Signs and symptoms
Individuals with catatonia often cannot provide a coherent history; however, collateral sources can often relate relevant historical information. A history of behavioral responses to others usually includes the presence of the following:
Echopraxia (repeating the movements of others)
Echolalia (repeating the words of others)
The alternative presentation of catatonia is an excited state, possibly with impulsivity, combativeness, and autonomic instability.
The history should inquire into the following:
Possible precipitating events, including infection, trauma, and exposure to toxins and other substances
Previous similar episodes of catatonia
Exposure to neuroleptics and other substances associated with catatonia
Comorbid disorders, including schizophrenia, mood disorders, psychological stressors, medical conditions, and obstetric conditions
Treatment modalities include pharmacotherapy and electroconvulsive treatment (ECT). Prompt treatment in the early phases of catatonic states is crucial to obtaining a lasting abatement of symptoms.
Treatable conditions must be identified immediately. Specifically, neuroleptic malignant syndrome (NMS), encephalitis, nonconvulsive status epilepticus, and acute psychosis must be diagnosed and treated. The first 3 constitute neurologic emergencies that merit admission to a neurologic or medical intensive care unit (ICU); acute psychosis merits admission for intensive psychiatric inpatient evaluation and treatment.
Refusal to eat necessitates the institution of parenteral nutrition. Supervised activity is indicated. Prompt intervention may be needed to prevent collapse from exhaustion.
The need to administer parenteral nutrition and fluids and to monitor vital signs may require a patient to be transferred from a psychiatric unit to a neurologic or medical unit. If the patient poses a risk of injury to himself or herself or to staff members, then the use of a 1-on-1 psychiatric attendant at all times is indicated.
Medications that may be used in the treatment of patients suffering from catatonia include benzodiazepines, carbamazepine, zolpidem, tricyclic antidepressants (TCAs), muscle relaxants, amobarbital, reserpine, thyroid hormone, lithium carbonate, bromocriptine, and neuroleptics.
Because neuroleptic malignant syndrome (NMS) may occur in patients with symptoms and signs of catatonia, prudent clinicians use neuroleptics, including atypical neuroleptics, with caution. Although success has been reported in cases of catatonia treated with a combination of lithium and a neuroleptic, the risk of adverse effects must be considered when this combination is given, even if an atypical neuroleptic is used.
Dr. Atul Chowdhury