While catatonia has long been considered a subtype of schizophrenia or a clinical feature of other medical and psychiatric conditions, the earliest descriptions by Kahlbaum et al in fact suggested a unique entity with a distinct clinical course. In this paper, we review the current understanding of the diagnosis, treatment, and pathophysiology of catatonia, and we identify several areas of uncertainty where further research is required.
Despite a renewed interest in the disorder over the last several decades, a number of questions remain regarding its causes and treatment. Overall, it is clear that catatonia is a common and serious problem that often remains unrecognized. These complications of catatonia highlight the importance of recognizing the syndrome and quickly initiating treatment. The very nature of catatonia can make it challenging, if not impossible, to carry out patient interviews and examinations, thereby interfering with the recognition of underlying diagnoses. Additionally, the immobility and refusal to eat or drink associated with catatonia can give rise to potentially serious medical complications, including dehydration, malnutrition, deep vein thrombosis and pulmonary embolism, pneumonia and other infections, pressure ulcers, and muscle contractures. This has important implications for the treatment of catatonia in the context of psychosis, which will be discussed later in this review. In particular, catatonia appears to be a risk factor for the development of neuroleptic malignant syndrome, which has a mortality rate of approximately 10% and may be clinically indistinguishable from malignant catatonia. The catatonic syndrome is associated with other disorders, underscoring the necessity of rapid diagnosis and treatment. The relative prevalence and diagnostic significance of catatonic signs differ among studies and patient populations, but there is general agreement that catatonia occurs in 9%-17% of patients with acute psychiatric illnesses and that retarded catatonia is the more frequently observed subtype. This so-called “malignant” or “lethal” catatonia can be rapidly fatal if not appropriately treated. Excited catatonia, on the other hand, is characterized by severe psychomotor agitation, potentially leading to life-threatening complications such as hyperthermia, altered consciousness, and autonomic dysfunction. Catatonia of the retarded type is associated with signs reflecting a paucity of movement, including immobility, staring, mutism, rigidity, withdrawal and refusal to eat, along with more bizarre features such as posturing, grimacing, negativism, waxy flexibility, echolalia or echopraxia, stereotypy, verbigeration, and automatic obedience. Two subtypes have been described: Retarded and excited. In this paper, we present a review of the current literature on catatonia along with findings from the 220 cases we have assessed and treated.Ĭatatonia is a clinical syndrome characterized by a distinct constellation of psychomotor disturbances. Since 1989, we have systematically assessed patients presenting to our psychiatry service with signs of retarded catatonia. Because catatonia is common, highly treatable, and associated with significant morbidity and mortality if left untreated, physicians should maintain a high level of suspicion for this complex clinical syndrome.
The pathobiology of catatonia is poorly understood, although abnormalities in gamma-aminobutyric acid and glutamate signaling have been suggested as causative factors. Patients with longstanding catatonia or a diagnosis of schizophrenia may be less likely to respond. Most patients with the syndrome respond rapidly to low-dose benzodiazepines, but electroconvulsive therapy is occasionally required. In many cases, the catatonia must be treated before any underlying conditions can be accurately diagnosed. Once thought to be a subtype of schizophrenia, catatonia is now recognized to occur with a broad spectrum of medical and psychiatric illnesses, particularly affective disorders.
Excited catatonia is a less common presentation in which patients develop prolonged periods of psychomotor agitation. Catatonia of the retarded type is characterized by immobility, mutism, staring, rigidity, and a host of other clinical signs. Two subtypes of the syndrome have been identified. Catatonia is a psychomotor syndrome that has been reported to occur in more than 10% of patients with acute psychiatric illnesses.