covering almost evrything about catatonia

1. CATATONIA
DR MOSAM PHIRKE,
RESIDENT,
DEPT. OF PSYCHIATRY,
SION HOSPITAL.

2. CATATONIA
 1ST REPORTED AND TERM COINED BY KARL
LUDWIG KAHLBAUM (1874).
 KRAEPLIN AND BLEULER CONSIDERED
CATATONIA AS A PART OF SCHIZOPHRENIA

3. CAUSES
 Northoff (2002)- a ‘top-down modulation’ of basal ganglia
due to deficiency of cortical gamma-amino butyric acid
(GABA).
 hyperactivity of GLUTAMATE, the primary excitatory
neurotransmitter.
 Osman & Khurasani (1994)- sudden and massive
blockade of dopamine.
 Yeh et al, 2004- Clozapine-withdrawal Catatonia.
 Moskowitz (2004)- an evolutionary fear response
 PET scan- Decreased density of GABA in sensorimotor
cortex.
 NMS- Reduced GABA in CSF.

4. RISK FACTORS
 INCREASING AGE AS RISK FACTOR FOR CATATONIA
IN DEPRESSION (Starkstein et al, 1996).
 BRAIN INJURY AND PHYSICAL ILLNESS AT ONSET OF
PSYCHOSIS (Wilcox & Nasrallah, 1986).
 SEVERE INFECTIOUS DISEASES IN CHILDHOOD
(Wilcox, 1986).
 HYSTERIA
 THROMBOTIC THROMBOCYTOPENIC PURPURA (Yacoub
et al, 2004).
 SUBSTANCE (COCAINE, OPIUM, ECSTASY) (Gingrich et al,
1998)

5. FEATURES
 Ambitendency
 Automatic obedience
 Aversion
 Catalepsy
 Echolalia
 Echopraxia
 Excitement
 Forced grasping
 Gegenhalten
 Grimacing
 Immobility
 Logorrhoea
 Mannerisms
•Mitgehen
•Mitmachen
•Mutism
•Negativism
•Obstruction
•Perseveration
•Posturing
•Psychological pillow
•Rigidity
•Staring
•Stereotypies
•Stupor
•Verbigeration
•Waxy flexibility
•Withdrawal

6. DSM 5
THREE OR MORE OF
 STUPOR
 MUTISM
 NEGATIVISM
 CATALEPSY
 WAXY FLEXIBILITY
 POSTURING
 AGITATION
 ECHOLALIA
 ECHOPRAXIA
 GRIMACING
 MANNERISM
 STEREOTYPY

7. CATATONIA ASSOCIATED WITH ANOTHER
MENTAL DISORDER 293.89
 MOOD DISORDER (MANIA>DEPRESSION)$
 BRIEF PSYCHOTIC DISORDER,
SCHIZOPHRENIFORM DISORDER,
SCHIZOPHRENIA.
 NEURODEVELOPMENTAL DISORDER.
$Abrams & Taylor (1976), Barnes et al (1986)

8. CATATONIA DUE TO ANOTHER
MEDICAL CONDITION 293.89
 NEOPLASM, HEAD TRAUMA, CVA, HEAT
STROKE.
 METABOLIC LIKE HYPERCALCEMIA,
HYPONATREMIA, HEPATIC
ENCEPHALOPATHY,HOMOCYSTINURIA,
DIABETIC KETOACIDOSIS
 MEDICATION INDUCED CORTICOSTEROIDS,
IMMUNOSUPPRESSANTS, OPIUM, COCAINE,
ANTIPSYCHOTICS.

9. CATATONIA DUE TO ANOTHER
MEDICAL CONDITION 293.89
 NEUROLOGICAL-
1. POSTENCEPHALITIC STATE
2. PARKINSONISM
3. NON CONVULSIVE STATUS EPILEPTICUS a.k.a.
ICTAL CATATONIA (Lim et al, 1986).
4. B/L GLOBUS PALLIDUS DISEASE
5. LESION OF THALAMUS, PARITAL OR FRONTAL
LOBE.
6. TEMPORAL LOBE EPILEPSY (Kirubakaran et al, 1987).

10. UNSPECIFIED CATATONIA 293.89
 NATURE OF UNDERLYING DISORDER IS
UNCLEAR
 FULL CRITERIA ARE NOT MET
 INSUFFICIENT DATA FOR MAKING DIAGNOSIS

11. ICD-10
CATATONIC SCHIZOPHRENIA F20.2
ONE OR MORE OF
 STUPOR OR MUTISM
 EXCITEMENT
 POSTURING
 NEGATIVISM
 RIGIDITY
 WAXY FLEXIBILITY
 COMMAND AUTOMATISM & PERSEVERATION
ORGANIC CATATONIC DISORDER F06.1

12. DSM IV TR -> DSM 5
CRITERIA FOR CATATONIA ARE DISCRIBED
UNIFORMLY ACROSS DSM 5.
CATATONIA MAY BE DIAGNOSED WITH A
SPECIFIER ( FOR DEPRESSION,BIPOLAR,
PSYCHOTIC DISORDER ), IN THE CONTEXT OF
A KNOWN MEDICAL CONDITION, OR AS AN
OTHER SPECIFIC DIAGNOSIS.

13. CATATONIA SUBTYPES
 Taylor & Fink 2003
 Van Den Eede & Sabbe 2004
 Wernicke–Kleist–Leonhard school of psychiatry
 Hare & Malone, 2004 Catatonia asso with
developmental disorder. Autistic catatonia Chro 15
•

14. DIFFERNTIAL DIAGNOSIS
 ELECTIVE MUTISM ( PD,STRESSORS,ETC. )
 STROKE MUTISM ( LOCKED-IN SYNDROME )
 STIFF PERSON SYNDROME
 MALIGNANT HYPERTHERMIA
 AKINETIC PARKINSONISM

15. MANAGEMENT
 ASSESMENT
1. HISTORY ABOUT DRUGS EXPOSURE,
STRESSOR AND MEDICAL CONDITIONS.
2. COMPLETE NEUROLOGICAL EXAMINATION
3. INVESTIGATION- TPR, CBC, LFT, RFT, BSL,
TFT, CPK LEVELS, BRAIN IMAGING STUDIES
(CT / MRI), EEG.

16. MANAGEMENT
RATING SCALES
1. Bush–Francis Catatonia Rating Scale (BFCRS)
2. Modified Rogers Scale (MRS)

17. TREATMENT
 BENZODIAZEPINES- LORAZEPAM 4 MG
1 MG ORALLY REPEAT AFTER 3 HOURS AND IF
NO RESPONSE GIVE BY IM ROUTE.
INCREASE TILL 8 – 24 MG AFTER 2 DAYS IF NO
RESPONSE.
 ECT DEFINATIVE TREATMENT FOR CATATONIA
 ALONE OR IN COMBINATION
 TREATMENT OF CAUSATIVE FACTOR.

18. TREATMENT
 OTHER TREATMENTS (RESERVED FOR RESISTANT
TO BZD AND ECT’s)
 Mood stabilisers: especially CARBAMAZEPINE. Kritzinger
& Jordaan (2001)
 Antipsychotics
 NMDA antagonists: amantadine and memantine (Northoff et
al, 1999 Thomas et al, 2005)
 Dopamine agonists (e.g. bromocriptine) and skeletal
muscle relaxants (e.g. dantrolene),especially if
neuroleptic malignant syndrome is suspected.

19. TREATMENT
 Mann et al, 2001- NMS IS A ANTIPSYCHOTIC INDUCED LETHAL
CATATONIA.
 Castillo et al (1989)-&, Lethal Catatonia begins with extreme
psychotic excitement whereas the NMS characteristically starts
with severe extrapyramidal muscular rigidity.
 ANTIPSYCHOTIC DRUGS
White and Robbins described 5 patients with excited
catatonia—characterized more by frenzied activity than
immobility—who went on to develop NMS after being treated
with antipsychotic drugs (APDs), and Lee confirmed this
finding, proposing that low serum iron might be a marker for
those at risk of developing NMS when exposed to APDs.

20. CHILD AND ADOLOSENT
 Catatonia has been increasingly recognized as a co-
morbid syndrome of Autism, CDD, Kleine-Levin
syndrome, Prader-Willi syndrome, tic disorder, and
autoimmune encephalitis.
 Good response if diagnosed & treated with BZD
&ECT’s.
 Padder willi syndrome genetic model of catatonia as
linked to chro 15.
Catatonia is Hidden in Plain Sight Among Different Pediatric Disorders: A Review
ArticleDirk M. Dhossche, MD, PhD and Lee E. Wachtel, MD

21. COMPLICATIONS
 DEEP VAIN THROMBOSIS
 PULMONARY EMBOLISM
 DEATH
 CAN BE SUICIDAL OR HOMICIDAL IN EXCITED
STAGE OF CATATONIA

22. THANK YOU