The Geezer’s Dirty Dozen on Catatonia

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Catatonia is a complex neuromotor disorder which is not well-studied, partly because of its relative rarity. It can be seen in both medical and psychiatric disorders and is eminently treatable sometimes with benzodiazepines and most importantly, electroconvulsive therapy (ECT), which can be life-saving. Patients can suffer and even die from such medical complications as dehydration and blood clots.

The link to a very well done MedScape article on catatonia by Dr. James Robert Brasic, MD, MPh is Catatonia. The reader can readily discern that catatonia is both a psychiatric and a medical problem.

The most effective treatment for catatonia is electroconvulsive therapy (ECT) and the link to the January, 2011 New York Times article about ECT reclassification F.D.A. Panel Is Divided Over Electroshock Risks – The article indicates that the FDA advisory panel voted in favor (barely) to approve the use of ECT for treatment of catatonia, mainly because there is virtually no other effective treatment for the disorder which can have a mortality rate between 10%-20%, although benzodiazepines can produce near-immediate and startling but often temporary reversal of the syndrome. I’m well aware of the controversy surrounding ECT as a treatment, and of the recent FDA advisory panel hearings which may threaten the availability of this life-saving treatment. See my previous posts about the ECT device reclassification controversy at links:

Future of ECT as Life-Saving Treatment at Risk? « The Practical Psychosomaticist: James Amos, M.D.

FDA Reclassification of Electroconvulsive Therapy « The Practical Psychosomaticist: James Amos, M.D.

Slide 3: This is a short definition of catatonia, which demonstrates our lack of an adequate understanding of this life-threatening syndrome.

Slide 4: This is some historical background on the conceptualization of catatonia as a syndrome, beginning with Karl Ludwig Kahlbaum’s description in 1874.

Slide 5: There are both medical and psychiatric causes of catatonia, making it much more than a psychiatric disorder. The phenomenology and broadly effective treatments point to a generalized syndrome of neuromotor dysfunction about which there needs to be more research, (see the Dhossche et al paper, J ECT 2010).

Slide 6: This is a slide about what is increasingly thought of as a drug-induced catatonia, Neuroleptic Malignant Syndrome (NMS). The medically safest approach in patients who demonstrate catatonic behaviors is to immediately stop all antipsychotics and other dopaminergic agents because of their association with precipitating NMS, another life-threatening syndrome which also happens to be responsive to ECT.

Slide 7: This slide lists some of the many behaviors which are typical of patients suffering from catatonia. Most are included what is widely regarded as the best rating scale for catatonia, the Bush-Francis Catatonia Rating Scale (BFCRS).

Slide 8: The DSM-IV compared to the DSM-5 proposals for changes in the diagnostic schemata.

Slide 9: A short differential diagnosis of catatonia. For a comprehensive description of the differences and similarities between NMS and Serotonin Syndrome, the reader can have a look at one of the best sites for clinicians, the Neuroleptic Malignant Syndrome Information Service (NMSIS), at link

Slide 10: This slide shows a few of the treatable causes of catatonia.

Slide 11: This slide is about diagnosis and treatment, for which use of a validated rating scale, preferably the BFCRS and ECT, are highly recommended. One other non-validated way to evaluate for catatonia not often written about but used when there may be clinical concerns about using intravenous benzodiazepine (e.g., no IV access), is the so-called “telephone effect”, first described by a neurologist, C. Miller Fisher (see my post Catatonia and Delirium: Medical Emergencies « The Practical Psychosomaticist: James Amos, M.D.) and the historically important reference is: Fisher, C. M. (1983). “Honored guest presentation: painful states: a neurological commentary.” Clin Neurosurg 31: 32-53. An excerpt from my post:

Another less invasive test that doesn’t use medicine is the “telephone effect” described in the 1980s by a neurologist, C. Miller Fisher. It was used to temporarily reverse abulia, which in a subset of cases of stupor is probably the neurologist’s word for catatonia. Sometimes the mute patient suffering from abulia can be tricked into talking by calling him on the telephone. It’s pretty impressive when a patient who is mute in person answers questions by cell phone. I have never tried texting.

Slide 12: The usual selected reference list

Daniels, J. (2009). “Catatonia: clinical aspects and neurobiological correlates.” J Neuropsychiatry Clin Neurosci 21(4): 371-380.

Catatonia is a neuropsychiatric syndrome that can occur due to medical or psychiatric disorder. This review synthesizes over 20 years of original research and comprehensive review articles with attention to the most recent findings. Though catatonia is common and highly treatable, there have been few research studies investigating the syndrome. Pooled case reports suggest that catatonia due to an underlying general medical condition and catatonia due to a psychiatric illness can be treated similarly and that the catatonic symptoms and the underlying illness must be addressed in both types. Benzodiazepines and ECT continue to be mainstays of treatment. Evidence is mounting for the use of NMDA antagonists in catatonia refractory to lorazepam.

Dhossche, D. M., L. Stoppelbein, et al. (2010). “Etiopathogenesis of catatonia: generalizations and working hypotheses.” J ECT 26(4): 253-258.

Catatonia has been rediscovered over the last 2 decades as a unique syndrome that consists of specific motor signs with a characteristic and uniform response to benzodiazepines and electroconvulsive therapy. Further inquiry into its developmental, environmental, psychological, and biological underpinnings is warranted. In this review, medical catatonia models of motor circuitry dysfunction, abnormal neurotransmitters, epilepsy, genetic risk factors, endocrine dysfunction, and immune abnormalities are discussed. Developmental, environmental, and psychological risk factors for catatonia are currently unknown. The following hypotheses need to be tested: neuroleptic malignant syndrome is a drug-induced form of malignant catatonia; Prader-Willi syndrome is a clinical GABAergic genetic-endocrine model of catatonia; Kleine-Levin syndrome represents a periodic form of adolescent catatonia; and anti-N-methyl-d-aspartate receptor encephalitis is an autoimmune type of catatonia.

Fink, M. (2010). “The intimate relationship between catatonia and convulsive therapy.” J ECT 26(4): 243-245.

Fink, M., E. Shorter, et al. (2010). “Catatonia is not schizophrenia: Kraepelin’s error and the need to recognize catatonia as an independent syndrome in medical nomenclature.” Schizophr Bull 36(2): 314-320.

Catatonia is a motor dysregulation syndrome described by Karl Kahlbaum in 1874. He understood catatonia as a disease of its own. Others quickly recognized it among diverse disorders, but Emil Kraepelin made it a linchpin of his concept of dementia praecox. Eugen Bleuler endorsed this singular association. During the 20th century, catatonia has been considered a type of schizophrenia. In the 1970s, American authors identified catatonia in patients with mania and depression, as a toxic response, and in general medical and neurologic illnesses. It was only occasionally found in patients with schizophrenia. When looked for, catatonia is found in 10% or more of acute psychiatric admissions. It is readily diagnosable, verifiable by a lorazepam challenge test, and rapidly treatable. Even in its most lethal forms, it responds to high doses of lorazepam or to electroconvulsive therapy. These treatments are not accepted for patients with schizophrenia. Prompt recognition and treatment saves lives. It is time to place catatonia into its own home in the psychiatric classification.

Francis, A. (2010). “Catatonia: Diagnosis, Classification, and Treatment.” Current Psychiatry Reports 12(3): 180-185.

Catatonia is a distinct neuropsychiatric syndrome that is becoming more recognized clinically and in ongoing research. It occurs with psychiatric, metabolic, or neurologic conditions. It may occur in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy leads to a dramatic and rapid response, although systematic, randomized trials are lacking. An important unresolved question is the role of antipsychotic agents in treatment and their potential adverse effects.

Francis, A., M. Fink, et al. (2010). “Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.” J ECT 26(4): 246-247.

Obregon, D. F., R. M. Velasco, et al. (2011). “Memantine and catatonia: a case report and literature review.” J Psychiatr Pract 17(4): 292-299.

Catatonia is a movement disorder with various possible etiologies. The majority of cases are associated with an underlying mood or psychotic disorder, while others are caused by medical conditions. Currently, benzodiazepines are the first-line psychopharmacologic agents in the treatment of catatonia. However, several cases have been reported in which treatment with memantine proved to be effective. We present the case of a 92-year-old female with major depressive disorder and associated catatonic symptoms. In this case, the patient’s symptoms remitted quickly after the initiation of memantine. We review the possible causes of catatonia and pharmacologic treatments for the condition and highlight the possible benefits of N-methylD-aspartic acid receptor antagonists such as memantine in the treatment of catatonia.

Rosebush, P. I. and M. F. Mazurek (2010). “Catatonia and its treatment.” Schizophr Bull 36(2): 239-242.

Psychiatric diagnoses are currently categorized on a syndromic basis. The syndrome of catatonia, however, remains in a diagnostic limbo, acknowledged predominantly as a subtype of schizophrenia. Yet, catatonia is present in about 10% of acutely ill psychiatry patients, only a minority of whom have schizophrenia. Among those with comorbid affective disorders, who comprise the largest subgroup of catatonic patients, the catatonic signs typically resolve dramatically and completely with benzodiazepine therapy. Those with schizophrenia respond less reliably, suggesting that the underlying processes causing the catatonia may be different in this group. The majority of patients with catatonia have concurrent psychosis. Failure to treat the catatonia before institution of antipsychotic medication may increase the risk of inducing neuroleptic malignant syndrome. At this point of time, the pathobiology of catatonia is unknown; the major reason for considering catatonia as a separate diagnostic entity would be to increase recognition of this eminently treatable neuropsychiatric syndrome.

Sienaert, P., J. Rooseleer, et al. (2011). “Measuring catatonia: A systematic review of rating scales.” Journal of Affective Disorders 135(1–3): 1-9.

Background Despite a growing scientific and clinical interest in catatonia, its precise definition remains debated. Aim The aim of this study was to offer a systematic review of the different rating scales that have been developed to assess catatonia in clinical practice. Methods A Medline-search was performed, up to December 2010. Results Seven catatonia rating scales were retrieved: the Modified Rogers Scale, the Rogers Catatonia Scale, the Bush–Francis Catatonia Rating Scale (BFCRS), and its revision, the Northoff Catatonia Rating Scale (NCRS), the Braunig Catatonia Rating Scale (BCRS), and the Kanner Scale. Conclusion Several catatonia rating scales are proposed to detect the catatonic syndrome and to evaluate treatment response. BFCRS, NCRS and BCRS are reliable for use in variable populations in which catatonia is prevalent. The BFCRS is preferred for routine use, because of its validity and reliability, and its ease of administration.

Narayanaswamy, J. C., P. Tibrewal, et al. “Clinical predictors of response to treatment in catatonia.” General Hospital Psychiatry(0).

Objective This study aims at identifying predictors of treatment response to lorazepam in catatonia. Methods The clinical charts of 107 inpatients, admitted over duration of 2 years, with a primary diagnosis of catatonia were examined for response to lorazepam trial. Trial was considered as having received 3–6 mg per day of lorazepam for at least 3 days. Results Out of these 107 patients, 99 received lorazepam and 8 received electroconvulsive therapy as the first line of management. There were 32 responders and 67 nonresponders to lorazepam. The nonresponders were characterized by rural background (85.1% vs. 62.5%, P=.01), longer duration of catatonic symptoms (108.88 vs. 25.12 days, P=.018), mutism (63.6% vs. 31.3%, P=.02) and presence of first-rank symptoms like third-person auditory discussing-type hallucinations (16.4% vs. 12.0%, P=.03) and made phenomena (7.5% vs. 0%, P=.04). The presence of waxy flexibility (12.5% vs. 4.5%, P=.03) predicted good response. Conclusions This study identifies that longer duration of illness, presence of catatonic sign of mutism and certain specific phenomena like third-person auditory hallucinations and made phenomena predicted poor response to lorazepam in catatonia. This could provide insight into the prediction and planning of the appropriate treatment strategies in this psychiatric emergency.

Kellner, C. H., MD (2011) “The FDA Advisory Panel on the Reclassification of ECT Devices.” Psychiatric Times 28.

Catatonia Quiz:

1. Catatonia can be marked by such behaviors as

A. Grimacing

B. Verbigeration

C. Purposeless excitement

D. Muteness

E. All of the above

2. Neuroleptic Malignant Syndrome is thought to be a form of drug-induced catatonia.

A. True

B. False

3. The major treatments for catatonia are:

A. Dopamine antagonists

B. Benzodiazepines


D. B and C

E.  Antidepressants

4. The first person to describe catatonia was

A. Eugen Bleuler

B. C. Miller Fisher

C. Karl Ludwig Kahlbaum

D. Eldridge Cleaver

5. The FDA advisory committee on ECT reclassification voted against ECT as a treatment for catatonia.

A. True

B. False

Catatonia Quiz Answer Key:

1.E;  2.A;  3.D;  4.C;  5.B

The video above is a portrayal of catatonia, which uses an actor in the role of patient.

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