Pharmacotherapy of Catatonia

Question 1

Catatonia DSM location

Answer 1

Catatonia is a specifier, not a sub- type, of psychotic disorders

• Specifier for major mood disorders
• Catatonic disorder due to a general medical condition
  —-Not if it occurs exclusively in the context of delirium
• Catatonic disorder unspecified

Question 2

Catatonia occurrence

Answer 2

prevalence
-7.6-38% in pt with psych illness
-90000 hospitalized suffer from catatonia

note associated with psychiatric and medical disorders
- mood and psychotic disorders
- stroke, parkinson, autoimmune, metabolic, neoplasms

poisoning and other drug exposures

Question 3

catatonia DSM diagnostic criteria

Answer 3

3+ sx:

Catalepsy
Waxy flexibility
stupor
agitation
mutism
negativism
posturing
mannerisms
stereotypes
grimacing
echolalia
echopraxia

Question 4

catatonia common sx

Answer 4

• Minimal response to environment
• Fixed gaze
• Odd postures or mannerisms
• Repetitive, purposeless movements
• Repeating words or movements of another
• Hypoactivity or hyperactivity
• Inappropriate behavior
• Undirected combativeness, without explanation or provocation

Question 5

catatonia subtypes

Answer 5

malignant

stuperous (retarded/withdrawn)

excited

Question 6

catatonia NMS subtypes

Answer 6

malignant
stuperous

Question 7

catatonia delirious mania subtypes

Answer 7

malignant
excited

Question 8

catatonia Periodic Catatonia subtypes

Answer 8

Stuperous
Excited

Question 9

Catatonia presentation: Excited

Answer 9

odd mannerisms

agitated

hold positions against gravity

stereotypic and repetitive movements

Question 10

Catatonia presentation: Stuperous

Answer 10

retarded/withdrawn

hold odd positions

no response or opposition to outside stimuli

poverty of speech

Question 11

Catatonia presentation: Malignant

Answer 11

Autonomic Instability

Neuroleptic Malignant Syndrome?

Question 12

Rx goals for tx of catatonia

Answer 12

decrease glutamate
- NMDA receptor antagonists
- some anticonvulsants

Increase GABA
- BZD
-Anticonvulsants

restore balance b/t GABA and glutamate

Question 13

1st line tx

Answer 13

Ativan challenge

BZD to enhance GABA activity

Question 14

Ativan challenge

Answer 14

1-2mg IM or IV initially
—-improvement usually occurs within 3 hrs of the first dose
—-can be as little as 15 min

Question 15

BZD for catatonia

Answer 15

• Lorazepam up to 32mg/day
• may help mobility issues
  -effective in 70% of cases
  -nonresponder may have had longer sx prior to tx

Question 16

other tx for catatonia

Answer 16

ECT

NMDA antagonist
- dec glutamate activity

anticonvulsants
- inc GABA
- glutamate antagonism

Atypical antipsychotics
- clozapine
-quetiapine

Question 17

NMDA antagonist rx

Answer 17

Modulate glutamate:

Amantadine

memantine

Dextromethorphan

Question 18

anticonvulsants rx

Answer 18

enhance GABA

Topamax

Valproic Acid/Divalproex

Carbamazepine

Lamotrigine

Question 19

other potential tx

Answer 19

zolpidem
dopaminergic agents
stimulants
minocycline
TMS

Question 20

Bush Francis Catatonia Rating Scale

Answer 20

23 item scale with 0-3 continuum for each sign

dx with 2 or more of the first 14

only observed during examination and only rate items that are clearly present