Catatonia

Catatonia is a neuropsychiatric syndrome of marked psychomotor disturbance, ranging from stupor, mutism and immobility to excitement and agitation, with abnormal posturing and negativism. It occurs in mood disorders (about 20 to 30 percent of cases are in depression or bipolar disorder), schizophrenia spectrum disorders, autoimmune and other medical conditions, and neurodevelopmental conditions.

• Diagnosis requires 3 or more of 12 signs: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, agitation not influenced by external stimuli, grimacing, echolalia, echopraxia.
• Subtypes: retarded (stuporous), excited, and malignant catatonia (fever, autonomic instability, rigidity, and altered consciousness, with a mortality of 10 percent or more if untreated).
• Medical and neurological causes are common and must be sought: autoimmune encephalitis (anti-NMDA receptor), epilepsy and nonconvulsive status, infections (HIV, neurosyphilis, encephalitis), metabolic disorders (hypercalcaemia, hepatic encephalopathy, uraemia, thyroid disease), vitamin B12 deficiency, systemic lupus erythematosus, structural lesions, drugs (antipsychotics, steroids, disulfiram, cannabis and synthetic cannabinoids), and withdrawal of benzodiazepines, clozapine or baclofen.
• It is treatable and frequently missed; prompt treatment prevents complications of immobility.

• Immobility, staring, reduced or absent speech, refusal to eat or drink, withdrawal.
• Maintaining odd postures against gravity (catalepsy), resistance to being moved (negativism), limb remaining where placed (waxy flexibility), repeated purposeless movements or phrases, copying others' words or movements.
• Excitement: purposeless, unprovoked agitation, impulsive violence.
• Autonomic signs: tachycardia, hypertension, fever, sweating, labile blood pressure; muscle rigidity.
• Complications: dehydration, malnutrition, pressure sores, deep vein thrombosis and pulmonary embolism, aspiration pneumonia, urinary retention and infection, contractures, rhabdomyolysis, renal failure, and malignant catatonia.
• Examination: formal catatonia rating scale (Bush-Francis Catatonia Rating Scale, 23 items; positive if 2 or more of the first 14 items), neurological examination for rigidity, fever, meningism, and focal signs.

• Clinical, using the rating scale; confirm by response to a lorazepam challenge.
• Lorazepam challenge: lorazepam 1 to 2 mg intravenously (or 1 to 2 mg intramuscularly), reassess in 5 to 10 minutes (intravenous) or 30 minutes (intramuscular), repeat the dose once if no response; a 50 percent or greater reduction in rating scale score supports the diagnosis.
• Investigations: FBC, urea and electrolytes, calcium, magnesium, phosphate, glucose, liver function, creatine kinase, serum iron (low iron is associated with risk of malignant catatonia and neuroleptic malignant syndrome), thyroid function, vitamin B12 and folate, urine toxicology, HIV, syphilis serology, blood cultures if febrile, ammonia, lupus screen, ECG.
• Neuroimaging (MRI brain) and EEG for new onset catatonia; lumbar puncture with cell count, protein, glucose, culture, and autoimmune encephalitis antibodies (anti-NMDA receptor) when there are seizures, movement disorder, prodromal illness, or no response to treatment.
• Differentials: neuroleptic malignant syndrome (same spectrum, history of dopamine blocker, severe rigidity, raised creatine kinase), serotonin syndrome, delirium (fluctuating attention), akinetic mutism, locked in syndrome, parkinsonism, stroke, depression with psychomotor retardation, and functional stupor.

Immediate measures

• Stop dopamine blocking drugs (antipsychotics, metoclopramide, prochlorperazine) and anticholinergics where possible, and treat any medical cause.
• Admit to a monitored ward; frequent vital signs; assess swallowing; keep hydration with intravenous fluids (0.9 percent sodium chloride, with potassium and glucose according to results), and consider nasogastric feeding if oral intake is poor.
• Venous thromboembolism prophylaxis: enoxaparin 40 mg subcutaneously once daily (20 mg if creatinine clearance is under 30 mL/min) plus compression stockings or intermittent compression, until mobile.
• Nursing care: change position every 2 hours, pressure area care, bladder and bowel care, prevent falls; avoid physical restraint.

Lorazepam (first line)

• Lorazepam 1 to 2 mg orally, intramuscularly or intravenously three times daily, increasing by 1 to 2 mg per dose daily (typical range 6 to 8 mg daily; up to 24 mg or more in severe cases) until symptoms remit. Watch for sedation, respiratory depression, and hypotension; hold for oversedation.
• Continue for 1 to 2 weeks after remission, then reduce by 10 to 25 percent every few days to avoid relapse; slow tapering matters when catatonia is linked to a chronic condition.
• Alternatives or additions if lorazepam is partly effective: diazepam 5 to 10 mg orally or intravenously three times daily; zolpidem 10 mg orally (test dose, then three times daily); clonazepam 0.5 to 1 mg twice daily.

Electroconvulsive therapy

• Offer if there is no clear response to lorazepam within 3 to 5 days, if there is malignant catatonia, severe refusal to eat or drink, or life threatening complications; bilateral ECT, 3 sessions a week, usually 6 to 20 sessions; continue lorazepam alongside.
• Response rates are about 80 to 90 percent.

Adjunctive options for resistant cases (specialist)

• Memantine 5 mg daily increasing to 10 mg twice daily; amantadine 100 mg twice daily increasing to 200 mg three times daily (reduce in renal impairment); valproate or carbamazepine; immunotherapy (methylprednisolone 1 g intravenously daily for 3 to 5 days, intravenous immunoglobulin 0.4 g/kg daily for 5 days, plasma exchange) for autoimmune causes.

Treat the underlying disorder

• Treat depression or bipolar disorder once catatonia improves; use antipsychotics cautiously, only after catatonia has resolved and with a low risk agent (for example aripiprazole 5 mg or quetiapine 25 mg) and close monitoring; avoid high potency dopamine blockers and clozapine withdrawal.
• Treat infections, metabolic disease, seizures, and autoimmune disorders.

Malignant catatonia and neuroleptic malignant syndrome

• Medical emergency: intensive care, lorazepam, active cooling, fluid resuscitation, early ECT; dantrolene 1 to 2.5 mg/kg intravenously and bromocriptine 2.5 mg three times daily orally may be added for neuroleptic malignant syndrome with severe rigidity.

Special groups

• Pregnancy: ECT is safe and preferred when benzodiazepine exposure is a concern; use obstetric and anaesthetic input.
• Older adults: start lorazepam at 0.5 mg and titrate slowly; higher risk of falls and delirium.
• Children and adolescents: lorazepam 0.5 to 1 mg orally or intravenously, increasing as tolerated under specialist care.