Catatonia

1. Catatonia Dr. Rajdeep Routh ST5 Old Age Psychiatry Leverndale Hospital, Glasgow Sept., 2012

2. Overview • Introduction • History • Classification • Clinical Features • Differential Diagnosis • Treatment • Future • Bibliography

3. Introduction • Neuropsychiatric syndrome of disturbed motor functions amid disturbances in mood and thought process • Prevalence: • rare • has been suggested that catatonia is under-recognised and under-diagnosed • 9%–15% of patients admitted to a typical acute care psychiatric service meet diagnostic criteria for catatonia (Rosebush P.I. 2010) • More common in mood disorders (28%-31% of catatonic patients had mixed mania or mania) • Only 10%-15% - underlying diagnosis of schizophrenia

5. History • Before 1874: “Stupor”/ stupidite´ • delineation of catatonia as a disease comparable to general paralysis of the insane (GPI) • Two schools emerged • one view supported the proposal of catatonia as a disease of its own. • The opposing view was that it was a complication of different pathophysiologies and not a distinctive disease

7. Contd. • The Kraepelin Position • First agreed with Kahlbaum • By the time of the sixth edition of his textbook in 1899 catatonia had become a category of dementia praecox along with hebephrenia and paranoid dementia. • Bleuler • had a milder view of schizophrenia • brought Kraepelin’s view that catatonia equaled schizophrenia to North America

9. Contd. • Karl Jaspers, • portrayed catatonia as an illness with special characteristics like opposing pairs of symptoms (negativism vs automatic obedience). • Kurt Schneider’s • psychology of catatonia, which he found unknowable: • ‘‘Sometimes it seems as though the patient is like a dead camera: He sees everything, hears everything, understands everything and yet is capable of no reaction, of no affective display, and of no action. Even though fully conscious he is mentally paralyzed.’’ • He considered Catatoinia a complication of many illnesses and rejected Kraepelin’s formulations

11. Contd. • highly influential figure in British psychiatry. • In 1954, he became the lead author—in collaboration with Eliot Slater and Martin Roth—of that era’s principal English language psychiatry textbook, “Clinical Psychiatry” • Mayer-Gross’s position on catatonia was resolutely Kraepelinian that catatonia was a type of schizophrenia.

12. Is it really a part of Schizophrenia? • George Kirby (1913) pictured catatonia as typically occurring among patients with manic-depressive illness • August Hoch(1921) described 25 psychiatric patients in stupor. Thirteen with manic-depressive illness had a favorable prognosis and 12 with general medical illnesses or schizophrenia had a poor prognosis • Lange (1922) reported an experience with 200 patients found catatonia to be more common among the manic-depressive patients than among those with dementia praecox. • The neurologic connection was established from studies of epidemic encephalitis by Von Economo (1931) who described catatonia in many patients in the acute and chronic phases of the illness

13. The Debate Continues • Stauder (1934) reported Malignant Catatonia in 27 patients with an acute onset and a lethal outcome • A periodic form of catatonia with hormonal connections was described by Gjessing. • Taylor and Abrams: 4 publications between 1973 and 1979, reported catatonia to be more common among manic and depressed patients • Morrison found catatonia in more than 10% of 500 patients, most commonly among those with mood disorders. • Gelenberg described catatonia among patients with neurologic and general medical illnesses • 1980: identification of the NMS withaccompanied by fever, tachycardia, hypertension, and tachypnea

14. Classification: DSM • 1952: Schizophrenic reaction: catatonic type • 3rd. Edition 1980: ignored new reports and again catalogued catatonia as a type of schizophrenia • 4th. Edition 1994: • diagnosis of ‘schizophrenia, catatonic type’ (code 295.20) • If a physical cause is identified the diagnosis is ‘catatonic disorder due to a medical condition’ (code 293.89) • no separate diagnostic category for catatonia due to either depression or mania, but catatonia can be added as a specifier in mood disorders

15. World Health Association’s International Classification of Diseases (ICD) • 6th. Ed. 1948: ‘‘catatonic type’’ among the ‘‘schizophrenic disorders.’’ • 10th. Edition 1992: unchanged; ‘‘For reasons that are poorly understood, catatonic schizophrenia is now rarely seen in industrial countries, though it remains common else where.’ • Catatonic schizophrenia (category F20.2) • Pt. With severe depression is in a stupor- a diagnosis of ‘severe depressive episode with psychotic symptoms’ (F32.3) • manic stupor will be diagnosed as having ‘mania with psychotic symptoms’ (F30.2) • Catatonia due to physical causes is diagnosed as ‘organic catatonic disorder’ (F06.1).

16. Clinical Features • Stupor • Posturing • Waxy flexibility (cerea flexibilitas) • Negativism (Gegenhalten) • Automatic obedience • Ambitendency • Psychological pillow • Forced grasping • Obstruction

17. Contd. • Echopraxia • Aversion • Mannerisms • Stereotypies • Excitement • Speech abnormalities • Echolalia, logorrhoea and verbigeration

18. Rating scales for catatonia • General agreement among researchers that the syndrome is poorly recognised • Bush–Francis Catatonia Rating Scale (BFCRS) • most widely used • 23 items • shorter, 14-item screening version • Modified Rogers Scale (MRS)

19. Catatonia Subtypes • Non-malignant • Retarded/ withdrawn- appear awake and watchful, but with minimal spontaneous speech and movement. Stupor, mutism, negativism, and posturing are common signs • excited - excessive purposeless motor activity associated with disorganised speech, disorientation, aggression, and violence • “Lethal" or "malignant" catatonia- escalating fever and autonomic instability • Resembles neuroleptic malignant syndrome (NMS) • Some authors also consider toxic serotonin syndrome as a subtype of malignant catatonia Van Den Eede & Sabbe (2004); Taylor & Fink (2003)

20. Differential Diagnosis • Mood disorders • Increasing age • Underlying seizure activity • Temporal lobe epilepsy • Abrupt discontinuation of clozapine • Cocaine, Ecstasy, Ciprofloxacin • Metabolic abnormalities- Hyponatraemia • Prior brain injury and physical illness at onset of psychosis • Hysteria • Idiopathic • females

21. Mechanism • deficiency of cortical gamma-aminobutyric acid (GABA) • hyperactivity of glutamate • sudden and massive blockade of dopamine • PET Scan has identified abnormalities in metabolism bilaterally in the thalamus and frontal lobes • fear response (Moskowitz 2004)

22. Investigations • Comprehensive physical examination, with specific emphasis on neurological signs • Bloods- FBC, Renal, LFT, TFT, Glucose, CK • Drug Screen • ECG • CT/ MRI • EEG • Culture • LP • Auto-Antibody Screen

23. Treatment • Supportive care/ high level of nursing care • Treatment with subcutaneous heparin, urinary catheterization • May require IV fluids, Nasogastric tube feeds or PEG tube placement. • Benzodiazepines are the drugs of choice for catatonia • Lorazepam was the most commonly used treatment, resolving symptoms in 70% of reported cases. • Other benzodiazepines such as diazepam, oxazepam, and clonazepam have also been reported to treat catatonia • Zolpidem, like the benzodiazepines, is a GABA-A agonist and has been reported in one case series to be effective in the treatment of catatonia • continue the benzodiazepines until the causative illness has been fully treated • ECT • ECT alone resulted in resolution of symptoms in 85% • In malignant catatonia, the response to ECT was 89%,

24. Electroconvulsive Therapy • Most reports of successful treatment of catatonia use bilateral ECT • Discontinuation of Benzodiazepines before ECT? • One case report described exacerbation of catatonia • Some physicians describe discontinuing benzodiazepine treatment just prior to ECT, • whereas others recommend continuing benzodiazepines during and beyond the ECT treatments. • A synergistic effect between benzodiazepines and ECT has also been postulated • Emergency ECT is the treatment of choice for malignant catatonia

25. NMDA Antagonists • When benzodiazepines and ECT fail or are not an option • Amantadine • anticholinergic side effects • Memantine

26. Antiepileptics/ Mood Stabilisers • Topiramate • Carbamazepine • Combination of lithium and an antipsychotic may be an option in treatment-resistant catatonic stupor

27. Antipsychotics • generally not recommended during a catatonic phase • catatonia represents a highly significant risk factor for subsequent neuroleptic malignant syndrome • atypical antipsychotics may have a role in the treatment of non-malignant catatonia (Van Den Eede et al 2005) • Multiple case reports and retrospective studies indicating the successful treatment of catatonia with atypical antipsychotics (olanzapine, risperidone, ziprasidone, aripiprizole, and clozapine) • Reports of atypical antipsychotics causing catatonia, though these studies were largely in patients with schizophrenia and only one focused on a patient with a medical illness • Advice- use atypical antipsychotics in catatonic patients with caution, given the risk of NMS

28. Prognosis • Two-thirds show marked improvement or remission • High incidence of recurrent catatonic episodes was reported for idiopathic catatonia and catatonia due to affective disorders • Following ECT high relapse rate within a year • continuation ECT is an efficacious treatment for maintaining response (Suzuki et al 2005)

29. In Future • divorce from schizophrenia • recognition as an independent syndrome • sufficiently common to warrant classification as an independent syndrome similar to delirium

30. References • Daniels J., Catatonia: Clinical aspects and neurobiological correlates, Journal of Neuropsychiatry and Clinical Neurosciences, 2009, 21, (4): 371-380 • Fink, Shorter, and Taylor, Catatonia Is not Schizophrenia: Kraepelin’s Error and the Need to Recognize Catatonia as an Independent Syndrome in Medical Nomenclature,Schizophrenia Bulletin, 2010 • Rajagopal S., Catatonia, Advances in Psychiatric Treatment, 2007, 13, (1): 51-59

31. Questions

32. Thanks