Catatonia is the neuropsychiatric syndrome characterized by a range of motor and behavioral abnormalities. It is often associated with various psychiatric, neurological, or medical conditions. Catatonia can manifest as a state of immobility, rigidity, or unusual posturing, along with other symptoms such as mutism, negativism, echolalia, or echopraxia. It was first described in the late 19th century by Karl Ludwig Kahlbaum.

Catatonia can occur as a primary condition known as primary catatonia, or as a secondary manifestation of an underlying disorder, such as mood disorders, schizophrenia, substance abuse, or medical conditions like autoimmune encephalitis, neurodegenerative diseases, or metabolic disturbances. It can also be induced by certain medications or drug withdrawal.

The exact underlying mechanisms of catatonia are not fully known, but it is believed to involve dysregulation of neurotransmitters, particularly gamma-aminobutyric acid (GABA) and glutamate. Dysfunction in specific brain regions and circuits, such as the basal ganglia and frontal cortex, may also help develop catatonic symptoms.

Catatonia can have a significant impact on an individual’s functioning and well-being, leading to impairment in daily activities, social withdrawal, and increased risk of complications. Early detection and appropriate treatment are crucial for managing catatonia and addressing the underlying cause.

The management of catatonia involves a multidisciplinary approach, including psychiatric evaluation, medical assessment, and close monitoring. Treatment may include medications such as benzodiazepines, electroconvulsive therapy (ECT), and addressing any underlying medical or psychiatric conditions. The prognosis for catatonia depends on the underlying cause and the promptness and effectiveness of treatment.

Prevalence: Catatonia is considered a rare condition, but it is true prevalence is uncertain due to underdiagnosis and varying diagnostic criteria across studies.

Age and Gender: Catatonia can occur at any age, but it is most observed in late adolescence and early adulthood. There is no significant gender difference in the prevalence of catatonia.

Underlying Conditions: Catatonia can occur as a primary condition or as a secondary manifestation of various underlying disorders. It is frequently associated with psychiatric conditions such as mood disorders (e.g., bipolar disorder, major depressive disorder) and schizophrenia. It can also be associated with medical conditions including autoimmune encephalitis, neurodegenerative disorders, metabolic disturbances, and substance abuse or withdrawal.

Risk Factors: There are no specific known risk factors for catatonia, but certain factors may increase the likelihood of developing catatonia, such as a history of psychiatric disorders, family history of catatonia, or exposure to certain medications or substances.

Geographical Variation: There is limited research on the geographical variation in the epidemiology of Catatonia. The available studies suggest that catatonia occurs worldwide without significant regional variation.

Neurotransmitter Dysfunction:

• Imbalances in neurotransmitters such as gamma-aminobutyric acid (GABA), dopamine, and glutamate have been implicated in the pathophysiology of catatonia.
• GABAergic dysfunction, specifically decreased GABAergic activity, may contribute to the characteristic features of catatonia, including motor abnormalities and altered consciousness.

Abnormal Brain Circuits:

• Disruptions in neural circuits involving the basal ganglia, frontal cortex, and thalamus have been observed in catatonia.
• Dysfunction in these circuits can lead to disturbances in movement control, cognition, and emotional processing.

Glutamate NMDA Receptor Hypofunction:

• Hypofunction of the N-methyl-D-aspartate (NMDA) subtype of glutamate receptors has been proposed as a potential mechanism in catatonia.
• NMDA receptor dysfunction can impair synaptic plasticity and contribute to the development of catatonic symptoms.

GABAergic and Dopaminergic Modulation:

• Altered GABAergic and dopaminergic signalling in the brain may influence the development of catatonia.
• GABAergic and dopaminergic dysregulation can disrupt the balance between inhibitory and excitatory neurotransmission, leading to abnormal motor and behavioural manifestations.

Genetics and Familial Risk:

• There is evidence to suggest a genetic predisposition to catatonia.
• Studies have identified potential genetic factors that may contribute to the development of catatonia, but further research is needed to fully understand the genetic basis of the condition.

Primary Catatonia:

• Primary catatonia refers to cases where catatonia is the primary clinical presentation without an underlying medical or psychiatric condition.
• The exact etiology of primary catatonia is not well understood, but it is believed to involve a combination of genetic, neurochemical, and neurodevelopmental factors.

Psychiatric Disorders:

• Catatonia can occur as a symptom of various psychiatric disorders, including schizophrenia, bipolar disorder, and major depressive disorder.
• In these cases, the etiology of catatonia is related to the underlying psychiatric condition and its associated neurochemical imbalances.

Neurological Disorders:

• Catatonia can also be associated with certain neurological conditions, such as encephalitis, brain injury, or neurodegenerative disorders.
• In these cases, the etiology of catatonia is related to the underlying neurological pathology affecting brain function.

Medical Conditions and Metabolic Disorders:

• Catatonia can occur because of certain medical conditions, such as autoimmune disorders, endocrine disorders, and metabolic imbalances.
• The etiology of catatonia in these cases is related to the physiological disruptions caused by the underlying medical condition.

Medications and Substance Abuse:

• Catatonia can be induced or exacerbated by certain medications, such as antipsychotics or benzodiazepines.
• Substance abuse, particularly with substances like alcohol or stimulants, can also contribute to the development of catatonia.

Underlying Cause:

• The prognosis of catatonia is dependent on the underlying cause or condition leading to its development. Catatonia associated with reversible conditions, such as medication-induced or metabolic disturbances, has a better prognosis compared to catatonia associated with severe psychiatric or neurological disorders.

Duration of Catatonic Symptoms:

• The duration of catatonic symptoms can influence the prognosis. Catatonia that resolves quickly with appropriate treatment has a better prognosis than catatonia that persists for a prolonged period.

Prompt Recognition and Treatment:

• Early detection and prompt initiation of appropriate treatment are associated with better prognosis. Timely intervention can help alleviate catatonic symptoms and prevent complications.

Response to Treatment:

• The response to treatment can vary among individuals. Some individuals with catatonia may respond well to treatment, while others may have a more resistant form of the condition. Those who respond positively to treatment tend to have a better prognosis.

Presence of Underlying Psychiatric Disorders:

• Catatonia associated with underlying psychiatric disorders, such as schizophrenia or mood disorders, may have a less favourable prognosis compared to catatonia with reversible or secondary causes.

Medical Complications:

• The presence of medical complications, such as dehydration, malnutrition, or immobility, can negatively impact the prognosis of catatonia. Prompt management of these complications is important for a better outcome.

Age Group:

• Catatonia can occur at any age, but it is most observed in late adolescence and early adulthood. However, it can also occur in children, middle-aged individuals, and older adults.

Associated Comorbidity or Activity:

• Psychiatric disorders: Catatonia can be seen in individuals with schizophrenia, mood disorders (such as bipolar disorder or major depressive disorder), and other psychotic disorders.
• Neurological conditions: Catatonia can occur in association with certain neurological disorders, such as epilepsy, encephalitis, or brain injury.
• Medical conditions: Catatonia can be related to medical conditions such as metabolic disorders, autoimmune diseases, infections, and substance withdrawal or intoxication.
• Developmental disorders: Catatonia may also be observed in individuals with autism spectrum disorders.

Acuity of Presentation:

• The onset of catatonia can be sudden or gradual, depending on the underlying cause. In some cases, it may develop acutely over a few hours or days, while in others, it may have a more insidious onset over weeks or months.
• The severity of catatonic symptoms can vary, ranging from mild to severe. Some individuals may experience intermittent episodes of catatonia, while others may have a persistent and chronic course.

General Appearance:

• Patients with catatonia may appear immobile or exhibit abnormal postures or movements. They may be found in a rigid or “frozen” position, or they may exhibit repetitive and purposeless movements.

Muscle Tone:

• Catatonic individuals may have abnormal muscle tone. They may exhibit increased muscle tone (hypertonia) with rigidity, or decreased muscle tone (hypotonia) with floppiness or “rag doll” appearance.

Motor Abnormalities:

• Catatonia is characterized by various motor abnormalities, including:
• Catalepsy: The patient may maintain a fixed posture or position for an extended period, even when it is uncomfortable or physically challenging.
• Waxy Flexibility: The patient’s limbs can be passively moved and placed in different positions, and they will maintain the new position until it is changed again.
• Stereotypies: Repetitive and purposeless movements or gestures, such as rocking, hand wringing, or finger tapping.
• Mutism: Inability or unwillingness to speak.
• Negativism: Resistance or opposition to any instructions or attempts to move or engage the patient.
• Echopraxia: Involuntary imitation or repetition of movements exhibited by others.

Posturing:

• Catatonic individuals may exhibit abnormal postures, such as assuming and maintaining unusual or fixed positions for prolonged periods. This can include postures such as the “waxy flexibility” mentioned earlier.

Cataplexy:

• Some individuals with catatonia may experience episodes of sudden loss of muscle tone (cataplexy), resulting in temporary weakness or collapse.

Neurological Examination:

• A comprehensive neurological examination may be performed to assess for any signs of underlying neurological conditions that may be contributing to catatonic symptoms.

TREATMENT PARADIGM

Neurology

Physical Medicine and Rehabilitation

Psychiatry/Mental Health

Lifestyle modifications:

• Physical Activity: Encouraging physical activity and exercise within the individual’s capabilities can have several benefits. It promotes circulation, helps maintain muscle tone, and improves overall well-being.
• Comfortable and Calm Environment: Create a comfortable and soothing environment that promotes relaxation. This may include comfortable seating, soft lighting, and calming elements such as pleasant scents or soothing music. Ensure adequate temperature control and ventilation in the environment.
• Behavioural Supports: Implement behavioural supports and interventions tailored to the individual’s needs. This may involve providing visual schedules, using positive reinforcement techniques, or utilizing assistive devices to facilitate communication or mobility.
• Stress Reduction: Stress can exacerbate catatonia symptoms, so it is important to minimize stressors as much as possible. This may involve creating a calm and supportive environment, reducing noise and sensory overload, and promoting relaxation techniques.
• Social Support: Maintaining social connections and having a supportive network can contribute to the well-being of individuals with catatonia. Encourage regular interactions with family and friends, participation in support groups, or involvement in community activities, if feasible.
• Healthy Sleep Hygiene: Establishing a regular sleep schedule and practicing good sleep hygiene can improve sleep quality and help regulate the circadian rhythm. This includes maintaining a consistent bedtime and wake-up time, creating a comfortable sleep environment, and avoiding stimulating activities or substances close to bedtime.
• Nutrition and Hydration: Ensuring a balanced and nutritious diet is important for overall health. Take diet that includes a variety of fruits, vegetables, whole grains, and lean proteins. Adequate hydration should also be emphasized to prevent dehydration.

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Physical Medicine and Rehabilitation

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• Hyperthermia: Hyperthermia, or dangerously high body temperature, can occur during catatonia treatment, particularly with the use of ECT. To manage hyperthermia, cooling measures should be initiated promptly. This may involve using cooling blankets, applying cold packs to the patient’s body, providing adequate hydration, and ensuring a cool environment. In severe cases, additional interventions like pharmacological agents to reduce body temperature may be necessary.
• Hypertension: Hypertension can arise during the treatment of catatonia. It is important to monitor blood pressure regularly during interventions such as ECT. If hypertension occurs, antihypertensive medications may be administered to control blood pressure and prevent potential complications. Close monitoring of blood pressure before, during, and after the procedure is crucial.
• Cardiopulmonary Instability: Catatonia treatment interventions, including ECT, can sometimes lead to cardiopulmonary instability, such as arrhythmias or cardiovascular collapse. It is important to have appropriate cardiac monitoring in place during these interventions to detect any abnormalities early.
• Deep Vein Thrombosis (DVT): Prolonged immobilization during catatonia can increase the risk of developing DVT. Measures to prevent DVT include early mobilization, range-of-motion exercises, and use of compression stockings or intermittent pneumatic compression devices. Prophylactic anticoagulation may also be considered in high-risk individuals.
• Pressure Ulcers: Prolonged immobilization and limited mobility can predispose catatonic patients to pressure ulcers. Frequent repositioning, adequate padding, and proper skin care are essential to prevent pressure ulcers. In severe cases, specialized support surfaces or mattresses may be used.

Internal Medicine

Neurology

Psychiatry/Mental Health

• Avoidance of dopamine-blocking drugs is an important consideration in the treatment of catatonia. Catatonia is characterized by a dysregulation of neurotransmitters in the brain, including dopamine. Dopamine-blocking drugs, such as typical antipsychotic medications (e.g., haloperidol) or antiemetics (e.g., metoclopramide), can worsen catatonic symptoms or potentially induce a neuroleptic malignant syndrome.
• These medications antagonize dopamine receptors in the brain, which can further disrupt the delicate balance of neurotransmitters in individuals with catatonia. As a result, dopamine-blocking drugs are contraindicated in the treatment of catatonia.
• Instead, the primary approach to treating catatonia involves the use of benzodiazepines, such as lorazepam or diazepam, which enhance the inhibitory effects of gamma-aminobutyric acid (GABA) in the brain. Benzodiazepines have been shown to be effective in relieving catatonic symptoms and promoting relaxation and muscle control. Electroconvulsive therapy (ECT) may also be considered for severe or refractory cases of catatonia.

Internal Medicine

Neurology

Psychiatry/Mental Health

• Malignant Catatonia: Lorazepam is often the first-line treatment for malignant catatonia. It is typically administered intravenously in high doses to rapidly alleviate the symptoms. The initial dose is usually 2 to 4 mg, which may be repeated as needed to achieve the desired effect. The dose may be adjusted depending on the individual’s response and tolerance. Lorazepam helps promote muscle relaxation, reduce agitation, and improve catatonic symptoms. It is often used as a bridge therapy until electroconvulsive therapy (ECT) can be initiated.
• Non-Malignant Catatonia: Lorazepam is also used in the treatment of non-malignant catatonia. It is usually given orally or intramuscularly, with the dosage determined based on the severity of symptoms and individual response. The initial oral dose is typically around 2 to 4 mg, which can be repeated as needed. In more severe cases, higher doses may be required. Lorazepam helps reduce muscle rigidity, improve motor function, and alleviate other catatonic symptoms.
• Electroconvulsive Therapy (ECT): ECT is considered the most effective treatment for severe or refractory cases of malignant catatonia. It involves the administration of a controlled electric current to induce a brief seizure under anesthesia, which can lead to rapid improvement in catatonic symptoms.
• NMDA receptor antagonists: In some cases, NMDA receptor antagonists, such as amantadine or memantine, may be considered as an adjunctive treatment. These medications modulate glutamate neurotransmission and have shown benefits in reducing catatonic symptoms.
• Other GABAergic medications: In addition to benzodiazepines, other GABAergic medications such as barbiturates (e.g., phenobarbital) or propofol may be used in severe or refractory cases of non-malignant catatonia.

Internal Medicine

Neurology

Psychiatry/Mental Health

Benzodiazepines, including lorazepam, are commonly used in the treatment of catatonia. Catatonia is the neuropsychiatric syndrome characterized by motor abnormalities, including immobility, posturing, rigidity, and repetitive movements. Benzodiazepines act as central nervous system depressants and have antianxiety, sedative, and muscle relaxant properties, which can help alleviate the symptoms of catatonia.

Lorazepam is often preferred due to its rapid onset of action and effectiveness in managing acute catatonic symptoms.

The use of benzodiazepines aims to reduce muscle rigidity, improve motor function, alleviate agitation or excitement, and promote relaxation. They work by enhancing the inhibitory effects of gamma-aminobutyric acid (GABA), a neurotransmitter that regulates brain activity.

Benzodiazepines like lorazepam can be effective in providing symptomatic relief and managing acute episodes of catatonia. However, the treatment approach should be individualized and guided by a comprehensive assessment of the patient’s condition and any underlying factors contributing to catatonic symptoms.

Internal Medicine

Neurology

Psychiatry/Mental Health

• Antipsychotic Medications: Risperidone, olanzapine, or quetiapine, may be used in the treatment of catatonia, especially when there are psychotic features present. These medications help to regulate neurotransmitter imbalances and can reduce catatonic symptoms.
• Mood Stabilizers: Mood stabilizers, such as lithium or valproate, may be prescribed in cases where catatonia is associated with mood disorders. These medications help to stabilize mood and may have a beneficial effect on catatonic symptoms.
• Benzodiazepine Receptor Agonists: Besides lorazepam, other benzodiazepine receptor agonists, such as diazepam or clonazepam, may be used in the treatment of catatonia. These medications have sedative and muscle-relaxant properties, which can help alleviate catatonic symptoms.
• NMDA Receptor Antagonists: N-methyl-D-aspartate (NMDA) receptor antagonists, such as amantadine or memantine, have been shown to be effective in some cases of catatonia. These medications modulate glutamate neurotransmission and may improve catatonic symptoms by enhancing synaptic plasticity and reducing hyperexcitability.
• Dopamine Modulators: Dopamine agonists or dopamine-depleting agents may be considered in cases of catatonia where there is suspected dopaminergic dysregulation. These medications can help regulate dopamine levels in the brain and may be beneficial in specific catatonic presentations.

Anesthesiology

Neurology

Psychiatry/Mental Health

Electroconvulsive therapy (ECT) is particularly used in cases where catatonia is severe, refractory to other treatments, or associated with a high risk of complications. ECT involves the controlled induction of a generalized seizure using electrical currents applied to the brain, under anesthesia.

ECT is believed to work by modifying the activity and connectivity of brain circuits involved in mood, cognition, and motor function. The exact mechanisms underlying its effectiveness in catatonia are not fully understood but may involve normalization of neurotransmitter imbalances, modulation of neuronal excitability, and restoration of functional connectivity.

ECT is considered a rapid and potentially life-saving intervention for severe catatonia. It can lead to a rapid improvement in catatonic symptoms, including motor abnormalities, mutism, and withdrawal. ECT is well-tolerated, with side effects such as temporary confusion, memory loss, and headache being transient.

The decision to use ECT in the treatment of catatonia is made on a case-by-case basis, considering the severity of symptoms, response to other treatments, potential risks, and individual patient factors.

Anesthesiology

Neurology

Psychiatry/Mental Health

Deep Brain Stimulation (DBS) is the neurosurgical procedure which involves implanting electrodes in specific areas of the brain and delivering electrical impulses to modulate abnormal neural activity. While DBS has been primarily used for the treatment of movement disorders like essential tremor and Parkinson’s disease, there is emerging evidence suggesting its potential benefit in the treatment of severe and refractory catatonia.

DBS in catatonia is considered an experimental treatment and is typically reserved for cases that have not responded to other treatment approaches. The specific target areas for DBS in catatonia may vary depending on individual cases and can include regions such as the anterior limb of the internal capsule, ventral striatum, or other structures involved in the regulation of motor and limbic functions.

The exact mechanism of action of DBS in catatonia is not fully understood. It is hypothesized that the electrical stimulation helps modulate abnormal brain activity and restore normal neural circuitry, leading to improvement in catatonic symptoms. However, further research is needed to better understand the underlying mechanisms and optimize the use of DBS in catatonia.

DBS is a complex procedure that requires careful patient selection, neurosurgical expertise, and post-operative management. The evaluation for DBS candidacy involves a thorough assessment by a multidisciplinary team, including neurologists, psychiatrists, and neurosurgeons. The procedure itself involves the surgical implantation of electrodes and subsequent programming and adjustment of stimulation parameters to achieve optimal therapeutic effects.

Neurology

Physical Medicine and Rehabilitation

Psychiatry/Mental Health

• The second phase focuses on the immediate treatment of acute catatonia symptoms to ensure patient safety and stabilize their condition.
• Benzodiazepines, such as lorazepam, are often the first-line treatment for acute catatonia due to their rapid onset of action and effectiveness in relieving symptoms. High-dose intravenous lorazepam is commonly used, followed by a transition to oral or intramuscular administration as needed.
• In severe or refractory cases, electroconvulsive therapy (ECT) may be considered as an effective and rapid-acting treatment option.

chronic Management:

• Chronic management in the treatment of catatonia focuses on long-term care and relapse prevention. This includes ongoing medication management, regular psychiatric and medical follow-ups, and monitoring for any signs of relapse or worsening symptoms.
• Psychotherapy, such as cognitive-behavioural therapy or supportive therapy, may be beneficial to address underlying psychological factors. Lifestyle modifications, including stress reduction techniques, healthy sleep habits, and maintaining a stable routine, can also support long-term stability and well-being