CATATONIA

DR MOSAM PHIRKE,

RESIDENT,

DEPT. OF PSYCHIATRY,

SION HOSPITAL.

CATATONIA

1ST REPORTED AND TERM COINED BY KARL

LUDWIG KAHLBAUM (1874).

KRAEPLIN AND BLEULER CONSIDERED

CATATONIA AS A PART OF SCHIZOPHRENIA

CAUSES

Northoff (2002)- a ‘top-down modulation’ of basal ganglia

due to deficiency of cortical gamma-amino butyric acid

(GABA).

hyperactivity of GLUTAMATE, the primary excitatory

neurotransmitter.

Osman & Khurasani (1994)- sudden and massive

blockade of dopamine.

Yeh et al, 2004- Clozapine-withdrawal Catatonia.

Moskowitz (2004)- an evolutionary fear response

PET scan- Decreased density of GABA in sensorimotor

cortex.

NMS- Reduced GABA in CSF.

RISK FACTORS

INCREASING AGE AS RISK FACTOR FOR CATATONIA

IN DEPRESSION (Starkstein et al, 1996).

BRAIN INJURY AND PHYSICAL ILLNESS AT ONSET OF

PSYCHOSIS (Wilcox & Nasrallah, 1986).

SEVERE INFECTIOUS DISEASES IN CHILDHOOD (Wilcox, 1986).

HYSTERIA

THROMBOTIC THROMBOCYTOPENIC PURPURA (Yacoub

et al, 2004).

SUBSTANCE (COCAINE, OPIUM, ECSTASY) (Gingrich et al,

1998)

FEATURES

Ambitendency

Automatic obedience

Aversion

Catalepsy

Echolalia

Echopraxia

Excitement

Forced grasping

Gegenhalten

Grimacing

Immobility

Logorrhoea

Mannerisms

•Mitgehen

•Mitmachen

•Mutism

•Negativism

•Obstruction

•Perseveration

•Posturing

•Psychological pillow

•Rigidity

•Staring

•Stereotypies

•Stupor

•Verbigeration

•Waxy flexibility

•Withdrawal

DSM 5THREE OR MORE OF

STUPOR

MUTISM

NEGATIVISM

CATALEPSY

WAXY FLEXIBILITY

POSTURING

AGITATION

ECHOLALIA

ECHOPRAXIA

GRIMACING

MANNERISM

STEREOTYPY

CATATONIA ASSOCIATED WITH ANOTHER

MENTAL DISORDER 293.89

MOOD DISORDER (MANIA>DEPRESSION)$

BRIEF PSYCHOTIC DISORDER,

SCHIZOPHRENIFORM DISORDER,

SCHIZOPHRENIA.

NEURODEVELOPMENTAL DISORDER.

$Abrams & Taylor (1976), Barnes et al (1986)

CATATONIA DUE TO ANOTHER

MEDICAL CONDITION 293.89

NEOPLASM, HEAD TRAUMA, CVA, HEAT

STROKE.

METABOLIC LIKE HYPERCALCEMIA,

HYPONATREMIA, HEPATIC

ENCEPHALOPATHY,HOMOCYSTINURIA,

DIABETIC KETOACIDOSIS

MEDICATION INDUCED CORTICOSTEROIDS,

IMMUNOSUPPRESSANTS, OPIUM, COCAINE,

ANTIPSYCHOTICS.

CATATONIA DUE TO ANOTHER

MEDICAL CONDITION 293.89

NEUROLOGICAL-

1. POSTENCEPHALITIC STATE

2. PARKINSONISM

3. NON CONVULSIVE STATUS EPILEPTICUS a.k.a.

ICTAL CATATONIA (Lim et al, 1986).

4. B/L GLOBUS PALLIDUS DISEASE

5. LESION OF THALAMUS, PARITAL OR FRONTAL

LOBE.

6. TEMPORAL LOBE EPILEPSY (Kirubakaran et al, 1987).

UNSPECIFIED CATATONIA 293.89

NATURE OF UNDERLYING DISORDER IS

UNCLEAR

FULL CRITERIA ARE NOT MET

INSUFFICIENT DATA FOR MAKING DIAGNOSIS

ICD-10

CATATONIC SCHIZOPHRENIA F20.2

ONE OR MORE OF

STUPOR OR MUTISM

EXCITEMENT

POSTURING

NEGATIVISM

RIGIDITY

WAXY FLEXIBILITY

COMMAND AUTOMATISM & PERSEVERATION

ORGANIC CATATONIC DISORDER F06.1

DSM IV TR -> DSM 5

CRITERIA FOR CATATONIA ARE DISCRIBED

UNIFORMLY ACROSS DSM 5.

CATATONIA MAY BE DIAGNOSED WITH A

SPECIFIER ( FOR DEPRESSION,BIPOLAR,

PSYCHOTIC DISORDER ), IN THE CONTEXT OF

A KNOWN MEDICAL CONDITION, OR AS AN

OTHER SPECIFIC DIAGNOSIS.

CATATONIA SUBTYPES

Taylor & Fink 2003

Van Den Eede & Sabbe 2004

Wernicke–Kleist–Leonhard school of psychiatry

Hare & Malone, 2004 Catatonia asso with

developmental disorder. Autistic catatonia Chro 15

•

DIFFERNTIAL DIAGNOSIS

ELECTIVE MUTISM ( PD,STRESSORS,ETC. )

STROKE MUTISM ( LOCKED-IN SYNDROME )

STIFF PERSON SYNDROME

MALIGNANT HYPERTHERMIA

AKINETIC PARKINSONISM

MANAGEMENT

ASSESMENT

1. HISTORY ABOUT DRUGS EXPOSURE,

STRESSOR AND MEDICAL CONDITIONS.

2. COMPLETE NEUROLOGICAL EXAMINATION

3. INVESTIGATION- TPR, CBC, LFT, RFT, BSL,

TFT, CPK LEVELS, BRAIN IMAGING STUDIES

(CT / MRI), EEG.

MANAGEMENT

RATING SCALES

1. Bush–Francis Catatonia Rating Scale (BFCRS)

2. Modified Rogers Scale (MRS)

TREATMENT

BENZODIAZEPINES- LORAZEPAM 4 MG

1 MG ORALLY REPEAT AFTER 3 HOURS AND IF

NO RESPONSE GIVE BY IM ROUTE.

INCREASE TILL 8 – 24 MG AFTER 2 DAYS IF NO

RESPONSE.

ECT DEFINATIVE TREATMENT FOR CATATONIA

ALONE OR IN COMBINATION

TREATMENT OF CAUSATIVE FACTOR.

TREATMENT

OTHER TREATMENTS (RESERVED FOR RESISTANT

TO BZD AND ECT’s)

Mood stabilisers: especially CARBAMAZEPINE. Kritzinger

& Jordaan (2001)

Antipsychotics

NMDA antagonists: amantadine and memantine (Northoff et

al, 1999 Thomas et al, 2005)

Dopamine agonists (e.g. bromocriptine) and skeletal

muscle relaxants (e.g. dantrolene),especially if

neuroleptic malignant syndrome is suspected.

TREATMENT

Mann et al, 2001- NMS IS A ANTIPSYCHOTIC INDUCED LETHAL CATATONIA.

Castillo et al (1989)-&, Lethal Catatonia begins with extreme psychotic excitement whereas the NMS characteristically starts with severe extrapyramidal muscular rigidity.

ANTIPSYCHOTIC DRUGS

White and Robbins described 5 patients with excited catatonia—characterized more by frenzied activity than immobility—who went on to develop NMS after being treated with antipsychotic drugs (APDs), and Lee confirmed this finding, proposing that low serum iron might be a marker for those at risk of developing NMS when exposed to APDs.

CHILD AND ADOLOSENT

Catatonia has been increasingly recognized as a co-morbid syndrome of Autism, CDD, Kleine-Levin syndrome, Prader-Willi syndrome, tic disorder, and autoimmune encephalitis.

Good response if diagnosed & treated with BZD &ECT’s.

Padder willi syndrome genetic model of catatonia as linked to chro 15.

Catatonia is Hidden in Plain Sight Among Different Pediatric Disorders: A Review ArticleDirk M. Dhossche, MD, PhD and Lee E. Wachtel, MD

COMPLICATIONS

DEEP VAIN THROMBOSIS

PULMONARY EMBOLISM

DEATH

CAN BE SUICIDAL OR HOMICIDAL IN EXCITED

STAGE OF CATATONIA

THANK YOU