Catatonia

psychiatry in internal medicine

1. Features
■Motor – posturing, catalepsy, stereotypy,
mannerism, rigidity, waxy flexibility,
echopraxia, echolalia
■Behavioural & Emotional – withdrawal,
excitement*, grimace, stupor, mutism,
staring, negativism, verbigeration,
perseveration, automatic obedience,
mitgehen, gegenhalten, ambitendency,
impulsivity, combativeness

2. Don’t miss!
■ambitendency
■mitgehen
■gegenhalten
■automatic obedience
■in speech- whispered, odd accent, robotic
■walking tiptoe, other mannerisms
■stereotypies

3. Examination
■Observe pt while
trying to converse

■Scratch head in
exaggerated manner

■Examine for
cogwheeling
■Activity level
Abnormal movements
Abnormal speech
■Echopraxia


■Negativism

4. Examination
■Check pulse by
supporting hand, then
leave it

■Ask patient to follow
simple commands

■Rapidly touch palm
and withdraw finger


■Posturing



■Active/ Passive
Negativism

■Magnet reaction

5. Examination
■Attempt to reposture
after instr to ‘keep
arm loose’ use alt
light and heavy force

■Try to raise arm with
finger pressure after
instruction ‘NOT TO
ALLOW’

■Waxy flexibility
Gegenhalten



■Mitgehen

6. Examination
■Offer hand and say
‘DO NOT SHAKE MY
HAND’

■Reach your pocket
and ask to show the
tongue ‘I want to stick
a pin in it’
■Ambitendence



■Automatic obedience

7. Examination
■Stroke the palm of the
hand gently

■Oral intake, output
monitoring, temp,
pulse and blood
pressure charts, any
incidents

■Indirect observation
■Grasp reflex


■Autonomic signs
Combativeness
Withdrawal

8. DSM IV
•Mutism: refusal to speak
•Immobility: lack or paucity of movement
•Stereotypies: 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

9. 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 !!

10. A Syndrome
■Multiple etiologies

■Organic – Neurological, Infectious,
Metabolic, Nutritional, Drug related, Misc

■Functional – Mood ds (mania commonly),
Schizophrenia, other Ψ, OCD, PTSD etc

11. Treatment of Catatonia
■Benzodiazepines – Lorazepam
■LZM (p.o./ i.v./ i.m.) 4 – 8 mg/d for upto 5 d
■Resolution by day 3, in most
■Failures respond to ECT by 3
rd
ECT

■Same treatment for NMS/ lethal catatonia
■Also, STOP ANY OFFENDING DRUGS !

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

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

14. Organic catatonia – Drugs
■Neuroleptics
■Alcohol
■Opioids
■Cannabis
■BZDs
■Disulfiram
■SSRI, TCA

15. Lethal catatonia
■physical and mental agitation, chorea,
stupor, rigidity, mutism
■fever, hypotension, sweating (like NMS)
■convulsions, delirium, coma, death
■prodrome of a few days exists in most
cases
■no elevations in CPK, WBC count etc

16. Serotonin syndrome
■hyperthermia, diaphoresis, excitement/
confusion, hyperreflexia, jerks/ seizures,
tremors, hypotension
■DIC
■rhabdomyolysis
■cardiovascular compromise

17. NMS
•Triad of fever, rigidity, confusion
•Autonomic symptoms – fever, sweating,
labile BP, tachypnea, cardiac arrythmias
•Extrapyramidal symptoms – rigidity,
tremor, dystonia, chorea, ocular flutter
•Confusion – disorientation, delirium,
seizures, coma
•Lab – leukocytosis, raised CPK

18. NMS
■Predisposing factors – young male,
exhaustion, iron def, affective ds, brain ds,
thyrotoxicosis

■Precipitating causes – dopamine receptor
antagonists (HPL, TFP), esp with Li;
levodopa, other dopamine receptor
agonists, SSRIs

19. NMS
■Treatment –
Supportive- cooling, fluid and
electrolyte balance, ventilation, dialysis
Specific-
Bromocriptine- 2.5 mg tid
Dantrolene- 2-3 mg/kg tid
Levodopa, Pergolide
BZDs , ECT

20. Differential diagnosis
■Elective mutism
■Locked-in syndrome
■Stiff-person syndrome
■Malignant hyperthermia
■Akinetic Parkinsonism
■Stupor
■Manic excitement