Catatonia Flashcards
in what types of disorders can catatonia develop
neurodevelopmental
psychotic
bipolar
depressive
other medical conditions
list some medical conditions in which catatonia can develop
cerebral folate deficiency
rare autoimmune + paraneoplastic disorders
how does the DSM categorize catatonia
- catatonia assoc. with another mental disorder (i.e bipolar, psychosis)
- catatonic disorder due to another medical condition
- unspecified catatonia
how many psychomotor features are listed in the criteria for catatonia
12
how many features must someone have out of the possible 12 in order to consider catatonia as a diagnosis
3 or more
what is the essential feature of catatonia
a marked PSYCHOMOTOR DISTURBANCE that may involve:
decreased motor activity
decreased engagement during interview or physical exam
or excessive and peculiar motor activity
why can the clinical presentation of catatonia be confusing?
because it can range from marked unresponsiveness to marked agitation
what is a severe example of motoric immobility assoc. with catatonia
stupor
what are examples of moderate motoric immobility associated with catatonia
waxy flexibility
catalepsy
what is an example of severely decreased engagement associated with catatonia
mutism
what is an example of moderately decreased engagement associated with catatonia
negativism
list the 12 symptoms of catatonia
stupor
catalepsy
waxy flexibility
mutism
negativism
posturing
mannerism
stereotypy
agitation, not influenced by external stimuli
grimacing
echolalia
echopraxia
what is stupor
no psychomotor activity, not actively relating to environment
what is catalepsy
passive induction of a posture held against gravity
what is waxy flexibility
slight, even resistance to positioning by examiner
what is mutism
no, or very little, verbal response (exclude if has known aphasia)
what is negativism
opposition or no response to instructions or external stimuli
what is posturing
spontaneous and active maintenance of a posture against gravity
what is mannerism
odd, circumstantial caricature of normal actions
what is stereotypy
repetitive, abnormally frequent, non goal directed movements
what is echolalia
mimicking anothers speech
what is echopraxia
mimicking anothers action
how many criteria are there for catatonia associated with another mental condition
just one–criterion A–which is the 3/12 symptoms needed
in what % of inpatients with schizophrenia is catatonia diagnosed
up to 35%
cases of catatonia associated with another mental disorder are most commonly associated with what mental disorders
depressive and bipolar
can catatonia be due to a medication
yes
what serious condition should be considered when assessing the etiology of catatonia
neuroleptic malignant syndrome
how many criteria are there for catatonia associated with another medical condition
5
criterion A for catatonia associated with another medical condition
3/12 of the symptoms
criterion B for catatonia associated with another medical condition
there is evidence from the history, physical examination, or lab findings that the disturbance is the direct pathophysiological consequence of another medical condition
criterion C for catatonia associated with another medical condition
disturbance not better explained by another mental disorder
criterion D for catatonia associated with another medical condition
disturbance does not occur only in the course of a delirium
criterion E for catatonia associated with another medical condition
disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
what two types of medical disorders can, in particular, cause catatonia
neurological and metabolic
examples of metabolic disorders that can cause catatonia
hypercalcemia
hepatic encephalopathy
homocystinuria
diabetic ketoacidosis
examples of neurological disorders that can cause catatonia
neoplasms
head trauma
cerebrovascular disease
encephalitis
can catatonia be life threatening
yes, in malignant form
what characterizes malignant form of catatonia
fever and autonomic disturbances
who first identified catatonia as a syndrome
Karl Ludwig Kahlbaum
german psychiatrist
1874
in what populations is catatonia underrecognized
pediatric and autism pops
what is the estimate prevalence of catatonia in CL populations
2-9%
what is the estimated prevalence of catatonia in inpatients with psychosis?
mood disorders?
7-17% –> psychosis
15-31%–> mood disorders
what are the risks stemming from hypoactive catatonia
can have impaired swallowing, dehydration, malnourishment from lack of eating
risk of aspiration, DVTs, PEs, contractures, pressure ulcers
what % of those with autism spectrum disorders can experience catatonia
up to 10%
risk factors for catatonia
prior episodes of catatonia
current or past EPS
mood disorders with psychomotor changes
autism spectru disorder
psychotropic medications (antipsychotics, antidepressants)
substances (cocaine, alcohol/benzo withdrawal)
withdrawal of long term anticholinergic use
electrolyte disturbance
dehydration
weight loss
meds that lower seizure threshold
what electrolyte disturbances are a risk factor for developing catatonia
hyponatremia
hypomagnesemia
low serum iron
what is a mnemonic to remember the core features of catatonia
WRENCHES
waxy flexibility rigidity echopraxia negativism catalepsy high level of motor activity echolalia stupor, stereotypy
what is a way, other than WRENCHES, to remember the features of catatonia
divide into categories of increased, decreased and abnormal motor activity
decreased behaviours--> stupor negativism mutism posturing catalepsy
abnormal behaviours--> stereotypy mannerism waxy flexibility echolalia echopraxia
increased behaviours–>
agitation
grimacing
what scale measures the non DSM criteria of catatonia
Bush-Francis scale
includes: verbigeration withdrawal mitgehen gegenhalten grasp reflex automatic obedience ambitendency autonomic abnormality combativeness
what three subtypes of catatonia have been identified
stuporous
excited
malignant
name an iatrogenic variant of malignant catatonia
NMS
why do you have to treat malignant catatonia rapidly
it is life threatening
how do you treat malignant catatonia
ECT
what causes NMS
excessive dopamine blockade from dopamine antagonists or withdrawal of an agonist or GABA-A agnoist
what is the dysfunctional neurotransmitter model of catatonia
?combo of:
- reduced GABA activity in the frontal cortex
- increased NMDA glutamatergic activity in the posterior parietal cortex
- dampened dopaminergic action in the basal ganglia
what is the neural network and circuits model of catatonia
suggests that disruption in the mesoencephalofrontal system (brainstem–> basal ganglia–> limbic system and cerebral cortex) causes it
what is locked in syndrome
caused by PONTINE lesions can can be distinguished from catatonia because patients will usually try to communicate with their eyes on locked in syndrome
what is stiff person syndrome
Stiff person syndrome is an autoimmune disorder that presents during severe stress with intense lower extremity spasmodic stiffness that may look like catatonic posturing. However, these patients can speak and talk about their pain.
what blood marker is associated with progression to malignant catatonia and NMS
low serum iron
how do you assess grasp reflex
firmly place two fingers in patients palm (they will tightly grasp your fingers, sometines even if you ask them not to if sign is positive)
what is “gegenhalten” and how do you assess for it
“opposition”
form of hypertonia
Instruct patient to “keep your arm loose”, move patient’s arm horizontally back and forth by the wrist, with varying degrees of lighter and heavier force–> Automatically resists movement in each direction, matching your strength with each move (i.e. - the more you push the stronger resistance you get)
how do you assess for negativism
ask patient to look at you–> they look away
how do you assess for echopraxia
scratch your head or nose in exagerrated way–> they will copy even if asked not to
how do you assess for waxy flexibility
reposition patients arm into unusual but painless position–> patient has initial resistance but then allows self to be repositioned and holds the post for more than a minute
what is “mitgehen”
anglepoise
assess by saying “dont let me raise your arm” then push patients arms in different directions with JUST YOUR FINGER–> can move patient’s arm with lightest touch “like an anglepoise lamp”
how do you assess for automatic obedience
reach into your pocket and say “stick out your tongue, I need to stick a pin in it” and they stick out tongue
or
extend hand and say “please dont shake by hand” and they shake your hand
what are the two mainstays of catatonia treatment
benzodiazapines
ECT
list the two first line treaments and doses for catatonia
ECT
or
lorazepam IV q6-8 hrs for 2-3 days (can also consider zolpidem) (usually 2mg q4-6h actually)
list second line treatments for catatonia
memantine 10mg po daily, titrate over 3-4 days to 20mg daily
amantadine 100mg po daily, titrate over 3-4 days to 600mg daily in divided doses
*can be monotherapy or in combo with benzo
list third line treatment for catatonia
valproic acid
carbamazepine
what med trial can be a helpful diagnostic test for catatonia
lorazepam 2mg IV challenge
negative response does not rule out catatonia but many patients will show improvement even with single dose
how quickly will people with catatonia usually respond to benzos
usually within 30min (range is 3-24 hours)
what % of those with catatonia will respond to lorazepam
70%
what is the general dosing of lorazepam for catatonia if first challenge is helpful
generally lorazepam 2mg IV q4-6h–> some require doses of up to 30mg daily (especially if malignant symptoms)
- doses should only be held if concerns over respiratory depression due to over sedation, not for sedation alone
- regular dosing of lorazepam is crucial to fully remitting sx of schizophrenia
why is IV lorazepam better for TX of catatonia
quick onset
preference for GABA-A receptors
longer duration of effect
can use IM if IV not available
what is the definitive treatment for catatonia that persists for more than 2-3 days or if malignant features
ECT
can you use both ECT and lorazepam
yes–> synergistic
what is the typical response rate for ECT in catatonia
80%
what type of ECT is preferred for catatonia
bitemporal–> 3x per week for at least a total of 6 sessions
how do we think ECT treats catatonia
by increasing cerebral bloow flow to the orbitofrontal and parietal cortex
+
increasing GABA activity and GABA receptor expression
+
?increased release of dopamine and modulation of dopamine receptors
what antipsychotic is felt to be least likely to worsen catatonia or cause conversion to malignant catatonia
aripiprazole
?b/c partial agonist
