenia should be seen as a syndrome associated with many psychiatric, neurological and general medical illnesses

Nosology
The idea that the catatonia is tied to schizophrenia was coded in all DSM and ICD editions
DSM-IV Continues to classify catatonia as a subtype of schizophrenia In addition, has added catatonia as a specifier in mood disorders and as a syndrome resulting from a general medical disorder

DSM IV TR
In DSMIV TR a diagnosis of schizophrenia,

catatonic type (295.20) is made if the clinical picture is

dominated by at least two of the following: motor immobility, excessive motor activity, extreme negativism, peculiarities of voluntary movements,and echolalia/echopraxia.

If a physical cause is identified the diagnosis is

catatonic disorder due to a medical condition (293.89).

 As in ICD10, there is no separate diagnostic

category for catatonia due to either depression or mania, but catatonia can be added as a specifier in mood disorders.

Catatonia in ICD-10
ICD 10 ORGANIC CATATONIC DISORDER(F06.1)

CATATONIC SCHIZOPHRENIA.(F20.2)

The ICD10
Catatonia due to physical causes is diagnosed

asorganic catatonic disorder (F06.1).

diagnosis of catatonic schizophrenia ( F20.2)

requires

at least one of the following catatonic features, stupor, excitement, posturing, negativism, rigidity, waxy flexibility and command automatism (automatic obedience). for at least 2 weeks

If a patient with severe depression is in a stupor, a diagnosis of severe depressive episode with psychotic symptoms (F32.3) is made, even if there are no delusions or hallucinations. Similarly, a patient with manic stupor will be diagnosed as having mania with psychotic symptoms (F30.2)

For depression or mania, only stupor, which is the

most extreme of catatonic signs, seems to have diagnostic implications, whereas for schizophrenia a broader range of signs are considered relevant.

Epidemiology
Organic disorders- 1/4 of catatonia 7-17% in acute psychiatric patients 13-31% occurrence in mood disorders (Caroff

et al 2004) Abraham & Taylor (1976)- significant number in affective illness(mania)-28% Approximately 10 % are associated with schizophrenia(incidence decreasing)

 Under-recognised and under-diagnosed

(Van der Heijden et al, 2005). The introduction of antipsychotics has reduced the incidence of catatonia,it is still not uncommon (Stompe et al, 2002) and Detection rate can be significantly improved by using a standardised rating scale (Van der Heijden et al, 2005). India 13.5% (Chalasani, 2005)

Hypothesis of Catatonia
Northoff (2002), a top-down modulation of

basal ganglia

G-aminobutyric acid (GABA) hypoactivity at the GABAA receptor(therapeutic effect of BZDs) Glutamate hyperactivity at the n-methyl-daspartate (NMDA) receptor

Osman & Khurasani (1994)

caused by a sudden and massive blockade of dopamine.(antipsychotics are not generally beneficial in catatonia)

 Serotonin hyperactivity at the 5-HT1A receptor

and hypoactivity at the 5-HT2A receptor and

Yeh et al, 2004

cholinergic and serotonergic rebound hyperactivity(Clozapine-withdrawal catatonia)

GABA A GABA B + -

CATATONIA

D2

+
5 HT2A 5 HT1A

 Moskowitz (2004)

Catatonia- evolutionary fear response,originating in ancestral encounters with carnivores whose predatory instincts were triggered by movement. This response, of remaining still, is now expressed in a range of major psychiatric or medical conditions, where catatonic stupor may represent a common end-state response to feelings of imminent doom.

PATHOPHYSIOLOGY
MOTOR SYMPTOMS

dysfunction in termination of movements and right posterior parietal cortex. strong, intense and uncontrollable emotional symptoms may be accounted for by dysfunction in medial orbitofrontal cortex and gaba-ergic neurotransmission.

AFFECTIVE SYMPTOMS

Cont
BEHAVIORAL SYMPTOMS

Bizarre behavioral abnormalities may be related to deficts in behavioral inhibition and lateral orbito frontal cortical activity. Vegetative abnormalities may be related with alteration in midbrain and brainstem nuclei.

Sub types
Catatonia appears in many guises (responses to

a lorazepam challenge)

Hypokinetic catatonia (Kahlbaum syndrome), Excited catatonia (delirious mania, oneiroid state), Malignant catatonia, The neuroleptic malignant and toxic serotonin syndromes, Periodic catatonia (rapid cycling), and Primary akinetic mutism Catatonia is also a feature in autism

 Following the DSM classification model,

designate three catatonia subtypes

nonmalignant, delirious, and malignant mood disorders, general medical conditions or toxic states, neurological disorders, or psychotic disorders.

and four specifiers, secondary to:

Causes of catatonia
1. Primary catatonia

2. Secondary catatonia

Causes of catatonia - primary

Psychiatric

schizophrenia, mood disorders( Taylor & Abrams, 1977), dissociative/ conversion disorder (Galenberg,1976; Ungvari et al.,1994) OCD (Hermesh 1989), reactive psychosis, acute and transient psychotic disorder (Banerjee & Sharma,1995;Payee et al.,1999),

postpartum/ puerperal psychiatric disorder (Bach-y-Rita & De Rainieri,1992; Ranzini et al.,1996), PTSD (Shiloh et al.,1995), under hypnosis (Kornfeld,1985), Autistic disorder ( pervasive developmental disorder) ( Dhossche, 1998; Zaw et al.,1999) and autistic spectrum disorder.

Secondary or organic
Neurological Medical Drugs

Organic catatonia - Neurological

Brain stem, diencephalic, basal ganglia, lesions

near III ventricle, amygdala Frontal lobe ds. (apallic syn.), SMA Parietal lobe ds. Limbic & temporal lobe ds. Head injury, dementia, MS, atrophy Encephalitis & other infections Epilepsy

Causes of catatonia - secondary

Medical conditions associated with catatonia

Hepatic failure Renal failure Metabolic encephalopathy (diabetic) Endocrine dysfunction Electrolyte imbalance Alcohol intoxication Drug over dosage

Organic catatonia - Metabolic

Periodic catatonia DM, in DKA Thyroid dysfunction Hepatic failure Renal failure Porphyrias Nutritional- Wernickes, pellagra, B12 def

Organic catatonia Drugs

Neuroleptics Alcohol Opioids Cannabis BZDs Disulfiram SSRI, TCA

Primary Vs Secondary Catatonia

In Primary catatonia

Patient responds to painful stimuli Patient keeps eyes open most of the time Patients reflexes are normal No focal neurological deficits Patient avoids self injury (arm test) Incontinence is of retention over flow
EEG pattern is that of awake test

Improves with lorazepam or continues to be same

Depressive Vs Schizophrenic catatonia

Depressive catatonia
Depressive face Athanassios (omega)

Schizophrenic catatonia
Vigilant face, Catatonic excitement Schnauzkrampf (snout

sign Eye movements PMA retardation Mood state Past history

spasm) Scanning

Rating Scales for catatonia

Bush-Francis Catatonia Rating Scale Braunig Catatonia Rating Scale Modified Rogers scale Lohr and Wisniewski scale (1987) Northoff catatonia scale (Northoff et al.,1999b)

Bush-Francis Catatonia Rating Scale

1. Excitement: 2. Immobility/stupor 13. Waxy flexibility 14. Withdrawal

3. Mutism
4. Staring 5. Posturing/catalepsy 6. Grimacing 7. Echopraxia/echolalia: 8. Stereotypy 9. Mannerisms

15. Impulsivity
16. Automatic obedience 17. Mitgehen 18. Gegenhalten 19. Ambitendency 20. Grasp reflex 21. Perseveration

10. Verbigeration
11. Rigidity 12. Negativism

22. Combativeness
23. Autonomic abnormality

WIRED N MIRED
W axy flexibility/catalepsy

I mmobility stupor
R efusal to eat or drink E xcitement

D eadpan staring
N egativism/negative symptoms M utism I mpulsivity R igidity E cholalia/echopraxia D irect observation
4/16/2013

Carroll et al (2005) Current Psychiatry 4 (3) : 56 - 64

35

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
If not sure rate 0 this is for research purposes

 Excitement : extreme hyperactivity, motor unrest which is

apparently non-purposeful. Not to be attributed to akathesia or goal directed agitation

Immobility/stupor: extreme hypo activity, immobile,

minimally responsive to stimuli.

Mutism : verbally unresponsive or minimally responsive.

Staring : fixed gaze, little or no visual scanning of

environment, decreased blinking

 Posturing/catalepsy : voluntary assumption and

maintenance of inappropriate or bizarre posture(s)

Grimacing : maintenance of odd facial expression. Echopraxia/echolalia: mimicking of examiners

movement or speech.
Stereotype : repetitive non goal directed motor activity. Mannerism : odd, purposeful movements Verbigeration: repetition of phrases or sentences

 Rigidity : maintenance of rigid position despite efforts to

be moved, exclude if cog-wheeling or tremor present

Negativism : apparently motiveless resistance to

instructions or attempts to move/examine patient. Contrary behavior, does exact opposite of instruction.
Waxy flexibility :maintenance of limbs and body in

externally imposed positions.

 Withdrawal : refusal to eat, drink and/or make eye

contact. Impulsivity : pt suddenly engages in inappropriate behavior without provocation. Afterwards can give no, or only a facile explanation
Automatic obedience: exaggerated co-operation with

examiners request or spontaneous continuation of movement requested

Mitgehen: Angelpose lamp 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 automatically rather than wilful.

Ambitendency : pt appears motorically stuck in

indecisive, hesitant movement.

Grasp reflex

Perseveration: repeatedly returns to same topic or

persists with movement.

 Combativeness: usually in an undirected manner, with

no, or only facile explanation

Autonomic abnormality : temp, BP, pulse, RR,

diaphoresis

Examination for Catatonia

Procedure Observe

Observe patient while trying to engage in Activity level a conversation Movements Speech Examiner scratches head in exaggerated Echopraxia manner

Attempt to reposture, instructing patient Waxy flexibility to "keep your arm loose" - move arm with alternating lighter and heavier force.

Examination for Catatonia

Procedure
Take the hand of the patient as if you are examining his pulse and leave his hand

Observe
Posturing

Patient does the exact opposite of what is asked to do Patient does not carry out any orders Extend hand and stating "DO NOT Shake my hand".

Active negativism Passive negativism Ambitendency Forced grasping

Examination for Catatonia

Procedure
Reach into pocket and state,"Stick out your tongue, I want to stick a pin in it".

Observe
Automatic obedience

Check for grasp reflex.

Grasp reflex +

When asked to co-operate, some patients oppose all passive movements with the same degree of force as that of which is been applied by the examiner

Gegenhalten or opposition

Examination for Catatonia

Procedure
Patients body can be put to any position without any resistance although he has been instructed to resist all movements.

Observe
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

Systematic catatonia
Insidious onset Progressive chronic course without remissions Poor response to antipsychotics Relatives at greater risk of developing

schizophrenia.

Periodic catatonia
Recurrent Typical bipolar course Prominent grimacing, stereotypes,impulsive

actions,aggressivity and negativism alternating with stupor,posturing,mutism and waxy flexibility Managed by BZDs, if unsuccessful by ECT

Oneroid state
Dream like state often associated with stupor or

excitement Successfully treated with ECT

Lethal Catatonia
A severe form of Catatonia.
EARLY SIGNS Increasing mental and physical agitation. Progresses to wild agitation and Chorea which can alternate rigidity, Stupor, mutism and refusal of food/fluids. OTHERS: Fever, hypotension and diaphoresis (which are similar to Neuroleptic Malignant Syndrome). SEVERE END STAGE CASES convulsions, delirium, coma and even death.

Examination for Catatonia

Check chart for reports of previous 24-hour period. oral intake, I/O Chart, vital signs

Attempt to observe patient indirectly, at least for a brief

period, each day.

Diagnostic evaluation of catatonia

Procedure History Kirbys proforma Physical exam Biochemical Haemogram CPK EEG CT or MRI of head Lumbar puncture Lorezpam inj Reason: Organcity Not to be forgotten Localizing neurologic signs Metabolic disease Malaria/Nutritional status NMS Seziures SOL Meningitis/encephalitis Functional improves but

Treatment options for catatonia

Treatments that have a strong evidence base

Benzodiazepines Electroconvulsive therapy resistant to benzodiazepines and ECT) Mood stabilisers: especially carbamazepine Antipsychotics NMDA antagonists: amantadine and memantine Dopamine agonists (e.g. bromocriptine) and skeletal muscle relaxants (e.g. dantrolene),especially if NMS is suspected

Other options (usually reserved for catatonia

BZDs
Benzodiazepines are the DOC for catatonia. Lorazepam

Intravenous / intramuscularly 4 to 8 mg/day for 3to 5 days

Organic catatonia also responds well In a prospective, open study (Ungvari et al,

1994a),

18 patients with catatonia were treated with eitheroral lorazepam or intramuscular diazepam; 16 showed significant clinical improvement within 48 h, with two showing complete remission after just one dose.

ECT
Like benzodiazepines, ECT is effective in

catatonia

functional psychiatric disorders (including schizophrenia) or organic causes (Rohland et al, 1993); hysterical catatonia(Dabholkar, 1988). good response to ECT in their sample of 65 patientswith catatonia, which included 30 with idiopathic presentation, 19 with schizophrenia and 16 with depression.

Benegal et al (1993) reported

Antipsychotics
Antipsychotics are generally not recommended

during a catatonic phase even if there is an underlying psychotic illness such as schizophrenia, as the risk of precipitating NMS is considerably increased. However, they may be effective in treatmentresistant catatonia: Hesslinger et al (2001) reported that a patient with catatonia unresponsive to benzodiazepines showed dramatic and persistent improvement on risperidone

DIFFERENTIAL DIAGNOSIS

NEUROLEPTIC MALIGNANT SYNDROME MALIGNANT HYPERTHERMIA SERATONIN SYNDROME ANTICHOLINERGIC SYNDROME ELECTIVE MUTISM LOKED IN STATE STIFF MAN SYNDROME PARKINSONS DISEASE METABOLIC INDUCED STUPOR

NEUROLEPTIC MALIGNANT SYND

Idiopathic reaction to dopamine antagonists

Develops rapidly over a few hours to days

No prodrome phase Tremors and dyskinesias are early signs Leadpipe muscular rigidity, hyperthermia,

fluctuating consciousness, and autonomic instability

Cont.
Severe complications, i.e., rhabdomyolysis with

elevated creatine phosphokinase, myoglobinuria, renal failure and intravasular thrombosis with pulmonary embolism and respiratory failure Possible 20%-30% mortality with full syndrome.

SEROTONIN SYNDROME
Use of proserotonergic drugs

Mild cases have tachycardia, shivering,

diaphoresis, or mydriasis. Nuerological examination reveals intermittent tremor or myoclonus, as well as hyperreflexia. Moderate cases tachycardia, hyperthermia, and hypertension. Physical examination reveals mydriasis, hyperactive bowel sounds, diaphoresis and normal skin color, hyprereflexia greater in lower extremities

SEROTONIN SYNDROME
Mental status includes mild agitation or hyper

vigilance, slightly pressured speech. Peculiar head turning behavior characterized by repetitive rotation of the head with head held in moderate extension. Severe cases may have severe hypertension and tachycardia that abruptly deteriorate into frank shock.

MALIGNANT HYPERTHERMIA
Autosomal dominant condition

Occurs within minutes after exposure to

inhalation anesthetics and depolarizing muscle relaxants Clinically cynotic areas contrasting with patches of bright red flushing, hypretonicity, hyporeflexia, increasing concentration of end tidal CO2 Confirmed by muscle biopsy

ANTICHOLINERGIC SYNDROME
Use of anticholinergic agents

Normal reflexes
Toxidrome of mydriasis, agitated delirium

Dry oral mucosa, hot, dry, erythematous skin

urinary retentation Absence of bowel sounds

ELECTIVE MUTISM
Preexisting personality disorder

Identifiable stressor
No other catatonic feature Does not respond to lorazepam challenge Neurological causes to be ruled out as mutism is

seen in number of neurological condition

STIFF MAN SYNDROME

Associated with painful spasms that are

precipitated by touch, noise or emotional stimuli. Baclofen which relive stiff man syndrome

LOKED IN SYNDROME
Associated with total immobility except for

vertical eye movements and blinking They try to communicate with these movements No other features of catatonia Does not respond to lorazepam challenge Associated with lesions in ventral pons and both cerebellar peduncles

PARKINSONS DISEASE
Akinetic parkinsonism resemble catatonia May be mute and immobile and may posture

Occurs year after illness with parkinsonian

symptoms and dementia. Anticholinergic drugs may provide some benifit

PROGNOSIS
Although the overall prognosis was excellent, a

high incidence of recurrent catatonic episodes was reported for idiopathic catatonia and catatonia due to affective disorders (Barnes et al, 1986). continuation ECT is an efficacious treatment for maintaining response for those who relapse after initially responding to ECT the prognosis for the acute catatonic phase seems to be good, but the long-term prognosis probably depends on the underlying cause of the catatonia.

DSM V
Catatonic disorders will be treated similarly

across the system. It will be a specifier associated with the specific condition and will be coded in the fifth digit (xxx.x5)

295.x5 (Schizophrenia, Schizophreniform disorder, or Schizoaffective disorder with catatonia) 296.x5 (Major mood disorder with catatonia) 293.89 (General medical condition with catatonia) 298.99 (Catatonia NOS) 29x.x5 (Substance Induced Psychotic Disorder) 298.85 (Brief Psychotic Disorder)

 Catatonia defined as three or more of the

following:

1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Negativism 7. Posturing 8. Mannerisms 9. Stereotypies 10. Grimacing 11. Echolalia 12. Echopraxia

 A new chapter on catatonia, discussing its

etiology and clinical implications will be added. This will compile recent advances in its understanding, and discuss clinical implications.

Conclusion
A behavioral syndrome associated with several

conditions particularly mood disorders

Can be identified reliably by a cluster of clinical

features
Responds to specific treatment May warrant classification as an independent

diagnostic category in psychiatric disorders

Thank u