Catatonia

Claire Willman

Background 

Catatonia is a psychomotor syndrome and is associated with both psychiatric and medical conditions.

  • Catatonia can present as hypoactive or hyperactive.
  • May be secondary to a medical or psychiatric condition.
    • Recommend AMS workup as appropriate while awaiting psychiatric evaluation.
  • Severity can range from mild with subtle abnormalities to severe and possibly fatal.
  • Onset of catatonia can range from hours to days or weeks.
  • Episodes can be acute, chronic and persistent, or periodic and recurring.
  • Duration of catatonia related to intoxication or underlying medical conditions relates to the duration of the underlying cause.

Evaluation 

  • Presentations are often varied, so early psychiatric intervention is important given possibility of autonomic instability that can be fatal.
  • If catatonia is considered on the differential, a psychiatric consultation is encouraged early-on.
  • Catatonia can include quantitative changes in psychomotor activity and qualitatively bizarre behaviors.
  • Some clues may include increased muscle tone, decreased speech production, decreased PO intake, abnormal movements or behaviors that do not seem goal-oriented, maintaining odd postures, refusing to follow commands, repetitive movements such as pacing, repeating phrases, or grimacing.
  • Hypoactive catatonia specifically can present as a quantitative decrease in psychomotor activity and includes paucity of movement, immobility, staring, mutism, rigidity, withdrawal and refusal to eat, ambitendency, and negativism.
  • Excited catatonia can include severe psychomotor agitation, impulsivity, and combativeness.
  • Abnormal psychomotor activity can be seen in both hypoactive and excited catatonia and can include posturing, grimacing, waxy flexibility, echolalia or echopraxia, stereotypy, verbigeration, and automatic obedience.

Treatment 

  • Early psychiatry consultation is important due to thorough evaluation of catatonia involving response to treatment (diagnostic and therapeutic).
  • Reversal and treatment of underlying causes of catatonia.
  • First line treatment for catatonia is benzodiazepines.
  • Typically start with lorazepam 2 mg IV and assess response.
  • Response to treatment can be rapid within minutes.
  • If catatonia does not respond well to benzodiazepines, ECT is considered.
  • Treatment with benzodiazepines and/or ECT often continues for weeks to months following initial diagnosis.
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