Catatonia

Ben Johnson, Laura Artim

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
      • Would 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 relate to the duration of the underlying cause
    • Prevalence estimates vary widely due in large part to a variety of presentations and inconsistent diagnosis
      • Estimates range from 10-30%

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 earlyon.
  • 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, specifically, includes 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
      • Early psychiatry involvement is important for this reason for full evaluation of symptoms before and after intervention
      • Catatonia due to non-psychiatric etiologies typically respond less robustly to benzodiazepines
  • Treatment with benzodiazepines and/or ECT often continues for weeks to months following initial diagnosis
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