Evidence-Based Reviews

Catatonia: How to identify and treat it

Current Psychiatry. 2018 August;17(8):16-26

References

1. Kahlbaum KL. Catatonia. Baltimore, MD: John Hopkins University Press; 1973.
2. Kahlbaum KL. Die Katatonie oder das Spannungsirresein. Berlin: Hirschwald; 1874.
3. Tang VM, Duffin J. Catatonia in the history of psychiatry: construction and deconstruction of a disease concept. Perspect Biol Med. 2014;57(4):524-537.
4. Carroll BT. Kahlbaum’s catatonia revisited. Psychiatry Clin Neurosci. 2001;55(5):431-436.
5. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003;160(7):1233-1241.
6. Fink M, Fricchione GL, Rummans T, et al. Catatonia is a systemic medical syndrome. Acta Psychiatr Scand. 2016;133(3):250-251.
7. Medda P, Toni C, Luchini F, et al. Catatonia in 26 patients with bipolar disorder: clinical features and response to electroconvulsive therapy. Bipolar Disord. 2015;17(8):892-901.
8. Mazzone L, Postorino V, Valeri G, et al. Catatonia in patients with autism: prevalence and management. CNS Drugs. 2014;28(3):205-215.
9. Fink M, Kellner CH, McCall WV. Optimizing ECT technique in treating catatonia. J ECT. 2016;32(3):149-150.
10. Kocha H, Moriguchi S, Mimura M. Revisiting the concept of late catatonia. Compr Psychiatry. 2014;55(7):1485-1490.
11. Lin CC, Hung YL, Tsai MC, et al. Relapses and recurrences of catatonia: 30-case analysis and literature review. Compr Psychiatry. 2016;66:157-165.
12. Saddawi-Konefka D, Berg SM, Nejad SH, et al. Catatonia in the ICU: An important and underdiagnosed cause of altered mental status. A case series and review of the literature. Crit Care Med. 2013;42(3):e234-e241.
13. Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry. 2015;86(8):825-832.
14. Grover S, Chakrabarti S, Ghormode D, et al. Catatonia in inpatients with psychiatric disorders: a comparison of schizophrenia and mood disorders. Psychiatry Res. 2015;229(3):919-925.
15. Oldham MA, Lee HB. Catatonia vis-à-vis delirium: the significance of recognizing catatonia in altered mental status. Gen Hosp Psychiatry. 2015;37(6):554-559.
16. Tuerlings JH, van Waarde JA, Verwey B. A retrospective study of 34 catatonic patients: analysis of clinical ‘care and treatment. Gen Hosp Psychiatry. 2010;32(6):631-635.
17. Ohi K, Kuwata A, Shimada T, et al. Response to benzodiazepines and the clinical course in malignant catatonia associated with schizophrenia: a case report. Medicine (Baltimore). 2017;96(16):e6566. doi: 10.1097/MD.0000000000006566.
18. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms appearing before autonomic symptoms help distinguish neuroleptic malignant syndrome from malignant catatonia. Intern Med. 2016;55(19):2893-2897.
19. Lang FU, Lang S, Becker T, et al. Neuroleptic malignant syndrome or catatonia? Trying to solve the catatonic dilemma. Psychopharmacology (Berl). 2015;232(1):1-5.
20. Beach SR, Gomez-Bernal F, Huffman JC, et al. Alternative treatment strategies for catatonia: a systematic review. Gen Hosp Psychiatry. 2017;48:1-19.
21. Kugler JL, Hauptman AJ, Collier SJ, et al. Treatment of catatonia with ultrabrief right unilateral electroconvulsive therapy: a case series. J ECT. 2015;31(3):192-196.
22. Raffin M, Zugaj-Bensaou L, Bodeau N, et al. Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia. Eur Child Adolesc Psychiatry. 2015;24(4):441-449.
23. DeJong H, Bunton P, Hare DJ. A systematic review of interventions used to treat catatonic symptoms in people with autistic spectrum disorders. J Autism Dev Disord. 2014;44(9):2127-2136.
24. Wachtel L, Commins E, Park MH, et al. Neuroleptic malignant syndrome and delirious mania as malignant catatonia in autism: prompt relief with electroconvulsive therapy. Acta Psychiatr Scand. 2015;132(4):319-320.
25. Fink M, Taylor MA. Catatonia: subtype or syndrome in DSM? Am J Psychiatry. 2006;163(11):1875-1876.
26. Khan M, Pace L, Truong A, et al. Catatonia secondary to synthetic cannabinoid use in two patients with no previous psychosis. Am J Addictions. 2016;25(1):25-27.
27. Komatsu T, Nomura T, Takami H, et al. Catatonic symptoms appearing before autonomic symptoms help distinguish neuroleptic malignant syndrome from malignant catatonia. Intern Med. 2016;55(19):2893-2897.
28. Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.
29. Wilson JE, Niu K, Nicolson SE, et al. The diagnostic criteria and structure of catatonia. Schizophr Res. 2015;164(1-3):256-262.
30. Ducharme S, Dickerson BC, Larvie M, et al. Differentiating frontotemporal dementia from catatonia: a complex neuropsychiatric challenge. J Neuropsychiatry Clin Neurosci. 2015;27(2):e174-e176.
31. Narayanaswamy JC, Tibrewal P, Zutshi A, et al. Clinical predictors of response to treatment in catatonia. Gen Hosp Psychiatry. 2012;34(3):312-316.
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ECT was first used for catatonia in 1934, when Laszlo Meduna used chemically induced seizures in catatonic patients who had been on tube feeding for months and no longer needed it after treatment.^6,7 As was true for other disorders, this approach was replaced by ECT.⁷ In various case series, the effectiveness of ECT in catatonia has been 53% to 100%.^7,13,15 Right unilateral ECT has been reported to be effective with 1 treatment.²¹ However, the best-established approach is with bitemporal ECT with a suprathreshold stimulus,⁹ usually with an acute course of 6 to 20 treatments.²⁰ ECT has been reported to be equally safe and effective in adolescents and adults.³⁴ Continued ECT is usually necessary until the patient has returned to baseline.⁹

ECT usually is recommended within 24 hours for treatment-resistant malignant catatonia or refusal to eat or drink, and within 2 to 3 days if medications are not sufficiently effective in other forms of catatonia.^12,15,20 If ECT is initiated after a benzodiazepine trial, the benzodiazepine antagonist flumazenil is administered first to reverse the anticonvulsant effect.⁹ Some experts recommend using a muscle relaxant other than succinylcholine in the presence of evidence of muscle damage.⁷

Alternatives to benzodiazepines and ECT. Based on case reports, the treatments described in Table 8^{13,15,17,20,25} have been used for patients with catatonia who do not tolerate or respond to standard treatments. The largest number of case reports have been with NMDA antagonists, while the presumed involvement of reduced dopamine signaling suggests that dopaminergic medications should be helpful. Dantrolene, which blocks release of calcium from intracellular stores and has been used to treat malignant hyperthermia, is sometimes used for NMS, often with disappointing results.

Whereas first-generation antipsychotics definitely increase the risk of catatonia and second-generation antipsychotics (SGAs) probably do so, SGAs are sometimes necessary to treat persistent psychosis in patients with schizophrenia who develop catatonia. Of these medications, clozapine may be most desirable because of low potency for dopamine receptor blockade and modulation of glutamatergic signaling. Partial dopamine agonism by aripiprazole, and the potential for increased subcortical prefrontal dopamine release resulting from serotonin 5HT2A antagonism and 5HT1A agonism by other SGAs, could also be helpful or at least not harmful in catatonia. Lorazepam is usually administered along with these medications to ameliorate treatment-emergent exacerbation of catatonia.

There are no controlled studies of any of these treatments. Based on case reports, most experts would recommend initiating treatment of catatonia with lorazepam, followed by ECT if necessary or in the presence of life-threatening catatonia. If ECT is not available, ineffective, or not tolerated, the first alternatives to be considered would be an NMDA antagonist or an anticonvulsant.²⁰

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Catatonia: How to identify and treat it

References

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