Understanding the Definition, Causes, and Treatments of Catatonia
"Expression is catatonia, in which the limbs assume and retain indefinitely the position in which they are placed. One form is called catatonic rigidity and another called waxy flexibility" - Image sourced from Mental Medicine and Nursing, 1915, by Chase, Robert Howland
Definition
Catatonia is a complex syndrome involving disrupted mental status and physical muscular abnormalities. Individuals with catatonia are unable to interact with the world through their body, such as moving or speaking, even though there is no functional barrier to doing so. It presents in two primary forms: hypoactive and hyperactive. Hypoactive catatonia involves stupor, immobility, and mutism, while hyperactive catatonia features excessive movement, agitation, and potentially dangerous behaviors. Despite it being first documented more than 150 years ago, it remains challenging to diagnose and is often missed.
Etiology
The etiology of catatonia is multifaceted and often linked to underlying psychiatric or medical conditions. It can be secondary to mood disorders, particularly bipolar disorder and major depressive disorder, as well as schizophrenia. Additionally, catatonia can arise from general medical conditions, including metabolic abnormalities, neurological diseases (like Parkinson's disease), and substance use disorders. Identifying the root cause is critical for effective treatment, as catatonia may also be triggered by medications or withdrawal from substances.
Pathophysiology
The pathophysiology of catatonia remains incompletely understood, but it is thought to involve disruptions in neurotransmitter systems, particularly gamma-aminobutyric acid (GABA) and glutamate. Imbalances in these neurotransmitters can affect the brain's motor and emotional regulation circuits. Newer research has shown chronic catatonia patients to have significantly higher levels of blood circulation and activity in parts of the brain with pathways responsible for higher-level planning of movement. Some theorize that hyperconnectivity and overactivity in the brain is responsible for disrupting the balance of these pathways.
Treatment
The treatment of catatonia is tailored to each individual and typically begins with addressing any underlying conditions. First-line treatments include benzodiazepine challenges, often with Ativan (lorazepam) through an IV. Although these medications are usually sedating, catatonia patients will show remarkable improvement within minutes of being given an adequate dose. In severe refractory cases where patients do not improve with benzodiazepines or treatment of other underlying conditions, electric convulsive therapy (ECT) can rapidly reverse catatonic symptoms and improve the patient's overall condition. In addition to these primary treatments, supportive care is crucial. This includes ensuring adequate nutrition, hydration, and preventing complications such as pressure sores and deep vein thrombosis due to immobility. Antipsychotic medications are generally avoided initially, as they can exacerbate catatonic symptoms in some cases. However, they may be considered in specific scenarios where an underlying psychotic disorder is suspected.
Conclusion
Catatonia is a complex and potentially life-threatening condition that requires prompt recognition and treatment. Since it can be caused by a great number of things and presents in diverse ways, diagnosing it can be a challenge, with catatonia often being underdiagnosed. Understanding the underlying pathophysiological mechanisms, although still incomplete, guides effective treatment strategies. Early and appropriate intervention can significantly improve outcomes for individuals suffering from this debilitating syndrome.
References
Heckers S, Walther S. Caring for the Patient With Catatonia. JAMA Psychiatry. 2021;78(5):560–561. doi:10.1001/jamapsychiatry.2021.0096.
Rogers JP, Zandi MS, David AS. The diagnosis and treatment of catatonia. Clin Med (Lond). 2023 May;23(3):242-245. doi: 10.7861/clinmed.2023-0113. PMID: 37236789; PMCID: PMC11046566.
Walther S, Stegmayer K, Wilson JE, Heckers S. Structure and neural mechanisms of catatonia. Lancet Psychiatry. 2019 Jul;6(7):610-619. doi: 10.1016/S2215-0366(18)30474-7. Epub 2019 Jun 10. PMID: 31196794; PMCID: PMC6790975. Assessed and Endorsed by the MedReport Medical Review Board