Kristen Shirey Catatonia

8/9/2019 Kristen Shirey Catatonia

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Catatonia

Kristen Shirey, M.D.

Duke University Hospital

Internal Medicine and Psychiatry


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Catatonia

Common

Signs are easily identifiable

Many faces NMS is a form of malignant catatonia

Differential diagnosis

Syndrome of motor dysregulation Good-prognosis condition

Easy to treat


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Catatonia is common

Prevalence is estimated at 6-15% of adult

psychiatric inpatients

Approximating incidence at 10%, catatonia

may be 2-3 times more common thansuicide in the United States

Immobility & mutism often recognized

while whispered/robotic voice, pacing, orother purposeless movement missed

Rating scale has inter-rater reliability >0.90[Norhoff et al. Movement Disorders 1999 14/3; 404-416]


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Definition of catatonia

First described by Kahlbaum in 1874 as aspecific motor dysfunction, phase ofprogressive illness including stages of

mania, depression, psychosis ending indementia

Includes 3 distinct categories ofsymptoms: hypo/hyperkinetic, affective &behavioral

Excellent review by Taylor & Fink AMJP 2003;160:1233-41


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Classic signs of catatonia

StuporExtreme hypoactivity, immobility,

minimally responsive to stimuli

(including pain) Mutism

Verbally minimally responsive

Negativism

Involuntary/amotivational resistance,

oppositional behavior (Gegenhalten)


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Additional signs

Automatic obedienceExaggerated cooperation withexaminers request; mitgehen

StereotypyRepetitive, non-goal-directed motoracitivity, echopraxia, echolalia,verbigeration

Catalepsy/PosturingMaintains postures ie. pillow-sign,waxy flexibility


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ProcedureBush Examines

Observe patient while trying to engage in a conversation Activity level

Abnormal movements

Abnormal speech

Examiner scratches head in exaggerated manner Echopraxia

Examine arm for cogwheeling. Attempt to reposture,

instructing patient to "keep your arm loose" - move arm

with alternating lighter and heavier force.

Negativism

Waxy flexibility

Gegenhalten

Ask patient to extend arm. Place one finger beneath handand try to raise slowly after stating, "Do NOT let me raise

your arm".

Mitgehen

Extend hand stating "Do NOT shake my hand". Ambitendency

Reach into pocket and state,"Stick out your tongue, I

want to stick a pin in it".

Automatic obedience

Check for grasp reflex. Grasp reflex

Check chart for reports of previous 24-hour period. In

particular check for oral intake, vital signs, and any

incidents.

Attempt to observe patient indirectly, at least for a brief

period, each day.


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DSM IV => specifier of schizophrenia,

mood disorder or general medical

condition

2 out of following 5 criteria:

Motoric immobility ( catalepsy, waxy flexibility,

stupor) Excessive motor activity (purposeless, not

influenced by external stimuli)

Extreme negativism (rigid posture, resistance to

instructions, gegenhalten, mutism) Peculiarities of voluntary movement (grimacing,

bizarre postures, stereotyped movements)

Echolalia or echopraxia


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Finks proposed catatonia classification Diagnostic criteria:

A. Immobility, mutism or stupor

for at least 1 hour + one of

the following:

Catalepsy, automatic

obedience, posturing,observed or elicited at least

twice

B. In the absence of immobility,

mutism or stupor, need to

observe or elicit at least twiceat least two of the following:

stereotypy, echophenomena,

catalepsy, automatic

obedience, posturing,

negativism, ambitendency

Catatonia:

1. Non-malignant catatonia:criteria A

2. Delirious mania (excitedcatatonia): criteria B +severe mania or excitement

3. Malignant catatonia A orB+ fever and autonomicinstability

Modifiers:

i. 2/2 Mood disorderii. 2/2 General medical

condition or toxic state

iii. 2/2 a Brain disorder

iv. 2/2 Psychotic disorder


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Clinical features of MC/NMS

Fever

Muscle rigidity

Dyskinesia

Posturing, waxy flexibility, catalepsy, mutism

Dysarthria, dysphagia, sialorrhea

Altered consciousness, may appear comatose Autonomic instability: lability of blood pressure,

tachycardia, vasoconstriction, diaphoresis


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Early signs of MC/NMS

Mania with fever

Any catatonic features within 24h of

antipsychotic initiation

Autonomic instability or sialorrhea within 24 h of

antipsychotic initiation

Rapidly developed EPS symptoms with

administration of low dose of antipsychotic


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Drugs associated with

MC/NMS All antipsychotics

Metoclopramide

ATD combined with AP

Lithium MAOIs

CBZ

Valproic acid

Cyclobenzaprine

Alpha-methyltyrosine

Abrupt withdrawal from

antipsychotic

dopamine agonists

BZDantihistamines

anticholinergics

Intoxication with:

disulfiramcorticosteroids

PCP, cocaine

antihistaminergics

anticholinergics


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Abnormal labs in MC/NMS

Proteinuria

Myoglobinuria

Very high CPK

High LDH

Leukocytosis (10-25k)

Thrombocytosis

Low serum iron

Diffuse EEG slowing

Abnormal electrolytes:

Low calcium

Low magnesiumHigh potassium

Elevated LFTs:

AST, ALT,

rarely bilirubin


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Clinical risk factors for

MC/NMS Dehydration

Exposure to high

temperatures

Agitation Thyrotoxicosis

Basal ganglia

disorder:

TDakathisia

EPS from Rx

Past hx catatonia

Past hx NMS

Receiving high

potency AP or >1AP

IM antipsychotic

AP + ATD or mood

stabilizers

Recent alcohol

abuse with liver

dysfunction


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Most commonly associated

with psychiatric disorders

Bipolar and schizophrenia

Withdrawal from dopaminergicmedications or cocaine (also implicated inNMS)

Withdrawal from BZD (must exclude

nonconvulsive status epilepticus) Medical causes (up to 16%)


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Medical conditions associated with

catatonia Endocrinopathies: hypoparathyroidism, thyrotoxicosis,

pheochromocytoma

Infections: viral, HIV, typhoid fever

Tumors: esp fronto-temporal lesions Stroke: esp anterior brain regions

Traumatic brain injuries: subdural hematoma

Epilepsy: post-ictal immobility & NCSE

Autoimmune: SLE

Heat stroke

Toxins: tetanus, staph., fluoride, strychnine

Poisoning: salicylates, inhalational anesthesics


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False positives

Mutism alone is not sufficient; need at least 1

or 2 other motor symptoms

Stupor alone is not sufficient (EEG) Parkinson disease, in particular akinetic

parkinsonism, OCD, tic disorder, Tourette

syndrome

Malignant hyperthermia (rare AD genetic d/o)

Stiff-person syndrome and locked-in

syndrome


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Catatonia has a good prognosis

No RCTs of in Rx of catatonia

Management is well-defined

Important to treat emergently, as catatoniacan evolve in life-threatening condition

When properly treated almost all episodes

of catatonia fully resolveFink & Taylor

Most likely cause of failure is prolonged

inadequate treatment Fink & Taylor


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Treatment of catatonia

Benzodiazepines, most studied are

lorazepam and clonazepam at high doses:

70% response within 4 days

ECT bilateral usually 8- 15 sessions

3x/week

Benzodiazepines suspend the symptoms;

ECT treats underlying disease

Antipsychotics ineffective, often

detrimental


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Acute management

Hospitalization BZD challenge

BZD treatment trial

Maintain fluid and electrolyte balance Avoid antipsychotic agents

Avoid prolonged immobility

Identify and correct underlyingneuropsychiatric or medical cause

If not improved in 4 days => ECT

Tx may be augmented with NMDA

antagonists amantadine or memantine


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Conclusions

Common

Signs are easily identifiable

Many faces NMS is a form of malignant catatonia

Differential diagnosis

Syndrome of motor dysregulation Good-prognosis condition

Easy to treat

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Kristen Shirey Catatonia

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