Abstract
Background
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Clinical Setting
Although little prevalence data exist regarding catatonia in seriously ill patients, prospective studies suggest that 1.8% of adult hospitalized patients and 8.9% of elderly hospitalized patients for whom psychiatry was consulted exhibited signs and symptoms of catatonia.2–4 Among ventilated patients, 31% met the criteria for both delirium and catatonia and 3% for catatonia alone. 5 While depression, schizophrenia, and bipolar disorder are common psychiatric comorbidities, patients can develop catatonia from several medical etiologies, even when no pre-existing psychiatric disorder is present. 6 The proposed physiology involves dopamine and gama-aminobutyric acid (GABA) hypoactivity, and glutamate hyperactivity. Hence, dopamine antagonists such as haloperidol or metoclopramide can exacerbate these physiologic perturbations, as can the abrupt withdrawal of benzodiazepines. 7
Clinical Features
Rigidity, posturing, stupor, immobility, and mutism are the most common features. More broadly, catatonia is characterized by three or more of the following symptoms, categorized into four symptom clusters. Although features can fluctuate in severity and range from hypoactivity (e.g., transient stupor) to hyperactivity (e.g., repetitive and purposeless movements), without prompt identification, and especially in the setting of concurrent antipsychotic administration, catatonia can progress to a fulminant condition called “malignant catatonia,” involving fevers, autonomic instability, and unstable vital signs. 8
• Limited activity
○ Mutism: Decreased speech production or volume (not necessarily fully mute).
○ Stupor: Minimal responsiveness, muscles and posture often appear rigid.
○ Negativism: Opposition or no response to instructions or passive movements.
• Unusual positioning
○ Catalepsy: Abnormal posturing or maintenance of an abnormal position with repositioning.
○ Waxy flexibility: Slight but even resistance to positioning by examiner.
• Abnormal behaviors
○ Mannerism: Unusual purposeful actions or behaviors (e.g., ambulating on one foot).
○ Stereotypy: Repetitive, frequent, nongoal-directed movements.
○ Grimacing: Exaggerated facial expressions.
• Paroxysmal hyperactivity: Short episodes of agitation, excited motor movements, echolalia (mimicking of examiner's speech), and/or echopraxia (mimicking movements).
Diagnostic Challenges
Catatonia can clinically resemble delirium and many other medical conditions. This noncomprehensive list includes encephalitis, neuroleptic malignant syndrome, traumatic brain injury, stroke, developmental disorders, Parkinson's-related akinesia, and status epilepticus. 1 Its overlap with delirium can be especially difficult to differentiate, as up to a third of delirious patients also have features of catatonia.5,9 Several clinical features should clue clinicians to the presence of catatonia and prioritize a treatment trial for catatonia, given the concerns of symptom progression.
• Features favoring catatonia: Posturing; increased motor tone; mutism; negativism (resistance to instruction); echolalia or echopraxia; repetitive movements; symptoms worsen from neuroleptics.
• Features favoring delirium: Disorientation; inability to attend; disorganized thinking; hallucinations; impaired short-term memory; altered sleep-wake cycle; symptoms may improve with neuroleptics.
Management Strategies
Treatment is based largely on expert opinion, not controlled trials.1,8
• If available, psychiatry consultation is recommended.
• Promptly discontinue precipitating agents such as neuroleptics and restart recently withdrawn GABAergic medications, such as benzodiazepines.
• Benzodiazepines are first-line catatonia treatments. Lorazepam 1–2 mg IV is often used as a diagnostic test dose as it can often lead to rapid, although transient, improvement. If successful, a standing order for lorazepam 1–2 mg IV q4-8 hours as needed is recommended.
• If fever and autonomic instability occur in a patient with catatonia, intensive care unit transfer and urgent psychiatry consult may be necessary. Electroconvulsive therapy (ECT) and/or dopaminergic medications such as amantadine and bromocriptine are often required.