Catatonia

Aka: Catatonia, Catatonic, Catalepsy, Waxy Flexibility, Cerea Flexibilitas

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II. Definitions

  1. Catatonia
    1. Neuropsychiatric disorder with abnormal movement and behavior (e.g. immobility, stupor, mutism)
    2. Most commonly due to underlying psychiatric cause
  2. Catalepsy
    1. Decreased responsiveness in a trance-like state
    2. Muscle rigidity and patient maintains positions in which they are placed despite being against gravity
  3. Waxy Flexibility
    1. Resistance to movement when passively repositioning extremities (similar to bending a wax candle)

III. Epidemiology

  1. Incidence
    1. Inpatient Psychiatry: 5-20% (esp. Schizophrenia)
    2. Overall Psychiatric Ilness: <2%

IV. Types

  1. Excited Catatonia
  2. Retarded Catatonia
  3. Malignant Catatonia (lethal Catatonia)
    1. See Complications below

V. Signs

  1. Motor
    1. Immobility
    2. Muscular rigidity
    3. Posturing or grimacing
    4. Echopraxia (mimics movement in others)
    5. Stereotypical or repetitive movement (e.g. picking at clothes, staring, repeated odd gestures)
    6. Catalepsy
    7. Waxy Flexibility
  2. Verbal
    1. Non-verbal (mutism)
    2. Echolalia (repetitive nonsensical speech)
  3. Mental State
    1. Stupor
    2. Failure to follow commands (negativism)
  4. Other features
    1. May be labile with sudden outbursts of Agitation, Hallucinations, panic

VI. Causes

  1. Most common causes
    1. Schizophrenia
    2. Bipolar Disorder
  2. Other causes
    1. Major Depression
    2. Post-Traumatic Stress Disorder or Anxiety Disorder
    3. Autism

VII. Differential Diagnosis

  1. Neuroleptic Malignant Syndrome
  2. Serotonin Syndrome
  3. Encephalitis (including NMDA Encephalitis)
  4. Non-convulsive Status Epilepticus
  5. Advanced Parkinsonism
  6. Neurologic Injury (e.g. CVA, CNS Mass)

VIII. Management

  1. Benzodiazepines are the mainstay of management
    1. Lorazepam 1-2 mg IV
  2. Consider Electroconvulsive Therapy
  3. Avoid Antipsychotic Medications unless specifically directed by psychiatry
    1. Antipsychotics risk worsening Catatonia

IX. Complications: Malignant Catatonia

  1. Malignant Catatonia (lethal Catatonia) is a rare type of Catatonia with risk of death within days
  2. Presents in similar fashion to Malignant Hyperthermia (but without drug trigger)
    1. Fever and diaphoresis
    2. Muscle Rigidity
    3. Labile Blood Pressure
  3. Evaluate broadly
    1. Poison control or toxicology Consultation
    2. Psychiatry Consultation

X. References

  1. Burrow (2021) Catatonia, StatPearls, accessed 8/6/2021
    1. https://www.ncbi.nlm.nih.gov/books/NBK430842/
  2. Pensa and Werner (2021) EM:Rap 21(8): 13-4

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