Catatonia : Symptoms, Causes, & Treatment

What Is Catatonia ?

Catatonia describes a syndrome that includes specific symptoms; these include both a lack of communication and a lack of movement. In addition, catatonic individuals may experience agitation, confusion, and restlessness.² People who have catatonia lose awareness of the world around them and are minimally interactive. Catatonia can occur due to a variety of medical or mental illnesses.

Catatonia is most notably associated with schizophrenia. However, it is also less common in various other mood and mental health disorders including depression, bipolar disorder, and autism. Medical illnesses that might be accompanied by catatonia include stroke, autoimmune and neurodegenerative disorders, and infections.² Evidence also indicates that substance use and substance withdrawal could cause catatonia.³ Substances indicated included alcohol, marijuana, cocaine, opioids, and benzodiazepines.

Symptoms of Catatonia

Symptoms of catatonia can vary based on the specific diagnosis. The symptoms can be related to movement, awareness, verbalization, and facial expressions. It has been noted that catatonia might be misdiagnosed due to the unusual clinical symptoms of the disorder.⁴ Typical symptoms of catatonia include stupor, rigidity, agitation, and posturing. However, a diagnosis of catatonia requires at least three of 12 presenting features be present.

Common symptoms of catatonia include:

• Lack of verbal response (negativism): Catatonic individuals do not follow instructions or respond to questions. They can appear unaware of external events or stimuli.
• Repeating words (echolalia): In echolalia, a person echoes back what a person has just said to them. For instance, if they are asked a question, they mimic the question back to the questioner.
• Stupor: When someone is in a stupor, they do not engage in any psychomotor activity. They appear “out of it,” as they are unable to engage with others or engage with their environment.
• Catalepsy: This describes the state of a person whose muscles are rigid and immobile. People who have catatonia can appear to be locked in an unnatural and fixed position and does not respond to stimuli and has a decreased response to pain.
• Waxy flexibility: This describes the way in which people with catatonia arms and limbs can be positioned by another person.
• Mutism: This refers to people who have catatonia’s inability to verbally respond to others. Mutism may begin slowly with a person uttering fewer and fewer words over a course of days.
• Posturing: Posturing is an active engagement in a particular posture that is against gravity. It may involve sitting or standing and requires that muscles be engaged to maintain the posture.⁵
• Mannerism: Mannerisms are unusual movements by the people with catatonia. They may first appear to be “normal” movements, but are actually caricatures of normal movements.
• Stereotypy: This describes movements that are repetitive. They may be repeated and they have no discernible goal or purpose.
• Agitation: In catatonia, agitation may be exhibited. However, it may occur with no specific stimulus involved.
• Grimacing: This refers to the facial expression of an individual who is catatonic; their face is locked in a grimace or some other expression. The expression may seem incongruent with the situation.
• Echopraxia: This is similar to echolalia but refers to movements. In echopraxia, people with catatonia mimic the physical movements of another person. Depending on the specific disorder, this may include acting out behaviors or mimicking another’s mannerisms or hand movements.

Types of Catatonia

There are three main types of catatonia.⁶ These are akinetic catatonia, excited catatonia, and malignant catatonia. Akinetic catatonia is the most common type among the three. Each type presents differently, but it is important to determine the underlying cause of the catatonia to minimize the risk of mortality. The third type, malignant catatonia, can be fatal in a matter of days if it is not reversed.

The three types of catatonia include:

• Akinetic: In akinetic catatonia, a person tends to simply stare and appears to be non-responsive. They show little response to any external stimuli, although they are alert and aware of their environment. There is very little movement, if any.
• Excited: In excited catatonia, an individual may engage in movement. However, their movement is not goal directed or intentional. There may also be symptoms of agitation and delirium present. A person experiencing excited catatonia can potentially pose a threat to their own or others’ safety.
• Malignant: This type of catatonia is rare, but life threatening, which drives the need to diagnose it quickly. Malignant catatonia causes the body temperature to rise, extreme muscle rigidity, and autonomic instability, which is an inability to regulate the body. These can lead to death through kidney failure, collapse of the cardiovascular system, or extreme muscle damage.

What Causes Catatonia?

Catatonia is a symptom, not a disorder, and it can be affected by a number of factors and stressors, but no set explanation has been identified. It is diagnosed most frequently in cases of mental illnesses such as mood disorders and psychotic disorders. It is also diagnosed in individuals with autism spectrum disorder. Catatonia also appears in individuals who have medical diagnoses for diseases including diabetes, Parkinson’s disease, and encephalitis.

Associated Psychiatric Disorders

There are many psychiatric disorders associated with catatonia. These include schizophrenia, bipolar disorder, depression including postpartum depression, obsessive compulsive disorder, dissociative disorders, and psychosis. Although catatonia is most prevalent among those who suffer from mood disorders, including bipolar disorder and depression, it appears in as many as 35% of people diagnosed with schizophrenia.⁴

Possible causes of catatonia include:

• Bipolar disorder
• Schizoaffective disorder
• Schizophrenia
• Major depressive disorder
• Epilepsy
• Tourette syndrome
• Brain injuries
• Cocaine use
• Withdrawal from some medications, including clozapine

Medical Conditions

There are also medical conditions that can trigger catatonic states. Other risk factors include use of cocaine, low sodium, and some medications. While catatonia has been shown to be related to activity in the orbitofrontal, prefrontal, parietal, and motor cortical regions of the brain.⁷

Medical conditions that may trigger catatonic states include:

• Parkinson’s disease
• Diabetes
• Autoimmune disorders
• Metabolic disorders including thyroid conditions
• Encephalitis
• Electrolyte imbalances in the bloodstream
• Degenerative brain disease
• Stroke
• Folate deficiency

Neurochemical Imbalances

Although catatonia has a fairly high prevalence rate,⁸ its etiology is still not fully understood. However, it appears that there are multiple neurotransmitters that play a significant role in its onset: serotonin, glutamate, GABA, and dopamine.⁸ Glutamate and GABA may contribute to akinetic catatonia due to the under functioning of GABAergic receptors. Dopamine may be responsible for the movement and activity-related motor symptoms of catatonia.

Treatments for Catatonia

While there is no definitive understanding of the cause of catatonia, there are effective treatments for reversing the symptoms. There are several treatment pathways for addressing its causes and the disorders associated with the condition. The frontline treatment for catatonia is benzodiazepines, and Lorazepam specifically. Medication is preferred over other treatments due to its safety and effectiveness. Electroconvulsive Therapy, ECT, is another method for treating catatonia.

Medications

The best medication for treating catatonia varies depending on the underlying disorder that the person has been diagnosed with. If the disorder is medical, treatment for the illness should begin as early as possible. Other medications include zolpidem, a sedative-hypnotic; muscle relaxers; thyroid hormone; reserpine; a hypertension treatment; and lithium carbonate.

For individuals with mood disorders and schizophrenia, benzodiazepines can offer rapid improvement in catatonia. In some cases, antipsychotic medications can be helpful if schizophrenia is also present. However, the risk of malignant catatonia increases with the use of antipsychotics. Other medications include second-generation antipsychotics. For people with mood disorder-related catatonia, serotonin reuptake inhibitors (SSRIs) have proven useful.

Electroconvulsive Therapy (ECT)

Another effective treatment for catatonia is electroconvulsive therapy (ECT). In ECT, an electrical current is sent to the brain through electrodes placed on the scalp. The electrical current causes the brain to experience a seizure. The seizure effectively changes the brain’s chemistry in such a way that catatonia is rapidly reversed. There are few contraindications related to ECT and it has been found to be safe even for pregnant people. However, there is a continuing stigma attached to ECT that can lead some to feel hesitant about its use.

Treatment of the Underlying Causes

Addressing the underlying cause of the catatonia is the first priority, but ideally the catatonia should be treated concurrently due to its mortality rate.⁶ In some cases where the cause of the catatonia is not evident, reversal of the catatonic state may be required before accurately diagnosing the underlying cause. In medical-related cases, catatonia prevents a person from communicating their symptoms or health problems, so treating the catatonia is paramount. By addressing the underlying condition, physicians can help stabilize a person and work to prevent a future episode of catatonia.

When to Seek Professional Help for Catatonia

When the underlying cause of catatonia is a mental health disorder, such as schizophrenia or a mood disorder, symptoms of these disorders begin worsening prior to the onset of catatonia. If someone’s symptoms become more severe and normal functioning is impaired, professional help should be sought. Malignant catatonia can be fatal, so if symptoms are experienced, seek help quickly.

Catatonia can come on slowly or suddenly, so if someone’s activity and engagement levels seem unusually slow or if other worrying medical symptoms are present, seek help. If a person is experiencing worsening mental health symptoms, they should seek support from a professional helper. By referring to an online therapist directory, an appropriate professional can be found based on location, modality, and area of specialization.