Catatonia

# Overview
Catatonia  is a syndrome of psychic and motoric disturbances.  In the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (DSM-V), catatonia became recognized as a separate disorder. Catatonia is also associated with psychiatric conditions such as schizophrenia (catatonic type), bipolar disorder, post-traumatic stress disorder, depression and other mental disorders, as well as drug abuse and/or overdose. It may also be seen in many medical disorders including infections (such as encephalitis), autoimmune disorders, focal neurologic lesions (including strokes), metabolic disturbances and abrupt or overly rapid withdrawal from benzodiazepines. It can be an adverse reaction to prescribed medication. It bears similarity to conditions such as encephalitis lethargica and neuroleptic malignant syndrome. There are a variety of treatments available, and depending on the case, one or more drugs may be used, including antipsychotics and benzodiazepines.

# Clinical features
Patients with catatonia may experience an extreme loss of motor ability or constant hyperactive motor activity. Catatonic patients will sometimes hold rigid poses for hours and will ignore any external stimuli. Patients with catatonic excitement can die of exhaustion if not treated. Patients may also show stereotyped, repetitive movements. They may show specific types of movement known as "waxy flexibility" in which they maintain positions after being placed in them by someone else, or gegenhalten (lit. "counterhold"), in which they resist movement in proportion to the force applied by the examiner. They may repeat meaningless phrases or speak only to repeat what the examiner says.

## Subtypes
Stupor is a motionless, apathetic state in which one is oblivious or does not react to external stimuli. Motor activity is nearly non-existent. Individuals in this state make little or no eye contact with others and may be mute and rigid. One might remain in one position for a long period of time, and then go directly to another position immediately after the first position.
Catatonic excitement is state of constant purposeless agitation and excitation. Individuals in this state are extremely hyperactive although the activity seems to lack purpose.

# Causes

## Common Causes
- Acute intermittent porphyria
- Acute stress disorder
- Addison's Disease
- Alcohol intoxication
- Anorexia nervosa
- Arachnoid cyst in right parietal region
- Astrocytoma
- Autistic disorder
- Bilateral hemorrhagic lesions of temporal lobes
- Brain cyst
- Brain disorders
- Brain trauma
- Brain tumour
- Brief psychotic disorder
- Bronchorrhea
- Catatonic schizophrenia
- Central pontine myelinolysis
- Cerebellar catalepsy
- Cerebral hemorrhage
- Cerebral infarct
- Cerebrovascular disease
- Cns bleed
- Conversion disorder
- Cortical basal ganglionic degeneration
- Cortical venous thrombosis
- Delirium
- Drug withdrawal
- Dystonia
- Emotional trauma
- Encephalitis
- Encephalopathy
- Familial fatal insomnia
- Frontal lobe brain damage
- Frontal lobotomy
- Head trauma
- Heat stroke
- Hepatic encephalopathy
- Hepatic failure
- Hereditary coproporphyria
- Homocystinuria
- Huntington's disease
- Hydrocephalus
- Hyperparathyroidism
- Hyperthyroidism
- Hyponatremia
- Hypopituitarism secondary to postpartum hemorrhage
- Hypothermia
- Idiopathic recurring stupor
- Inherited neurometabolic disorders
- Intestinal atony
- Locked-in syndrome
- Lorazepam
- Meningitis
- Meningoencephalitis
- Mental illness
- Multiple sclerosis
- Neoplasms
- Neuroleptic malignant syndrome
- Neurosyphilis
- Nonconvulsive status epilepticus
- Pallidoluysian atrophy
- Paraneoplastic encephalitis
- Parkinson's disease
- Postencephalitic parkinsonism
- Posttraumatic stress disorder
- Presenile dementia, kraepelin type - catatonia
- Progressive multifocal leukoencephalopathy
- Progressive supranuclear palsy
- Reactive psychosis
- Schizencephaly
- Schizoaffective disorder
- Schizophrenia
- Schizophreniform disorder
- Sedative withdrawal
- Seizures
- Sibutramine
- Status epilepticus
- Stiff-man syndrome
- Stroke
- Strychnine poisoning
- Stupor
- Subarachnoid hemorrhage
- Subdural hematoma
- Subthalamic mesencephalic tumor
- Surgical removal of cerebellar tumor
- Syndrome of inappropriate antidiuretic hormone (siadh)
- Syphilis
- Systemic lupus erythematosus
- Tay-sachs disease
- Temporal lobe epilepsy
- Thrombotic thrombocytopenic purpura
- Tuberculosis
- Tuberous sclerosis
- Tumors
- Typhoid fever
- Vegetative state
- Viral encephalitis
- Wilson's disease

## Causes by Organ System

## Causes in Alphabetical Order
- Acute intermittent porphyria
- Acute stress disorder
- Addison's disease
- Aids
- Akinetic-rigid syndrome
- Alcohol intoxication
- Anorexia nervosa
- Arachnoid cyst in right parietal region
- Astrocytoma
- Atrophy of left amygdala
- Autistic disorder
- Bacterial septicemia
- Basilar artery thrombosis
- Bilateral hemorrhagic lesions of temporal lobes
- Brain cyst
- Brain disorders
- Brain trauma
- Brain tumour
- Brief psychotic disorder
- Bronchorrhea
- Carbon monoxide poisoning
- Carcinoid tumors
- Catatonic schizophrenia
- Central pontine myelinolysis
- Cerebellar catalepsy
- Cerebral hemorrhage
- Cerebral infarct
- Cerebrovascular disease
- Cns bleed
- Conversion disorder
- Cortical basal ganglionic degeneration
- Cortical venous thrombosis
- Delirium
- Depression
- Diabetic ketoacidosis
- Drug withdrawal
- Dystonia
- Electrolyte imbalances
- Emotional trauma
- Encephalitis
- Encephalopathy
- Familial fatal insomnia
- Fever
- Fibromuscular dysplasia with dissection of basilar artery
- Frontal lobe brain damage
- Frontal lobotomy
- Head trauma
- Heat stroke
- Hepatic encephalopathy
- Hepatic failure
- Hereditary coproporphyria
- Homocystinuria
- Huntington's disease
- Hydrocephalus
- Hypercalcemia
- Hyperparathyroidism
- Hyperthyroidism
- Hyponatremia
- Hypopituitarism secondary to postpartum hemorrhage
- Hypothermia
- Hysteria
- Idiopathic recurring stupor
- Inherited neurometabolic disorders
- Intestinal atony
- Locked-in syndrome
- Lorazepam
- Malaria
- Malignant hyperthermia
- Medications
- Meningitis
- Meningoencephalitis
- Mental illness
- Mood disorders
- Multiple sclerosis
- Neoplasms
- Neuroleptic malignant syndrome
- Neurosyphilis
- Nonconvulsive status epilepticus
- Pallidoluysian atrophy
- Paraneoplastic encephalitis
- Parkinson's disease
- Pervasive developmental disorders
- Poisoning
- Postencephalitic parkinsonism
- Posttraumatic stress disorder
- Presenile dementia, kraepelin type - catatonia
- Progressive multifocal leukoencephalopathy
- Progressive supranuclear palsy
- Reactive psychosis
- Renal failure
- Schizencephaly
- Schizoaffective disorder
- Schizophrenia
- Schizophreniform disorder
- Sedative withdrawal
- Seizures
- Sibutramine
- Status epilepticus
- Stiff-man syndrome
- Stroke
- Strychnine poisoning
- Stupor
- Subarachnoid hemorrhage
- Subdural hematoma
- Substance intoxication
- Subthalamic mesencephalic tumor
- Surgical removal of cerebellar tumor
- Syndrome of inappropriate antidiuretic hormone (siadh)
- Syphilis
- Systemic lupus erythematosus
- Tay-sachs disease
- Temporal lobe epilepsy
- Tetanus
- Thermal injury
- Thrombotic thrombocytopenic purpura
- Tuberculosis
- Tuberous sclerosis
- Tumors
- Typhoid fever
- Uremia
- Vegetative state
- Viral encephalitis
- Wilson's disease

# Catatonia Associated with Another Mental Disorder

## Risk Factors
- Bipolar disorders
- Depressive disorders
- Schizophrenia

## Natural History, Complications and Prognosis
Poor prognostic factors include:
- Bipolar disorder
- Depressive disorder
- Mental disorder
- Metabolic conditions
- Infectious conditions
- Psychotic disorder

## DSM-V Diagnostic Criteria for Catatonic Disorder Due to Another Medical Condition

# Catatonia Due to Another Medical Condition

## Differential Diagnosis
- Brief psychotic disorder
- Cerebrovascular disease
- Diabetic ketoacidosis
- Encephalitis
- Neoplasms
- Head trauma
- Hepatic encephalopathy
- Hypercalcemia
- Homocystinuria
- Schizoaffective disorder
- Schizophrenia
- Schizophreniform disorder
- Substance/medication-induced psychotic disorder
- Neuroleptic malignant syndrome
- Neuroleptic-induced movement disorder

## DSM-V Diagnostic Criteria for Catatonia due to Another Medical Condition

# Treatment
Initial treatment is aimed at providing relief from the catatonic state.  Benzodiazepines are the first line of treatment, and high doses are often required.  A test dose of 1-2 mg intramuscular lorazepam will often result in marked improvement within half an hour. In France, zolpidem has also been used in diagnosis and response may occur within the same time period. Ultimately the underlying cause needs to be treated.
Electroconvulsive therapy is an effective treatment for catatonia as well as for most of the underlying causes (e.g. psychosis, mania, depression).  Antipsychotics should be used with care as they can worsen catatonia and are the cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires the immediate discontinuation of the antipsychotic.