Catatonia

Ben Johnson, Laura Artim, reviewed by Jonathan Smith and Daniel Daunis

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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 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, including 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

  • Often lorazepam 2 mg IV

• 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

• Treatment with benzodiazepines and/or ECT often continues for weeks to months following initial diagnosis