Catatonia

Synonyms: waxy flexibility, flexibilitas cerea

Catatonia is a state of apparent un-responsiveness to external stimuli in a patient who appears to be awake. It is a presentation of a number of different conditions rather than a disease itself. It may be an episodic condition with periods of remission, and triggered by medication or other changes in circumstances.¹

Aetiology

This is not an exhaustive list!¹

• Neurology
  • Nonconvulsive status epilepticus, complex partial seizures
  • Encephalopathies
  • Cerebrovascular disease (thrombosis or haemorrhage, venous thrombosis, etc.)
  • Parkinsonism and dystonias
  • Tumours and other intracranial lesions (including post surgery)
  • Degenerative neurological diseases including multiple sclerosis and Huntington's disease
  • Central pontine myelinolysis
  • Hydrocephalus
  • Head injury and locked-in syndrome
• Psychiatry
  • Acute stress disorder, hysteria
  • Neuroleptic malignant syndrome
  • Major depression and mood disorders
  • Pervasive developmental disorders including autism
  • Psychosis and schizophrenia
  • Substance intoxication, or drug withdrawal
  • Anorexia nervosa
• Infective
  • Meningitis and/or encephalitis
  • Neurosyphilis
  • AIDS
  • Malaria
  • Septicaemia
  • Typhoid
  • Tuberculosis
• Medical
  • Addison's disease, hypopituitarism, carcinoid tumours,
  • Hyperthyroidism
  • Electrolyte imbalance, hyperparathyroidism
  • Acute intermittent porphyria
  • Diabetic ketoacidosis
  • Hepatic or renal failure
  • Systemic lupus erythematosus
  • Hypothermia or hyperthermia
  • Thrombotic thrombocytopenic purpura
  • Poisoning (carbon monoxide, lead)
• Inherited neurometabolic disorders
  • Homocystinuria
  • Hereditary coproporphyria
  • Tay-Sachs disease
  • Wilson's disease

History

Catatonia can occur in a huge range of conditions and it is very important to identify any treatable causes - particularly psychosis, nonconvulsive status epilepticus, neuroleptic malignant syndrome or encephalitis. No history will be forthcoming from the patient - but there may be relevant history from family or friends. Is there anything relevant in the medication list or past medical history to suggest a cause?

Examination

Perform a full examination. Check for a pyrexia, meningism or other signs of infection. Are there any neurological signs or abnormal movements, or cogwheel rigidity (Parkinsonism)? A grasp reflex may be present.²
Classic features:

• Motoric immobility - catalepsy (see below), waxy flexibility, stupor (extreme hypoactivity, minimal response to stimuli, including painful ones)
• Mutism - verbally minimally responsive
• Negativism - involuntary resistance to passive movement, or involuntary oppositional behaviour (Gegenhalten)

There may be automatic obedience or exaggerated co-operation, combativeness, or even ambitendency (alternating co-operation and opposition). Other features include mitgehen (e.g. arm raising in response to light finger pressure, despite instructions to the contrary), echopraxia, echolalia or verbigeration (repetition of phrases or sentences like a scratched record); or stereotypies (repetitive meaningless activities).

There is also an excited-delirious variety of catatonia with extreme hyperactivity (constant motor unrest or non-purposeful repetitive motor activity).² Patients may develop hyperthermia, tachycardia, and hypertension and be in danger of collapse from exhaustion.¹

The catatonia rating scale may be helpful in assessments.³

Investigations

• FBC, U&E creatinine, LFT, glucose, calcium, fibrin D-dimer, serum creatine kinase (usually elevated in neuroleptic malignant syndrome) , serum ceruloplasmin (to detect Wilson's disease)
• EEG should readily identify a seizure disorder
• CT, MRI or PET scan may be appropriate to exclude intracranial lesions

Management

The patient needs admission for identification and treatment of the underlying condition, and may require enteral feeding.

Historical note

Catatonia was first described by Karl Kahlbaum in 1874. The dancer Nijinsky was apparently a sufferer.⁴

Catalepsy

Catalepsy is a state characterised by a patient keeping an uncomfortable rigid fixed posture despite external stimulus or resistance. There may also be decreased sensitivity to pain. It is a feature seen in catatonia (see above).

Document references

1. Brasic JR, Catatonia, eMedicine updated Dec 2009.
2. Taylor MA, Fink M; Catatonia in psychiatric classification: a home of its own. Am J Psychiatry. 2003 Jul;160(7):1233-41. [abstract]
3. Catatonia Rating Scale, United Kingdom Psychiatric Pharmacy Group Website.
4. Ostwald P; The "God of the dance": treating Nijinsky's manic excitement and catatonia. Hosp Community Psychiatry. 1994 Oct;45(10):981-5.

Internet and further reading

• Fink M; Catatonia: a syndrome appears, disappears, and is rediscovered. Can J Psychiatry. 2009 Jul;54(7):437-45. [abstract]

Acknowledgements