Catatonia, “a syndrome of altered motor behavior accompanying many general and neurological disorders,”1 is common, affecting 9.8% of adults admitted to psychiatric hospitals.2 However, catatonia frequently goes unrecognized, leading to the erroneous conclusion that it is rare. A Dutch study found that clinicians identified catatonia in only 2% of 139 patients, whereas a research team identified catatonia in 18%.3

“Catatonia is treatable, but the sad component is that the true diagnosis is often not made and appropriate treatment is not provided,” Max Fink, MD, professor emeritus of psychiatry and neurology, Stony Brook School of Medicine, New York, told Psychiatry Advisor.

The History of Catatonia

One of the main reasons for the frequent misdiagnosis of catatonia is the continuing misconception that it is synonymous with schizophrenia, Dr Fink said.

It was Karl Ludwig Kahlbaum who first made the association between psychomotor symptoms and psychiatric disorders in 1874. Kahlbaum coined the term Die Katatonie and clustered 17 motor abnormalities into a single syndrome in patients with an array of disorders, including mood, psychosis, neurosyphilis, tuberculosis, and epilepsy.4

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In 1899, Emil Kraepelin categorized catatonia as a feature of dementia praecox and by 1913, catatonia had become “1 of the 8 subgroups into which dementia praecox was divided and clearly subordinated to the larger diagnosis.”1

Although this definition was by no means universally accepted and was fraught with ongoing controversy, both the Diagnostic and Statistical Manual of Mental Diseases (DSM)-I and DSM-II5,6 classified catatonia as a type of schizophrenia, which continued through the publication of DSM-III.7

However, descriptions of a toxic response to neuroleptic agents and subsequent identification of neuroleptic malignant syndrome (NMS) called this into question because of its similarity to malignant catatonia, Dr Fink explained.

Fink and Taylor argued that catatonia should not be exclusively linked with schizophrenia, leading to a change that recognized catatonia as a disorder caused by a medical condition and a features specifier in mood disorders, in DSM-IV.8,9

The development of rating scales and more effective examination procedures led to the discovery that between 9% and 17% of patients in psychiatric facilities and emergency departments met criteria for catatonia — even more among those with mood disorders or toxic states than among patients with schizophrenia.1

In the DSM-5, criteria for catatonia remained the same throughout the manual, independent of the initial diagnosis (eg, psychotic, bipolar, depressive, medical disorder, or unidentified medical condition). It was defined by the presence of at least 3 symptoms from a list of 12 and was no longer called a “subtype” of schizophrenia but rather a “specifier” for schizophrenia as well as for major mood disorders and 4 additional psychotic disorders. There was also a new diagnostic category: “catatonia not otherwise specified.”10 The DSM-5 definition of catatonia can be found below.

DSM-5 Definition of Catatonia

Catatonia is defined by the presence of 3 or more of the following10:

Catalepsy: Passive induction of postures held against gravity

Waxy flexibility: Slight and even resistance to repositioning by the examiner

Stupor: No psychomotor activity, no reactivity to the environment

Agitation: Not influenced by external stimuli

Mutism: No or minimal verbal response; not applicable in case of established aphasia

Negativism: Opposing or not responding to external stimuli, such as instructions

Posturing: Spontaneous and active maintenance of posture against gravity

Mannerism: Odd caricatures of ordinary actions

Stereotypes: Repetitive, frequent, non-goal-directed movements

Grimacing

Echolalia: Repeating the words spoken by the examiner

Echopraxia: Mimicking of the movements made by the examiner

Beyond the nosologic debate, another historical process affected how catatonia was regarded because “the bulk of psychiatric practice shifted from the asylum to the ambulatory clinic, with an emphasis on psychotherapy and the prescription of psychotropic agents,” Dr Fink noted.

In the ambulatory setting, less emphasis is placed on a medical examination and, coupled with the assumption that catatonia is associated mainly with schizophrenia, it became regarded as merely another form of psychosis, he added.

Illnesses associated with catatonia include the following2,11:

Psychiatric, including schizophrenia, bipolar disorder, depression, Tourette syndrome, autism

Metabolic, including renal failure, liver failure, ketoacidosis, vitamin B12 deficiency

Endocrine, including hyperthyroidism, hypercalcemia from parathyroid adenoma, Addison disease, Cushing disease, syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Neurologic, including encephalitis, multiple sclerosis, epilepsy

Rheumatologic, including systemic lupus erythematosus

Infectious diseases, including typhoid fever, mononucleosis, malaria

A Condition of Fear

“There are multiple causes behind catatonia, but one way to regard it is as a systemic response to unrequited fear,” said Dr Fink, who is the coauthor of the just-published book The Madness of Fear: A History of Catatonia.12

“Fear is induced in human beings in multiple ways,” he explained. “For example, if you are sick and become frightened, that fright can be manifested through withdrawal, stupor, posturing, or repetitive movements.”

“In Freudian terms, this can be seen as a defense adaptation, and the reason we can treat catatonia with sedative drugs or ECT [electroconvulsive therapy] is that we are treating the fear,” he said.

Types of Catatonia

Catatonia is not a single, undifferentiated entity but has several different forms, Dr Fink pointed out.

Retarded catatonia is the most common, consisting of movement that is inhibited by posturing, rigidity, mutism, and repetitive actions, as well as failure to respond to painful stimuli. When this presentation includes stupor, patients may require parenteral feeding and extending nursing care.11

Delirious mania is an excited form of catatonia, characterized by restless movements, talkativeness, agitation, frenzy, disorientation, and confusion.11

Malignant catatonia is “a syndrome of acute onset, fever in all but elderly individuals, and abnormal blood pressures, tachycardia, and tachypnea of life-threatening dimensions.”11 It is similar to NMS and neuroleptic-induced catatonia. Toxic serotonin syndrome can be seen as malignant catatonia associated with serotonergic drug overdose.11

Periodic catatonia is recurrent and reported among patients with bipolar disorder, in which the patient fluctuates between stupor and excitement. It is most likely to occur during a mixed mood state or period of rapid cycling.11

Agitated catatonia is often associated with self-injurious and typically stereotyped behavior, commonly seen in autism.13

These catatonia syndromes are referred to by several names, which are listed below.11,13

Catatonia Syndromes: Nomenclature

Retarded catatonia (benign stupor) is also referred to as Kahlbaum syndrome

Excited catatonia (delirious catatonia) is also referred to as manic excitement (manic delirium) (Bell mania)

Malignant catatonia (neuroleptic malignant syndrome; toxic serotonin syndrome) is also referred to as lethal catatonia, pernicious catatonia, acute fulminating psychosis (syndrome malin; neuroleptic-induced catatonia; serotonin syndrome)

Periodic catatonia (mixed affective state) is also referred to as rapid cycling mania

Agitated catatonia is also referred to as self-injurious behavior (eg, in autism)

Diagnosing Catatonia

Catatonia should be considered in every patient with dysregulated motor behavior, especially in those who also show changes in consciousness and mood, Dr Fink emphasized.

There are several rating scales that can help identify catatonic symptoms.14 A systematic review14 found the Bush-Francis Catatonia Rating Scale (BFCRS)15 to be preferable for routine use because of its validity, reliability, and ease of administration.

To verify the diagnosis, a lorazepam “challenge test” can be helpful because signs and symptoms of catatonia are commonly relieved by the intravenous (IV) administration of a barbiturate or benzodiazepine, Dr Fink said, adding that zolpidem may be considered an alternative to lorazepam.

“If you suspect catatonia, based on your observation and results of the rating scale, the lorazepam test can be useful,” Dr Fink said.

“Imagine a stuporous patient not responding, even if you pinch or stick them with a pin,” he continued. “You give them IV lorazepam and they pick up their head 5 or 10 minutes later, look at you and ask, ‘Where am I?’ That’s a positive response and you can treat that patient.”

The result is positive in 80% of tests in patients who have catatonia and respond to treatment. However, if the patient does not respond to the test dose, Dr Fink noted that it is repeated, or higher treatment doses are given. “If the patient does not fully respond to the sedative drug, ECT becomes the default,” he said.

High serum creatine kinase and low serum iron levels can be associated with malignant catatonia, particularly NMS, but are less useful in identifying other forms of catatonia.12

Treating Catatonia

Because catatonia is so frequently associated with schizophrenia or regarded as a form of psychosis, it is often inappropriately treated with antipsychotics, Dr Fink remarked.

Catatonia typically has a poor response rate to antipsychotics — as low as 7.5% — so they should be avoided. Introducing them can also complicate the clinical picture and promote the development of the malignant form of catatonia.2

In all patients, potential toxic precipitants should be eliminated and general medical and/or neurologic diseases should be treated.12

For those with retarded catatonia and body temperatures <39°C, parental or oral lorazepam should be administered, beginning with 3 mg/d and rapidly increasing to effective resolution, even as high as 20 to 30 mg/d.11 ECT can bring effective relief to patients with higher fevers, delirium, or physiologic risk or those who do not rapidly respond to lorazepam.11

High fever (≥39°C) is associated with various forms of malignant catatonia (eg, NMS, delirious mania). “Such states are life threatening and warrant intensive medical and nursing treatment: IV fluids, sponging, body care, sedation, and ECT — even daily ECT,” Dr Fink said.

Benzodiazepines and ECT can be used together, as they have a synergetic effect, but the dose of the benzodiazepine should be reduced because it can raise the seizure threshold.2

Most patients respond well to catatonia treatment, with up to 80% achieving relief through benzodiazepines or barbiturates and the remainder showing improvement from ECT.16 However, some patients seem to be resistant to treatment, particularly ECT. Possible reasons include chronic symptoms, diagnostic delay, high seizure threshold, and incorrect application of ECT (eg, insufficient number of sessions, short session duration, procedural failures, and concomitant use of benzodiazepines).16

Next Steps

“We can no longer regard catatonia as a psychiatric disorder specific to schizophrenia,” Dr Fink stated. Rather, “it is better regarded as a movement and behavioral syndrome with particular attributes and diverse antecedents.”

Additionally, “there has been relatively little biological, genetic, and imaging research devoted to catatonia.” It is important to begin expanding the research base and apply these powerful research tools to populations with confirmed catatonia, he said.

“Catatonia is a diagnosable and treatable entity,” Dr Fink concluded. More education is needed to reinforce this message for physicians, especially in emergency departments and psychiatric facilities.