Catatonic disorders are a group of symptoms characterized by disturbances in motor (muscular movement) behavior that may have either a psychological or a physiological basis. The condition itself is called catatonia .
Catatonic symptoms were first described by the psychiatrist Karl Ludwig Kahlbaum in 1874. Kahl-baum described catatonia as a disorder characterized by unusual motor symptoms. His description of individuals with catatonic behaviors remains accurate to this day. Kahlbaum carefully documented the symptoms
and the course of the illness, providing a natural history of this unusual disorder.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (also known as the DSM-IV-TR) describes catatonia as having what may seem like contradictory symptoms. It can be characterized by immobility, a rigid positioning of the body held for a considerable length of time. Patients diagnosed with a catatonic disorder may maintain their body position for hours, days, weeks, or even months at a time. However, catatonia also can manifest as excessive movement, such as frantic running up and down a flight of stairs. People in semi-immobile catatonic states may allow a postural change and then “freeze” in the new posture, or may resist attempts at change. They may display a complete lack of verbalization, or echolalia (repeating or echoing heard phrases or sentences). This apparent paradoxical presentation of symptoms may have its root in the fact that catatonia has a variety of causes. In fact, some experts argue that, rather than being a discrete and describable classification, catatonia may instead be a collection of various illnesses without common
specificities. It has been associated with a laundry list of disorders, including psychotic disorders, depressive disorders , dementias, and reactive disorders. It is, however, currently classified into a handful of types in the DSM-IV-TR.
Rates of catatonia are extremely variable and have generally been recorded based on the accompanying co-morbidity or underlying cause. For example, the range of prevalence of catatonic schizophrenia is 7% to 17%. Studies also seem to suggest that diagnoses of catatonic schizophrenia has decreased dramatically over time. No one is sure what underlies this apparent decrease, although some explanations include changes in the definition of catatonia, improvement in approaches to care, and simple underdiagnosis. In patients with affective disorders (disorders related to the emotion or mood displayed to others), symptoms of catatonia occur in 13% to 31%, with higher prevalence among people with bipolar disorder .
DSM-IV types of catatonic disorder
A characteristic of disorders now classified under the schizophrenia umbrella is severe disturbance in motor behavior. Individuals with catatonic schizophrenia often show extreme immobility. They may stay in the same position for hours, days, weeks, or longer. The position they assume may be unusual and appear uncomfortable to the observer; for example, the person with catatonic schizophrenia may stand on one leg like a stork, or hold one arm outstretched for a long time. If an observer moves a hand or limb of the catatonic person’s body, he or she may maintain the new position. This condition is known as waxy flexibility. In other situations, a person with catatonic schizophrenia may be extremely active, but the activity appears bizarre, purposeless, and unconnected to the situation or surroundings. Catatonic stupor is characterized by slowed motor activity, often to the point of being motionless and appearing unaware of surroundings. Patients may exhibit negativism, which means that they resist all attempts to be moved, or all instructions or requests to move, without any apparent motivation.
DEPRESSION WITH CATATONIC FEATURES
People who are severely depressed may show disturbances of motor behavior resembling those of patients diagnosed with catatonic schizophrenia. These people with depression may remain virtually motionless, or move around in an extremely vigorous but apparently random fashion. Other parts of the symptomatic picture may include extreme negativism, elective mutism (choosing not to speak), peculiar movements, and echolalia or echopraxia (imitating another person’s movements). These behaviors may require caregivers to supervise patients to ensure they do not harm themselves or others.
MOOD DISORDERS AND CATATONIA
Catatonic behaviors may also occur in people with other mood disorders. People experiencing manic or mixed mood states (a simultaneous combination of manic and depressive symptoms) may at times exhibit either the immobility or agitated random activity seen in catatonia. A severely depressed person may experience intense emotional pain from simply moving a finger. Even getting up out of a chair can be a painful chore that may take hours for an individual with severe depression. As the depression begins to lift, the catatonic symptoms diminish.
CATATONIC DISORDER DUE TO A GENERAL MEDICAL CONDITION
People with catatonic disorder due to a medical condition show symptoms similar to those of catatonic schizophrenia and catatonic depression, except that the cause is believed to be related to an underlying medical condition. Neurological diseases such as encephalitis may cause catatonic symptoms that can be temporary or lasting. Overall, at least 35 distinct medical and neurological illnesses have been associated with catatonia; in addition to encephalitis as a common causative agent, others include structural damage to the central nervous system, metabolic disturbances, seizures, and exposure to some drugs.
Although the initiating factors of catatonia can vary greatly, research has identified common underlying mechanisms in some cases. For example, there may be imbalances or problems in regulating signaling among nerves in the central nervous system, involving neurotransmitters (nerve signaling molecules) like dopamine and serotonin. In addition, some brain imaging studies have found an enlarged cerebral cortex and reduced cerebellum in some people with catatonia, although this is not a consistent finding. People who have emerged from catatonic states report having had intense emotions, including uncontrollable anxiety and literally paralyzing fear. Others also report having experienced depression, euphoria, or aggression while in the catatonic state.
Catatonic schizophrenia manifests with prominent motor symptoms and abnormalities. These symptoms, as given in the DSM-IV-TR, include:
- catalepsy, or motionlessness maintained over a long period of time
- catatonic excitement, marked by agitation and seemingly pointless movement
- catatonic stupor, with markedly slowed motor activity, often to the point of immobility and seeming unawareness of the environment
- catatonic rigidity, in which a rigid position is assumed and held against all outside efforts to change it
- catatonic posturing, in which a bizarre or inappropriate posture is assumed and maintained over a long period of time
- waxy flexibility, in which a limb or other body part of a catatonic person can be moved into another position that is then maintained. The body part feels to an observer as if it were made of wax.
- akinesia, or absence of physical movement
DEPRESSION WITH CATATONIC FEATURES
Within the category of mood disorders, catatonic symptoms are most commonly associated with bipolar I disorder. Bipolar I disorder is a mood disorder involving periods of mania interspersed with depressive episodes. Symptoms of catatonic excitement, such as random activity unrelated to the environment or repetition of words, phrases, and movements may occur during manic phases. Catatonic immobility may appear during the most severe phase of the depressive cycle. The actual catatonic symptoms are indistinguishable from those seen in catatonic schizophrenia. It is also possible for catatonic symptoms to occur in conjunction with other mood disorders, including bipolar II disorder (involving a milder form of mania called hypomania ), mixed disorders (involving simultaneous mania and depression), and major depressive disorders.
CATATONIC DISORDER DUE TO GENERAL MEDICAL CONDITION
Symptoms of catatonic disorder caused by medical conditions are indistinguishable from those that occur in schizophrenia and mood disorders. Unlike persons with schizophrenia, however, those with catatonic symptoms due to a medical condition demonstrate greater insight and awareness into their illness and symptoms. They have periods of clear thinking, and their affect (emotional response) is generally appropriate to the circumstances. Neither of these conditions is true of patients with schizophrenia or severe depression.
According to the DSM-IV-TR, between 5% and 9% of all psychiatric inpatients show some catatonic symptoms. Of these, 25-50% are associated with mood disorders, 10-15% are associated with schizophrenia, and the remainder are associated with other mental disorders. Catatonic symptoms can also occur in a wide variety of general medical conditions, including infectious, metabolic, and neurological disorders. They may also appear as side effects of various medications, including several drugs of abuse .
Important diagnostic distinctions must be made to determine the cause of catatonic symptoms. Catatonic schizophrenia is diagnosed when the patient’s other symptoms include thought disorder, inappropriate affect, and a history of peculiar behavior and dysfunctional relationships. Catatonic symptoms associated with a mood disorder are diagnosed when patients have a prior history of mood disorder, or after careful psychiatric evaluation. Medical tests are necessary to determine the cause of catatonic symptoms caused by infectious diseases, metabolic abnormalities, or neurological conditions. Patients should be asked about recent use of both prescribed and illicit drugs to determine whether the symptoms are drug-related.
Treatment for catatonic symptoms can rely on drug-based approaches or on electroconvulsive therapy (ECT). Benzodiazepines (for example, lorazepam ) have often been the first-line treatment approach, although response to this therapy varies a great deal. One study has found that use of lorazepam was not effective in treating chronic catatonia, and there are other concerns about using benzodiazepines, including the fact that withdrawal from these drugs has itself been associated with inducing catatonia.
Other drugs that have been applied in cases of catatonia include antipsychotics. As with benzodiazepines, there are some concerns that the attempted cure could also be causative; these drugs have also been associated with precipitating catatonic episodes. On the flip side, the perceived reduction in rates of catatonic schizophrenia has accompanied the introduction and increasing use of these drugs. Other drugs, such as lithium or amantadine , have shown unpredictable success and elicited variable responses.
ECT, or electroconvulsive therapy, elicits negative reactions from many people, as it involves the administration of an electric shock to the brain to essentially cause a seizure. However, many psychiatrists maintain that it is a safe and effective approach and is the “ultimate treatment” for catatonia, especially if patients only partially respond to drug therapy.
Akinesia —Absence of physical movement.
Catalepsy —An abnormal condition characterized by postural rigidity and mental stupor, associated with certain mental disorders.
Catatonic disorder —A severe disturbance of motor behavior characterized by either extreme immobility or stupor, or by random and purposeless activity.
Catatonic schizophrenia —A subtype of a severe mental disorder that affects thinking, feeling, and behavior, and that is also characterized by catatonic behaviors—either extreme stupor or random, purposeless activity.
Dopamine —A chemical in brain tissue that serves to transmit nerve impulses (a neurotransmitter) and helps to regulate movement and emotions.
Echolalia —Meaningless repetition of words or phrases spoken by another.
Echopraxia —Imitation of another person’s physical movements in a repetitious or senseless manner.
Hypomania —A milder form of mania which is characteristic of bipolar II disorder.
Mutism —Inability to speak due to conscious refusal or psychological inhibition.
Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and the brain, and that works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.
Stupor —A trance-like state that causes a person to appear numb to his or her environment.
Waxy flexibility —A condition in which a person’s body part, usually a limb, can be moved by others into different positions, where it remains for long periods of time.
The prognosis for a person with catatonia varies with the cause underlying the disorder. With disorders such as alcohol-use disorder or affective disorder, the prognosis for resolution is relatively good; however, when catatonia accompanies schizophrenia, there is an association with earlier and higher levels of mortality. In one review, the authors ranked the associated disorder with the relative prognosis from best to worst, as follows: depression with catatonia, periodic catatonia, cycloid psychoses with catatonia, bipolar disorder with catatonia, catatonic schizophrenia, and non-catatonic schizophrenia. The choice of treatment also can influence prognosis.
There are no specific preventive measures for most causes of catatonia. Infectious disease can sometimes be prevented. Catatonic symptoms caused by medications or drugs of abuse can be reversed by suspending use of the drug.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.
Kaplan, Harold I., MD, and Benjamin J. Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Baltimore, MD: Lippincott Williams and Wilkins, 1998.
Sacks, Oliver. Awakenings. New York: HarperPerennial, 1990.
Carroll, B. T. “Kahlbaum’s Catatonia Revisited.” Psychiatry and Clinical Neuroscience 55.5 (Oct. 2001): 431–36.
Penland, Heath R., Natalie Weder, and Rajesh R. Tampi. “The Catatonic Dilemma Expanded.” Annals of General Psychiatry 5 (2006): 14. An open-access publication available at: <http://www.annals-general-psychiatry.com/content/5/1/14>.
Pfuhlmann, B., and G. Stober. “The Different Conceptions of Catatonia: Historical Overview and Critical Discussion.” European Archives of Psychiatry and Clinical Neruoscience 251, Supplement 1 (2001): 14–17.
Sarkstein, S. E., J. C. Golar, and A. Hodgkiss. “Karl Ludwig Kahlbaum’s Concept of Catatonia.” History of Psychiatry 6.22, part 2 (June 1995): 201–207.
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National Mental Health Association. 1021 Prince Street, Alexandria, VA, 22314. Telephone: (703) 684-7722.
Barbara Sternberg, PhD
Emily Jane Willingham, PhD