Catatonia is a complex syndrome characterized by psychomotor and volitional disturbances. It involves reduced (hypofunctional), excessive (hyperfunctional), or abnormal (parakinetic) motor actions. The occurrence of catatonia in Major Depressive Disorder is rare. Catatonia is predominantly associated with bipolar depression. Bipolar disorder is the most frequently observed psychiatric condition associated with symptoms of catatonia, followed by schizophrenia.
Catatonic depression is a combination of catatonia and depression. The extremly rare condition is categorized under the DSM-5 as Major Depressive Disorder with Catatonic Features.
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What is catatonia?
The term “catatonia” was first mentioned by Ludwig Karlbaum in 1874. It is characterised by a group of psychological, motor, behavioural, and autonomic symptoms.
Older authors like Emil Kraepelin and Karl Leonhard strictly linked catatonia to schizophrenia. However, in recent times, it’s been postulated that catatonic phenomena can occur independently of schizophrenic psychoses and are not specific to schizophrenia.
ICD-10 and ICD-11 Coding
According to ICD-10, the basis of contemporary WHA psychiatric diagnosis, catatatonia, is listed under: ICD-10 Code: F20.2.
Disorders with catatonia are characterized by a clinical picture including stupor, psychomotor agitation, postural stereotypes, negativism, catalepsy, varying flexibility, and other symptoms like command automatism and speech stereotypes.
With the introduction of ICD-11, catatonia was recognized as its own distinct diagnostic entity:
- Catatonia associated with another mental disorder (6A40)
- Catatonia induced by substances or medications (6A41)
- Unspecified catatonia (6A4Z)
Symptoms of Catatonia
Catatonia is characterized by severe motor disturbances, such as rigidity and withdrawal. During catatonic episodes, individuals exhibit grimacing or refusal to eat. Immobility and mutism are the most prevalent symptoms, along with stupor, a state of dulled consciousness. Other characteristics of catatonia are:
- Posturing and catalepsy, where someone maintains a position, are more severe manifestations of catatonia.
- Stereotypies, repetitive and purposeless movements, are also observed, like rocking back and forth.
- Echolalia involves repeating words spoken by others, while echopraxia mimics their movements.
- Mannerism refers to performing exaggerated or odd actions instead of typical ones, such as hopping instead of walking.
- Waxy flexibility, when resistance is followed by maintaining a manipulated body part’s position.
Pernicious catatonia
In the malignant form, known as pernicious catatonia, besides the mentioned catatonic symptoms, there is autonomic dysregulation with no detectable infection, characterized by high fever, circulatory disturbances, dehydration, and other functional impairments. Elevated creatine kinase levels are also observed.
Differential diagnosis should consider organically induced catatonic disorders and drug-induced catatonic phenomena, along with other diagnoses in the psychiatric spectrum like affective psychoses, neurological disorders, and metabolic disorders. Drug-induced psychotic disorders can also present with catatonic phenomena.
Causes of Catatonia
The causes of catatonia remain unclear, but several theories have been proposed. Research indicates that over a quarter of catatonia cases are caused by somatic illnesses, particularly neurological conditions such as epilepsy, infections, autoimmune diseases, or anti-NMDA receptor encephalitis. A disruption in the brain’s GABAergic system is suspected to play a role. Additionally, impaired dopamine and serotonin transmission, as well as inflammatory responses in the brain, may contribute to the development of catatonia.
The evolutionary theory suggests that catatonia may stem from an exaggerated primal fear response. Prehistoric ancestors, constantly facing predators, may have developed the ability to remain motionless for extended periods to avoid detection. Biologists observe catatonia in animals exposed to life-threatening situations.
Treatment for Catatonic Depression
Catatonic depression is a combination of catatonia and depression. Under the DSM-5, this condition is categorized as Major Depressive Disorder with Catatonic Features.
Catatonic depression requires a combination of treatments for both depression and catatonia. However, the main challenge is a rapid and successful treatment of catatonia, and first in the second stage, addressing the depression. Given the potential life-threatening complications caused by catatonia, prompt intervention is crucial.
Until the development of psychotropic medication in the 1950s, a significant portion of catatonic patients died due to complications like exhaustion, severe malnutrition, or self-harm. Nowadays, antipsychotic drugs, bensodiasepines, and advancements in non-pharmacological psychiatric therapies offer treatment options with high response rates.
Benzodiazepines and electroconvulsive therapy (ECT) are the primary treatments for catatonia, with additional use of certain atypical antipsychotics and additionally antidepressants in the later stage.
Under the benzodiazepines, Lorazepam is the preferred choice, offering rapid relief from catatonic symptoms including associated anxiety and sleeplessness. In treatment-resistant cases, electroconvulsive therapy (ECT) is the method of choice, especially for malignant catatonia.