Catatonic disorders are a group of symptoms characterized by disturbances in motor (muscular movement) behavior that may have either a psychological or a physiological basis. The best-known of these symptoms is immobility, which is a rigid positioning of the body held for a considerable length of time. Patients diagnosed with a catatonic disorder may maintain their body position for hours, days, weeks or even months at a time. Alternately, catatonic symptoms may look like agitated, purposeless movements that are seemingly unrelated to the person's environment. The condition itself is called catatonia .
A less extreme symptom of catatonic disorder is slowed-down motor activity. Often, the body position or posture of a catatonic person is unusual or inappropriate; in addition, he or she may hold a position if placed in it by someone else.
Types of catatonic disorder
CATATONIC SCHIZOPHRENIA. Schizophrenia is a severe, usually life-long mental illness that affects every aspect of human functioning. Thinking, feeling, and behavior are all affected by the disorder; and the person with schizophrenia usually has difficulties in interpersonal relationships as well as in obtaining and keeping meaningful employment. The catatonic subtype of schizophrenia is, fortunately, rare today in North America and Europe. It is characterized by severe disturbances in motor behavior. Individuals with catatonic schizophrenia often show extreme immobility. They may stay in the same position for hours, days, weeks, or longer. The position they assume may be unusual and appear uncomfortable to the observer; for example, the person may stand on one leg like a stork, or hold one arm outstretched for a long time. If an observer moves a hand or limb of the catatonic person's body, he or she may maintain the new position. This condition is known as waxy flexibility. In other situations, a person with catatonic schizophrenia may be extremely active, but the activity appears bizarre, purposeless, and unconnected to the situation or surroundings. The patient may, for example, run up and down a flight of stairs repeatedly. Catatonic stupor is characterized by extremely slowed motor activity, often to the point of being motionless and appearing unaware of surroundings. The patient may exhibit negativism, which means that he or she resists all attempts to be moved, or all instructions or requests to move, without any apparent motivation.
Catatonic symptoms were first described by the psychiatrist Karl Ludwig Kahlbaum in 1874. Kahlbaum described catatonia as a disorder characterized by unusual motor symptoms. His description of individuals with catatonic behaviors remains accurate to this day. Kaulbaum carefully documented the symptoms and the course of the illness, providing a natural history of this unusual disorder.
DEPRESSION WITH CATATONIC FEATURES. People who are severely depressed may show disturbances of motor behavior resembling those of patients diagnosed with catatonic schizophrenia. These depressed persons may remain virtually motionless, or move around in an extremely vigorous but apparently random fashion. Extreme negativism, elective mutism (choosing not to speak), peculiar movements, and imitating someone else's words or phrases (echolalia) or movements (echopraxia) may also be part of the symptomatic picture. These behaviors may require caregivers to supervise the patient, to insure that he or she does not hurt him- or herself or others.
Catatonic behaviors may also occur in persons with other mood disorders. Persons experiencing manic or mixed mood states (a simultaneous combination of manic and depressive symptoms) may at times exhibit either the immobility or agitated random activity seen in catatonia. A severely depressed person may experience intense emotional pain from simply moving a finger. Even getting up out of a chair can be a painful chore that may take hours for the severely depressed individual. As the depression begins to lift, the catatonic symptoms diminish.
CATATONIC DISORDER DUE TO A GENERAL MEDICAL CONDITION. Persons with catatonic disorder due to a medical condition show symptoms similar to those of catatonic schizophrenia and catatonic depression, except that the cause is believed to be physiological. Such neurological diseases as encephalitis may cause catatonic symptoms that can be temporary or lasting.
Psychiatric symptoms caused by physiological illnesses can appear early in the course of an illness. For this reason, it is important to consider possible physical causes when catatonic symptoms appear. Persons with catatonic symptoms of physical origin generally show greater self-awareness or insight, and more distress about their symptoms than those suffering from schizophrenia. This difference can help clinicians distinguish between patients whose catatonic symptoms stem from psychiatric causes versus those whose symptoms have a medical origin.
Causes and symptoms
CATATONIC SCHIZOPHRENIA. The cause of schizophrenia remains unknown. During the past decade, however, research has pointed to abnormalities in structure or function of certain areas of the brain , including the limbic system, the frontal cortex, and the basal ganglia. These three regions are interconnected, so that dysfunction in one area may be related to structural problems in another. Brain imaging of living people and studies of the brains of deceased persons point to the limbic system as the potential site of pathology in at least some, if not most, schizophrenic patients.
DEPRESSION WITH CATATONIC FEATURES. Mood disorders are believed to be at least partially caused by irregularities in production of neurotransmitters within the brain. Neurotransmitters are chemicals that conduct impulses along a nerve from one nerve cell to another. Two of the most important neurotransmitters associated with depression are norepinephrine and serotonin. In animal studies, virtually all effective antidepressant medications affect the receptors for these neurotransmitters. Dopamine is another neurotransmitter that plays a role in the development of depressive disorders.
CATATONIC DISORDER DUE TO A GENERAL MEDICAL CONDITION. Numerous medical conditions can cause psychiatric symptoms. Some of the more common are infectious, metabolic, and neurological conditions. Catatonic symptoms have been linked to earlier infection with encephalitis and to Parkinson's disease. Although the appearance of patients with post-encephalitis catatonia may be similar to that of catatonic schizophrenic patients, the majority of post-encephalitic patients are not psychotic. Oliver Sacks vividly describes catatonic disorder due to encephalitis and Parkinson's disease in his 1973 book Awakenings .
CATATONIC SCHIZOPHRENIA. Catatonic schizophrenia is a form of thought disorder with prominent motor symptoms and abnormalities. These symptoms include:
- Catalepsy, or motionlessness maintained over a long period of time.
- Catatonic excitement, marked by agitation and seemingly pointless movement.
- Catatonic stupor, with markedly slowed motor activity, often to the point of immobility and seeming unawareness of the environment.
- Catatonic rigidity, in which the person assumes a rigid position and holds it against all efforts to move him or her.
- Catatonic posturing, in which the person assumes a bizarre or inappropriate posture and maintains it over a long period of time.
- Waxy flexibility, in which the limb or other body part of a catatonic person can be moved into another position that is then maintained. The body part feels to an observer as if it were made of wax.
- Akinesia, or absence of physical movement.
DEPRESSION WITH CATATONIC FEATURES. Within the category of mood disorders, catatonic symptoms are most commonly associated with bipolar I disorder. Bipolar I disorder is a mood disorder involving periods of mania interspersed with depressive episodes. Symptoms of catatonic excitement, such as random activity unrelated to the environment or repetition of words, phrases and movements may occur during manic phases. Catatonic immobility may appear during the most severe phase of the depressive cycle. The actual catatonic symptoms are indistinguishable from those seen in catatonic schizophrenia. It is also possible for catatonic symptoms to occur in conjunction with other mood disorders, including bipolar II disorder (in which a milder form of mania called hypomania occurs); mixed disorders (in which mania and depression occur at the same time); and major depressive disorders.
CATATONIC DISORDER DUE TO A GENERAL MEDICAL CONDITION. Symptoms of catatonic disorder caused by medical conditions are indistinguishable from those that occur in schizophrenia and mood disorders. Unlike persons with schizophrenia, however, those with catatonic symptoms due to a medical condition demonstrate greater insight and awareness into their illness and symptoms. They have periods of clear thinking, and their affect (emotional response) is generally appropriate to the circumstances. Neither of these conditions is true of patients with schizophrenia or severe depression.
According to the handbook used by mental health professionals to diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision, also known as the DSM-IV-TR ,
Catatonic symptoms are quite noticeable. Important diagnostic distinctions, however, must be made to determine their cause. Catatonic schizophrenia is diagnosed when the patient's other symptoms include thought disorder, inappropriate affect, and a history of peculiar behavior and dysfunctional relationships. Catatonic symptoms associated with a mood disorder are diagnosed when there is a prior history of mood disorder, or after careful psychiatric evaluation. Medical tests are necessary to determine the cause of catatonic symptoms caused by infectious diseases, metabolic abnormalities, or neurological conditions. The patient should be asked about recent use of both prescribed and illicit drugs in order to determine whether the symptoms are drug-related.
Treatment for catatonic symptoms depends on the underlying cause. Catatonic schizophrenia is treated by a variety of pharmacological and psychotherapeutic methods. Hospitalization may be necessary to protect the patient's safety. Supportive psychotherapy and family education can help persons with schizophrenia and their families adjust to problems created by the illness. Such other supportive services as sheltered workshops and special education may also be necessary.
Treatment of catatonic symptoms due to mood disorder involves therapy directed at the underlying mood disorder. Manic episodes are treated with such mood stabilizers as lithium and valproic acid (Depakote). Depressive episodes are treated with antidepressant medications or, if necessary, electroconvulsive treatment (ECT).
Catatonic symptoms caused by a medical disorder require correct diagnosis of the underlying medical condition, followed by appropriate treatment. Levodopa and amantadine (Symmetrel) have shown some effectiveness in reducing catatonic symptoms due to post-encephalitic Parkinson'sdisease. Hospitalization and careful supervision of persons with catatonic symptoms may be necessary to insure that they do not hurt themselves or others.
Catatonic schizophrenia is usually a debilitating lifelong illness. Symptoms typically emerge in adolescence. Social and environmental stressors, such as leaving home for college or military service, use of an illicit drug, or the death of a close friend or relative may trigger the initial symptoms of schizophrenia. The classic pattern is one of worsened symptoms alternating with remissions rather than cure, although about 20% of patients eventually resume their previous level of functioning. Following the initial episode, most patients suffer a relapse within five years of the diagnosis. The course of the disorder varies, with women having a somewhat better prognosis, but persons with schizophrenia remain vulnerable to stress for their lifetime.
Catatonia associated with mood disorders is somewhat more treatable, although it may also recur from time to time throughout the patients life.
Catatonic symptoms caused by medical conditions can be treated and sometimes cured. Infections are the most completely curable. Metabolic and neurological conditions may be treatable, but various degrees of impairment may remain throughout the patient's life.
There are no specific preventive measures for most causes of catatonia. Infectious disease can sometimes be prevented. Catatonic symptoms caused by medications or drugs of abuse can be reversed by suspending use of the drug.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Kaplan, Harold I., MD and Benjamin J. Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition. Baltimore, MD: Lippincott Williams and Wilkins, 1998.
Sacks, Oliver. Awakenings. New York: HarperPerennial, 1990.
Carroll, B. T. "Kahlbaum's catatonia revisited." Psychiatry and Clinical Neuroscience 55, no. 5 (October 2001):431-6.
Pfuhlmann, B., and G. Stober. "The different conceptions of catatonia: historical overview and critical discussion." European Archives of Psychiatry and Clinical Neruoscience 251 Supplement 1 (2001):14-7.
Sarkstein, S. E., J. C. Golar, A. Hodgkiss. "Karl Ludwig Kahlbaum's concept of catatonia." History of Psychiatry 6, no. 22, part 2 (June 1995): 201-7.
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Barbara Sternberg, Ph.D.