catatonia

1
CATATONIA

• Dr.Muhammed Musthafa

2
Definition of Catatonia

• Catatonia is a neuropsychiatric syndrome with a
  unique combination of mental, motor, vegetative
  and behavioral signs.

3
Kahlbaum (1874).
Coined the term Catatonia or Tension Insanity
4

• Catatonia is a Disturbance of motor behavior that
  can have either a psychological or neurological
  cause
• a state of apparent unresponsiveness to external
  stimuli in a person who is apparently awake
• difficult to differentiate from diffuse
  encephalopathy and nonconvulsive status
  epilepticus

5
Diagnostic criteria

• DSM-IV
• motor immobility as evidenced by catalepsy
  (including waxy flexibility) or stupor
• excessive motor activity (purposeless, not
  influenced by external stimuli)
• extreme negativism (motiveless resistance to all
  instructions or maintenance of a rigid posture
  against attempts to be moved) or mutism
• peculiarities of voluntary movement as evidenced
  by posturing, stereotyped movements, prominent
  mannerisms, or prominent grimacing
• echolalia or echopraxia

6

• "With catatonic features" specifier can be
  applied if the clinical picture is dominated by
  at least two
• Two of the items are required to diagnose
  catatonia in schizophrenia and mood disorder.
• Only one item is required to diagnose catatonia
  in general medical conditions.

7
Causes of catatonia

• Primary Psychiatric  
• Acute psychosis
• Affective disorder
• Schizophrenia
• Dissociative disorders
• Obsessive compulsive disorder
• Personality disorders

8
Organic/secondary

• Medical conditions

• Neurologic conditions

• Metabolic disturbances
• Endocrinopathies
• Viral Infections (H.I.V.)
• Typhoid fever
• Heart stroke
• Autoimmune diseases

• Post-encephalitic states
• Parkinsonism
• Bilateral globus pallidus lesions
• Thalamic lesions
• Parietal lobe lesions
• Frontal lobe
• Seizure disorder in children

9
Causes of catatonia

• Organic/secondary
• Drugs-
• neuroleptics (NMS)
• dopamine withdrawal
• alcohol
• stimulants
• hallucinogens
• anticonvulsants (carbamazapine)
• steroids

10
LETHAL CATATONIA (MALIGNANT)

• Hyperpyreia,extreme rigidity, autonomic
  dysfunction leading to death but without exposure
  to any neuroleptic
• Can occur when levodopa or amantidine is abruptly
  discontinued in patients with Parkinsons disease
  who have no previous history of psychiatric
  dysfunction

11
Classic signs of catatonia

• Mutism refusal to speak/verbally unresponsive
• Stupor lack or paucity of movement /
  hypokinesia
• Echophenomenon Echopraxia or Echolalia
• Stereotypies purposeless,repetitive
  movements/speech
• Mannerisms repetitive, purposeful movements

12

• Negativism motiveless, resistance to all
  interference
• Posturing/catalepsy maintenance of bizarre
  postures, facial posturing-grimacing
• Waxy Flexibility plastic resistance for
  examiners manipulations with preservation of
  final posture.
• Excitement purposeless, excessive movement

13
Negativistic Phenomena in Catatonia

• Gegenhalten (To hold against), the apparent
  resistance of the movement of the extremities by
  the examiner
• Mitgehen (To go along with)
• Movement in the direction of a slight push
  from the examiner in spite of the command to
  remain still
• Motor persistence - the maintenance of a posture
  when commanded to not maintain the posture
• Withdrawal from all usual activities, refusal to
  eat

14

• Automatic obedience, the performance of tasks at
  the command of the examiner even though the tasks
  are inappropriate or dangerous

15

• Echolalia, the repetition of the words spoken by
  the examiner
• Echopraxia, the repetition of the motor acts
  performed by the examiner

16
Stereotypies in Catatonia

• repetitive, regular movements that are not
  goal-directed
• Repetitive movements of the mouth and the jaw
• Repetitive eye movements
• Repetitive tapping of the foot, the finger, or
  the hand
• Repetitive abdomen patting, shoulder shrugging,
  or body rocking
• Mannerisms, postures, gaze fixation
• Choreoathetoid movements of the trunk and
  extremities

17

• Psychological pillow
• assumes a reclining posture, with their head a
  few inches above the bed surface
• maintain position - prolonged periods

18
Pathophysiology

• Imbalances in the excitatoryinhibitory ratio
• Dopaminergic blockade
• Glutamatergic dysfunction
• Decreased binding to gamma-aminobutyric acid
  (GABA)-A receptors in the left sensorimotor
  cortex
• Dysfunction in neurotransmission of noradrenaline
  and serotonin

19
Assessment of Catatonia

• Previous psychiatric/medication history
• Family history of psychiatric disorders
• Developmental history
• Investigations to rule out organicity
• Investigations to look for NMS
• Assessment of co-occurring medical/physical
  problems

20
Diagnostic evaluation of catatonia

• Detailed physical and neurological examination
• Investigate all patients
• Haemogram- WBC counts,LFT
• S.cerruloplasmin
• EEG
• CT or MRI of brain, Lumbar puncture if required.

21
Waxy flexibility
Attempt to reposture, instructing patient to
"keep your arm loose" - move arm with alternating
lighter and heavier force
22
(No Transcript)
23
(No Transcript)
24
Complications

• Aspiration
• Cachexia
• Dehydration its sequelae
• Pneumonia
• Pulmonary emboli
• Thrombophlebitis
• Urinary incontinence
• Urinary retention its sequelae

25
Principles of Management

• Early recognition/diagnosis
• Close observation, frequent vitals
• Supportive care (eg. hydration, nutrition,
  mobilization)
• Discontinue antipsychotic or other drugs,
  (eg.metoclopramide, which can cause or worsen
  catatonia)

26
Management

• Benzodiazepines
• Dopamine Agonists
• NMDA Antagonists
• Atypical Antipsychotics
• Vitamins
• ECT

27
Benzodiazepines (BZD)

• Lorazepam 1-2mg PO/IM/IV
• A test dose of 12 mg of intramuscular lorazepam
  will often result in marked improvement within
  half an hour

28
ECT

• Effective treatment
• 2-3 ECT sessions often suffice to clear catatonia
• 4-6 ECT sessions usually given to prevent relapse

29
Acute management

• Hospitalization
• BZD challenge
• BZD treatment trial
• Maintain fluid and electrolyte balance
• Avoid antipsychotic agents
• Avoid prolonged immobility
• Identify and correct underlying neuropsychiatric
  or medical cause
• If not improved in 4 days gt ECT
• Tx may be augmented with NMDA antagonists
  amantadine or memantine

30
Other Rx

• Muscle relaxants
• Calcium channel blockers
• Carbamazepine
• Anticholinergic drugs
• Lithium
• Thyroid medication
• Corticosteroids

30
31
Thank you