Catatonia: Diagnosis, Etiology, and Controversies

Introduction

Catatonia is a neuropsychiatric syndrome characterized by a spectrum of motor and behavioral disturbances, ranging from profound immobility to excessive psychomotor agitation. Historically associated with schizophrenia, it is now recognized to occur across a broad range of psychiatric, neurological, and medical conditions. Despite its long history in psychiatry, catatonia remains poorly understood and often underdiagnosed, leading to significant morbidity if not promptly treated. This comprehensive article explores the diagnosis, etiology, and controversies surrounding catatonia, providing insights from highly regarded academic sources.

Diagnosis

The diagnosis of catatonia is primarily clinical, relying on the observation of specific motor and behavioral symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), catatonia is not classified as an independent disorder but as a specifier for other mental disorders (e.g., schizophrenia, bipolar disorder) or due to another medical condition (e.g., neurological disorders, autoimmune diseases) (DSM-5). The DSM-5 criteria require the presence of three or more of the following 12 symptoms:

The International Classification of Diseases, 11th Revision (ICD-11) includes similar criteria but extends the symptom list to 15, incorporating signs like automatic obedience and ambitendency (ICD-11). Standardized diagnostic tools, such as the Bush-Francis Catatonia Rating Scale (BFCRS), are instrumental in screening and assessing severity, covering 23 symptoms, including non-DSM-5 signs like verbigeration (repetitive speech) and mitgehen (exaggerated compliance with movement) (Bush et al., 1996).

Diagnostic challenges stem from symptom overlap with conditions like delirium, akinetic mutism, and psychogenic parkinsonism. For example, delirium and catatonia both involve altered consciousness, but catatonia’s motor signs and benzodiazepine responsiveness distinguish it (Edinoff et al., 2021). A lorazepam challenge test, administering 1-2 mg intravenously or intramuscularly, can confirm the diagnosis if symptoms improve rapidly (Denysenko et al., 2018). In acute settings, up to 37% of patients evaluated for delirium may have catatonia, underscoring the need for careful differentiation (Farkas, 2023).

Etiology

Catatonia’s etiology is multifaceted, encompassing psychiatric, medical, substance-related, and neurobiological factors, reflecting its occurrence across diverse clinical contexts (Denysenko et al., 2018). Research suggests disruptions in cortico-basal ganglia-thalamic circuits, though precise mechanisms remain elusive (Oldham et al., 2021).

• Psychiatric Causes: Catatonia is most prevalent in mood disorders, with up to 35% of acute bipolar disorder and major depressive disorder cases exhibiting catatonic features (Taylor & Fink, 2003). Schizophrenia accounts for approximately 10% of cases, often during acute psychotic episodes (Taylor & Fink, 2003). Other psychotic disorders, including brief psychotic disorder and schizoaffective disorder, may also present with catatonia (Edinoff et al., 2021).
• Medical Causes: Approximately 20% of catatonia cases are medically induced, with significant contributions from:
  • Neurological Disorders: Encephalitis, stroke, traumatic brain injury, epilepsy (Sienaert et al., 2014).
  • Metabolic Disturbances: Hypercalcemia, hepatic encephalopathy, vitamin B12 deficiency (Denysenko et al., 2018).
  • Infectious Diseases: HIV, syphilis, tuberculosis, viral encephalitis (Fink & Taylor, 2009).
  • Autoimmune Conditions: Systemic lupus erythematosus, NMDAR encephalitis, with 72% of autoimmune-related cases linked to NMDAR encephalitis (Denysenko et al., 2018).
• Substance-Related Causes: Catatonia can be triggered by high-potency antipsychotics (e.g., haloperidol), clozapine, or withdrawal from benzodiazepines or alcohol, possibly due to altered excitatory neurotransmission (Fink & Taylor, 2009).
• Genetic and Neurobiological Factors: Familial patterns suggest a heritable component, though specific genetic markers are unidentified (Taylor & Fink, 2003). Neurotransmitter imbalances, particularly in GABA, dopamine, serotonin, and glutamate, are implicated, affecting cortico-basal ganglia-thalamic circuits (Fink & Taylor, 2009).

Controversies

The diagnosis and classification of catatonia are subject to significant intellectual debates, reflecting its complexity and evolving understanding:

1. Classification as a Separate Disorder: A central debate is whether catatonia should be recognized as an independent diagnostic entity or remain a specifier for other disorders. The DSM-5 and ICD-11 classify it as a specifier, but researchers advocate for a standalone category to enhance recognition across etiologies (Taylor & Fink, 2003).
2. Diagnostic Criteria Variability: Discrepancies between DSM-5 (12 symptoms) and ICD-11 (15 symptoms, including automatic obedience) lead to inconsistent diagnoses. Over 40 catatonic signs are recognized, but diagnostic thresholds vary, complicating standardization (Sarkar & Sakey, 2014).
3. Overlap with Other Syndromes: Catatonia shares symptoms with delirium, akinetic mutism, and psychogenic parkinsonism, leading to frequent misdiagnosis. For example, 37% of delirium cases may be catatonia, necessitating careful differentiation (Farkas, 2023).
4. Treatment Response Variations: Psychiatric catatonia often responds to benzodiazepines, while medically induced cases may require addressing the underlying condition, with variable responsiveness (Sienaert et al., 2014).

Clinical Pearls

• Early Recognition: Prompt identification prevents complications like dehydration, malnutrition, and venous thromboembolism (Denysenko et al., 2018).
• Lorazepam Challenge Test: Administering 1-2 mg lorazepam can confirm diagnosis if symptoms improve rapidly (Denysenko et al., 2018).
• Investigate Underlying Causes: A thorough workup for psychiatric, medical, and substance-related causes is essential (Oldham et al., 2021).
• Monitor Complications: Vigilant monitoring is needed to manage risks of untreated catatonia (Sarkar & Sakey, 2014).
• Multidisciplinary Approach: Collaboration among specialists ensures comprehensive care, especially for medically induced cases (Oldham et al., 2021).

Conclusion

Catatonia is a complex neuropsychiatric syndrome with significant diagnostic and etiological challenges. Its recognition across psychiatric and medical contexts, coupled with ongoing debates about classification, underscores the need for refined diagnostic criteria and increased clinical awareness. By leveraging standardized tools and addressing underlying causes, clinicians can improve outcomes for patients with catatonia.

References

• Bush, G., et al. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129-136.
• Denysenko, L., et al. (2018). Catatonia in medically ill patients: An evidence-based review. Psychosomatics, 59(5), 431-439.
• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
• Edinoff, A. N., et al. (2021). Catatonia: Clinical overview of the diagnosis, treatment, and clinical challenges. Neurology International, 13(4), 570-586.
• Farkas, J. (2023). Catatonia. Internet Book of Critical Care (IBCC).
• Fink, M., & Taylor, M. A. (2009). The catatonia syndrome: Forgotten but not gone. Archives of General Psychiatry, 66(11), 1173-1177.
• World Health Organization. (2019). International Classification of Diseases, 11th Revision (ICD-11).
• Oldham, M. A., et al. (2021). Catatonia associated with medical and psychiatric conditions: A systematic review. General Hospital Psychiatry, 70, 1-10.
• Sarkar, P., & Sakey, S. (2014). The catatonia conundrum: Controversies and challenges. Journal of Psychosomatic Research, 76(2), 89-94.
• Sienaert, P., et al. (2014). A clinical review of the treatment of catatonia. Frontiers in Psychiatry, 5, 181.
• Taylor, M. A., & Fink, M. (2003). Catatonia in psychiatric classification: A home of its own. American Journal of Psychiatry, 160(7), 1233-1241.