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Catatonia. Kristen Shirey, M.D. Duke University Hospital Internal Medicine and Psychiatry. Catatonia. Common Signs are easily identifiable Many faces NMS is a form of malignant catatonia Differential diagnosis Syndrome of motor dysregulation Good-prognosis condition Easy to treat.

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Kristen Shirey, M.D.

Duke University Hospital

Internal Medicine and Psychiatry

  • Common
  • Signs are easily identifiable
  • Many faces
  • NMS is a form of malignant catatonia
  • Differential diagnosis
  • Syndrome of motor dysregulation
  • Good-prognosis condition
  • Easy to treat
catatonia is common
Catatonia is common
  • Prevalence is estimated at 6-15% of adult psychiatric inpatients
  • Approximating incidence at 10%, catatonia may be 2-3 times more common than suicide in the United States
  • Immobility & mutism often recognized while whispered/robotic voice, pacing, or other purposeless movement missed
  • Rating scale has inter-rater reliability >0.90 [Norhoff et al. Movement Disorders 1999 14/3; 404-416]
definition of catatonia
Definition of catatonia
  • First described by Kahlbaum in 1874 as a specific motor dysfunction, phase of progressive illness including stages of mania, depression, psychosis ending in dementia
  • Includes 3 distinct categories of symptoms: hypo/hyperkinetic, affective & behavioral
  • Excellent review by Taylor & Fink AMJP 2003; 160:1233-41
classic signs of catatonia
Classic signs of catatonia
  • StuporExtreme hypoactivity, immobility, minimally responsive to stimuli (including pain)
  • MutismVerbally minimally responsive
  • NegativismInvoluntary/amotivational resistance, oppositional behavior (Gegenhalten)
additional signs
Additional signs
  • Automatic obedienceExaggerated cooperation with examiner’s request; mitgehen
  • StereotypyRepetitive, non-goal-directed motor acitivity, echopraxia, echolalia, verbigeration
  • Catalepsy/PosturingMaintains postures ie. pillow-sign,waxy flexibility
other sx
Other sx
  • Excitement
  • Staring
  • Grimacing
  • Mannerisms: odd, purposeful movements
  • Rigidity
  • Impulsivity
  • Ambitendency (alternating cooperation and opposition)
  • Combativeness
dsm iv specifier of schizophrenia mood disorder or general medical condition
DSM IV => specifier of schizophrenia, mood disorder or general medical condition

2 out of following 5 criteria:

  • Motoric immobility ( catalepsy, waxy flexibility, stupor)
  • Excessive motor activity (purposeless, not influenced by external stimuli)
  • Extreme negativism (rigid posture, resistance to instructions, gegenhalten, mutism)
  • Peculiarities of voluntary movement (grimacing, bizarre postures, stereotyped movements)
  • Echolalia or echopraxia
fink s proposed catatonia classification
Diagnostic criteria:

Immobility, mutism or stupor for at least 1 hour + one of the following:Catalepsy, automatic obedience, posturing, observed or elicited at least twice

In the absence of immobility, mutism or stupor, need to observe or elicit at least twice at least two of the following: stereotypy, echophenomena, catalepsy, automatic obedience, posturing, negativism, ambitendency


Non-malignant catatonia: criteria A

Delirious mania (excited catatonia): criteria B + severe mania or excitement

Malignant catatonia A or B + fever and autonomic instability


2/2 Mood disorder

2/2 General medical condition or toxic state

2/2 a Brain disorder

2/2 Psychotic disorder

Fink’s proposed catatonia classification
malignant catatonia
Malignant Catatonia
  • Dopamine loss, sympathetic overdrive lead to hyperadrenergic state.
  • Tachycardia, fever (hotness of body), hypertension, diaphoresis ensue
  • Increased vagal tone in the heart stimulates mechanoreceptors, which in turn modulate sympathetic tone -> hypotension, bradycardia, and even asystole…
clinical features of mc nms
Clinical features of MC/NMS
  • Fever
  • Muscle rigidity
  • Dyskinesia
  • Posturing, waxy flexibility, catalepsy, mutism
  • Dysarthria, dysphagia, sialorrhea
  • Altered consciousness, may appear comatose
  • Autonomic instability: lability of blood pressure, tachycardia, vasoconstriction, diaphoresis
early signs of mc nms
Early signs of MC/NMS
  • Mania with fever
  • Any catatonic features within 24h of antipsychotic initiation
  • Autonomic instability or sialorrhea within 24 h of antipsychotic initiation
  • Rapidly developed EPS symptoms with administration of low dose of antipsychotic
drugs associated with mc nms
All antipsychotics


ATD combined with AP




Valproic acid



Abrupt withdrawal from antipsychotic

dopamine agonists BZDantihistaminesanticholinergics

Intoxication with:disulfiramcorticosteroidsPCP, cocaineantihistaminergicsanticholinergics

Drugs associated with MC/NMS
abnormal labs in mc nms


Very high CPK

High LDH

Leukocytosis (10-25k)


Low serum iron

Diffuse EEG slowing

Abnormal electrolytes:Low calciumLow magnesiumHigh potassium

Elevated LFTs:AST, ALT, rarely bilirubin

Abnormal labs in MC/NMS
clinical risk factors for mc nms

Exposure to high temperatures



Basal ganglia disorder:TDakathisia

EPS from Rx

Past hx catatonia

Past hx NMS

Receiving high potency AP or >1 AP

IM antipsychotic

AP + ATD or mood stabilizers

Recent alcohol abuse with liver dysfunction

Clinical risk factors for MC/NMS
most commonly associated with psychiatric disorders
Most commonly associated with psychiatric disorders
  • Bipolar and schizophrenia
  • Withdrawal from dopaminergic medications or cocaine (also implicated in NMS)
  • Withdrawal from BZD (must exclude nonconvulsive status epilepticus)
  • Medical causes (up to 16%)
medical conditions associated with catatonia
Medical conditions associated with catatonia
  • Endocrinopathies: hypoparathyroidism, thyrotoxicosis, pheochromocytoma
  • Infections: viral, HIV, typhoid fever
  • Tumors: esp fronto-temporal lesions
  • Stroke: esp anterior brain regions
  • Traumatic brain injuries: subdural hematoma
  • Epilepsy: post-ictal immobility & NCSE
  • Autoimmune: SLE
  • Heat stroke
  • Toxins: tetanus, staph., fluoride, strychnine
  • Poisoning: salicylates, inhalational anesthesics
false positives
False positives
  • Mutism alone is not sufficient; need at least 1 or 2 other motor symptoms
  • Stupor alone is not sufficient (EEG)
  • Parkinson disease, in particular akinetic parkinsonism, OCD, tic disorder, Tourette syndrome
  • Malignant hyperthermia (rare AD genetic d/o)
  • Stiff-person syndrome and locked-in syndrome
catatonia has a good prognosis
Catatonia has a good prognosis
  • No RCTs of in Rx of catatonia
  • Management is well-defined
  • Important to treat emergently, as catatonia can evolve in life-threatening condition
  • “When properly treated almost all episodes of catatonia fully resolve” Fink & Taylor
  • “Most likely cause of failure is … prolonged inadequate treatment” Fink & Taylor
treatment of catatonia
Treatment of catatonia
  • Benzodiazepines, most studied are lorazepam and clonazepam at high doses: 70% response within 4 days
  • ECT bilateral usually 8- 15 sessions 3x/week
  • Benzodiazepines suspend the symptoms; ECT treats underlying disease
  • Antipsychotics ineffective, often detrimental
acute management
Acute management
  • Hospitalization
  • BZD challenge
  • BZD treatment trial
  • Maintain fluid and electrolyte balance
  • Avoid antipsychotic agents
  • Avoid prolonged immobility
  • Identify and correct underlying neuropsychiatric or medical cause
  • If not improved in 4 days => ECT
  • Tx may be augmented with NMDA antagonists amantadine or memantine
  • Common
  • Signs are easily identifiable
  • Many faces
  • NMS is a form of malignant catatonia
  • Differential diagnosis
  • Syndrome of motor dysregulation
  • Good-prognosis condition
  • Easy to treat