Catatonia

This presentation gives detailed description of symptoms of catatonia with its etiologies and differential diagnoses. It should help to differentiate catatonia in neurological and psychiatric disorders.

1. Catatonia : An Overview Kapil S Kulkarni Resident Doctor, Jagjivan Ram Hospital, Mumbai Central Guided by- Dr Pinto, Dr Rawat , Dr Dave

2. PRESENTATION DEFINITION  HISTORICAL REVIEW HYPOTHESIS SYMPTOMS & SIGNS (PHENOMENOLOGY)  CAUSES OF CATATONIA   RATING SCALE   EXAMINATION  DIFFERENTIATING CATATONIA COMMON D/D OF CATATONIA  TREATMENT OF CATATONIA

3. DEFINITION A syndrome of multiple etiologies (organic or functional) presenting with different features. Features are classified as motor and behavioral. Motor - posturing , catalepsy, stereotypy, mannerism, rigidity , waxy flexibility , echopraxia , echolalia. Behavioral - withdrawal, excitement, grimace, stupor , mutism , staring , negativism , verbigeration , perseveration, automatic obedience, mitgehen , gegenhalten , ambitendency , impulsivity, combativeness.

4. HISTORICAL OVERVIEW Described in 1874 by Kahlbaum , its neurological causes were also appreciated. Kraepelin and Bleuler - Described it relation to schizophrenia. 1976 – Abraham & Taylor – in mania 1976 – Gelenberg – concept of syndrome

5. DSM-IV (1994) Diagnostic Criteria for Catatonic Disorder Due to a General Medical Condition and also they classify it in affective disorder “with catatonic symptoms” thus placing the syndrome beyond the limits of schizophrenia.

6. HYPOTHESIS OF CATATONIA G- aminobuteric acid (GABA) HYPOACTIVITY at the GABA A receptor. Dopamine HYPOACTIVITY at the D 2 receptor. Glutamate HYPOACTIVITY at the N-methyl-D- aspartate (NDMA) receptor. Serotonin HYPERACTIVITY at the 5-HT 1A receptor and HYPOACTIVITY at the 5-HT 2A receptor.       

7. PHENOMENOLOGY

8. PHENOMENOLOGY Excitement- Extreme hyperactivity, constant motor unrest which is apparently non purposeful. Not to be attributed to akathisia or goal directed agitation. Immobility/ stupor- Extreme hypo activity, immobile, minimally responsive to stimuli.

9. Mutism - Verbally unresponsive or minimally responsive. Staring- Fixed gaze, little no visual scanning of environment, decreased blinking. Posturing/ catalepsy- Spontaneous maintenance of posture(s), including mundane. (e.g. sitting or standing for long period without reacting) PHENOMENOLOGY

10. Grimacing- Maintenance of odd facial expression. Echopraxia / echolalia- Mimicking of examiner’s movement or speech. Stereotype- Repetitive non goal directed motor activity (e.g. finger play, repeatedly touching, pitting or rubbing self); abnormality not inherent in act but in frequency. PHENOMENOLOGY

11. Mannerism- Odd, purposeful movement (hopping or walking tip toe, or exaggerated caricatures of mundane movements); abnormality inherent in act itself. Verbigerations - Repeatation of phrases or sentences (like a scratched record); it does not require stimulus to occur. PHENOMENOLOGY

12. Rigidity- Maintenance of rigid position despite of efforts to be moved, exclude if cogwheel or tremors present. Negativism- Apparently motiveless resistance to instructions or attempt to move/ examine patient. Contrary behavior does exact opposite of instructions. PHENOMENOLOGY

13. Waxy flexibility- During reposturing of patient, patient offers initial resistance before allowing himself to be repositioned (similar to that of bending candle). Withdrawal- Refusal to eat, drink and/ or make eye contact. PHENOMENOLOGY

14. Impulsivity- Patient suddenly engages in inappropriate behavior without provocation (e.g. runs down hallway, starts screaming or takes off clothes). Afterwards can give no or only facile explanation. Automatic obedience- Exaggerated cooperation with examiners request or spontaneous continuation of movement requested. Mitgehen and mitmachen are types of automatic obedience PHENOMENOLOGY

15. Mitgehen - Arm raising in response to light pressure of finger, despite instruction to the contrary. Gegenhalten - Resistance to passive movement which is proportional to strength of the stimulus , appears automatic rather than willful. PHENOMENOLOGY

16. Ambitendancy - Patient appears motorically “stuck” in indecisive, hesitant movement. Grasp reflex- As per neuro exam Perseveration- Repeatedly returns to same topic or persists with movement. even after stimulus is removed. PHENOMENOLOGY

17. Combativeness- Usually in undirected manner with no or only facile explanations afterwards. Autonomic abnormality- Temp, BP, pulse, RR, diaphoresis. PHENOMENOLOGY

18. DSM IV Mutism : refusal to speak Immobility: lack or paucity of movement Stereotypes : purposeless, repetitive movements Negativism: active or passive refusal to follow commands Mannerisms: repetitive, purposeful movements Posturing: maintenance of bizarre postures Grimacing: repetitive facial posturing Catalepsy or Waxy Flexibility: maintenance of posture Echopraxia or Echolalia: repetition of words or the imitation of actions Excitement: purposeless, excessive movement

19. DSM IV 1 criterion needed for general medical condition or substance induced catatonia 2 criteria for catatonia that is associated with a psychiatric condition ICD 10 Only under psychotic disorders. NO ORGANIC CATATONIA DESCRIBED !!

20. CAUSES OF CATATONIA

21. CAUSES OF CATATONIA Organic (Secondary) – Neurological Metabolic Nutritional Drug related Misc Functional (Primary) – Schizophrenia Mood disease (mania commonly) O ther Ψ OCD PTSD etc

22. Organic catatonia - Neurological Brain stem, diencephalic , basal ganglia, lesions near III ventricle, amygdala . Frontal lobe, Parietal lobe ds . Limbic & temporal lobe ds . Head injury, dementia, MS, atrophy. Encephalitis & other infections Epilepsy

23. Organic catatonia - Metabolic Periodic catatonia DM, in DKA Thyroid dysfunction Hepatic failure Renal failure Porphyrias Nutritional- Wernickes , pellagra, B 12 deficiency.

24. Organic catatonia – Drugs Neuroleptics Alcohol Opioids Cannabis Disulfiram SSRI, TCA

25. Common organic etiologies CNS structural damage/ Neoplasm Encephalitis and other CNS infections Seizures or EEG with epileptiform activity Metabolic disturbances Phencyclidine exposure Neuroleptic exposure CNS lupus Corticosteroids Porphyria and other conditions CVA Wernicke's encephalopathy Posttraumatic Multiple sclerosis Cerebral malaria

26. Comparison of Psychiatric Catatonia vs. Organic catatonia

27. PRIMARY AND SECONDARY CATATONIA In Primary catatonia: Patient responds to painful stimuli. Patient usually keeps his eyes open most of the times. Patient’s reflexes would be normal. No focal neurological deficits . Patient avoid self injury. (arm test) Overflow incontinence seen. EEG pattern is that of awake test. Lorezapam injection improves or continues to be same .

28. How to differentiate between depressive and schizophrenic catatonia ?

29. How to differentiate between depressive and schizophrenic catatonia ? Depressive catatonia: Depressive face Veraguth sign Athanassio’s (omega sign) Eye movements PMA retardation Mood state Past history Schizophrenic catatonia : Vigilant face Catatonic excitement Schnauzkrampf (snout spasm) Scanning Less marked

30. Rating Scale Bush-Francis Catatonia Rating Scale Braunig Catatonia Rating Scale Modified Roger ’ s scale

31. Bush-Francis Catatonia Rating Scale Use the presence or absence of items 1 - 14 for screening. Use the 0 - 3 scale for items 1 -23 to rate severity.

32. Examination for Catatonia

33. Examination for Catatonia PROCEDURE EXAMINES Observe patient while trying to engage in a conversation Activity level Movements Speech Examiner scratches head in exaggerated manner Echopraxia Attempt to reposture , instructing patient to "keep your arm loose"-> moves arm with alternating lighter and heavier force. Waxy flexibility

34. Examination for Catatonia PROCEDURE EXAMINES Take the hand of the patient as if you are examining his pulse and leave his hand posturing Patient does the exact opposite of what is asked to do Patient does not carry out any orders Active Negativism Passive Negativism Extend hand stating "DO NOT Shake my hand". Ambitendency Forced grasping

35. Examination for Catatonia PROCEDURE EXAMINES Reach into pocket and state,"Stick out your tongue, I want to stick a pin in it". Automatic obedience Check for grasp reflex. Grasp reflex Some patients oppose all passive movements with the same degree of force as that of which is been applied by the examiner. (Asked to co-operate) Gegenhalten

36. Examination for Catatonia PROCEDURE EXAMINES If examiner rapidly touches the palm and steadily withdraws his finger the patient ’ s hand follows the examiners hand like an iron following magnet.   Magnet reaction Patients body can be put to any position without any resistance although he has been instructed to resist all movements. Mitmachen Ask patient to extend arm. Place one finger beneath hand and try to raise slowly after stating, "Do NOT let me raise your arm". Mitgehen ( Anglepoise lamp)

37. Examination for Catatonia Check chart for reports of previous 24-hour period. In particular check for oral intake, I/O Chart, vital signs, and any incidents . Attempt to observe patient indirectly, at least for a brief period, each day. Record findings of one week in MSE.

38. DIAGNOSTIC EVALUATION OF CATATONIA

39. Diagnostic evaluation of catatonia Procedure History Physical exam Biochemical Haemogram CPK EEG CT or MRI of head Lumbar puncture Lorezpam inj Reason: Organicity Localizing neurologic signs Metabolic disease Malaria/Nutritional status NMS Seziures SOL Meningitis/encephalitis Functional improves but ……….

40. D/D Elective mutism Locked-in syndrome Stiff-Man syndrome Malignant hyperthermia Akinetic Parkinsonism Manic excitement

41. Treatment of Catatonia LORAZEPAM. Intravenous/intramuscularly 4 to 8 mg/day , 3 to 5 days, To be tapered. ELECTROCONVULSIVE THERAPY ANTIPSYCHOTICS ANTIDEPRESSANTS THYROID EXTRACTS

42. Lethal Catatonia A severe form of Catatonia . EARLY SIGNS – Increasing mental and physical agitation. Progresses to wild agitation and chorea which can alternate with rigidity, stupor, mutism and refusal of food / fluids. OTHERS: Fever, hypotension and diaphoresis. (which are similar to NMS) SEVERE END STAGE CASES Convulsions, delirium, coma and even death.

43. DISTINCTION BETWEEN NMS & LETHAL CATATONIA Lethal Catatonia usually has a longer prodrome of days to weeks . NMS also has the abnormal laboratory values . Treatment: Supportive care. ECT. Restarting or increase in antipsychotic dose. Short term use of lorazepam .

44. TAKE HOME MESSAGE Despite low incidence, catatonia is a serious diagnostic and treatment challenge. After the main causes of secondary catatonia have been ruled out, primary catatonia should be considered. If a trial of lorazepam fails, ECT should be used. 25

45. T h a n k Y o u