Catatonia in General
What is Catatonia?
“Catatonia is a behavior syndrome of movement and mood, classically marked by stupor, mutism, posturing, rigidity and repetitive speech and acts. Usually acute in onset, its signs are recognizable, and when recognized, it can be successfully treated.”
Fink, M, Shorter, E (2018). The Madness of Fear: A History of Catatonia. Oxford University Press.
Catatonia is difficult to define in simple and concise terms due to its many expressions and various symptoms. It has been referred to in the literature as a neuropsychiatric or behavioral syndrome and as a psychomotor disorder. Both are accurate because Catatonia involves a set of associated symptoms that disrupt normal physical and mental functions.
“Catatonia is more than a movement disorder. It entails negativistic behavior [refusal to comply with requests] and psychotic ideation [perceiving or interpreting things differently from reality] as well as rigidity, immobility, posturing [spontaneous adoption of positions that are held for an abnormal length of time], muscle tension, stupor, agitation, tics, echolalia [repeating other's words], echopraxia [imitating other's movements] and mannerisms [exaggerated example of normal action.]” (Fink and Shorter, 2018, page 2).
A diagnosis of Catatonia does not require that all of the symptoms are exhibited by the patient. In fact, a diagnosis is typically made if three or more diagnostic symptoms are identified. The symptoms may wax and wane making a diagnosis difficult.
Catatonia is considered a brain disease and patients with this disease are frequently overwhelmed by fear, dread and anxiety. They experience psychotic symptoms and are out of touch with reality.
While Catatonia used to be associated with schizophrenia, it is now commonly known that Catatonia is NOT schizophrenia.
It's important to recognize that Catatonia has many expressions with certain symptoms commonly associated with each expression. Retarded (Akinetic) Catatonia involves immobility and stupor. Excited Catatonia involves delirium, disorientation and confusion. Agitated Catatonia is typically seen in patients with autism or developmental disorders and may involve self-injurious or unprovoked aggressive behavior. Malignant Catatonia has autonomic instability and may be brought on by certain medications. Catatonia may also be associated with anti-NMDA receptor encephalitis or COVID-19.
One of the common features of all the expressions of Catatonia is that it typically comes on suddenly and the behaviors are extremely out of character for the person exhibiting them. This should raise suspicion for Catatonia.
Click here for a description of the different expressions of Catatonia.
Click here for a description of the symptoms of Catatonia and how to diagnose it.
Catatonia typically responds to the benzodiazepine Lorazepam (Ativan) and electroconvulsive therapy (ECT). It is important to note that the symptoms of patients with Catatonia who are treated with antipsychotic medication may worsen.
The treatment options that may be also considered for Catatonia associated with anti-NMDA receptor encephalitis include high-dose steroids, IV immunoglobulin or plasma exchange.
Click here for more information about treatment options.
Catatonia and Fear
Catatonia is described as a movement and behavioral disorder but its cause is not well understood. The focus of healthcare professionals has been on diagnostic criteria based on the observation of a variety of movements and behaviors. Fear is a theme that comes up as a possible cause and it appears that suffering and distress seems to be prominent in patients with Catatonia.
Karl Kahlbaum, the German psychiatrist who formulated the syndrome of Catatonia in 1874, noticed that these patients conveyed impressions of profound mental anguish, or an immobility induced by severe mental shock.
Dr. Max Fink has expressed the idea that Catatonia is based in fear in his book, The Madness of Fear: The History of Catatonia and in recent articles.
“While it may seem that patients with Catatonia have either withdrawn into themselves or are caught in a web of delusion, there appears to be a preoccupation with heightened distress and active fears that fully occupy their consciousness.”
A few studies have addressed the patient’s experience during an episode of Catatonia by questioning them after their recovery. Patients have described intense emotions like fear and heightened anxiety that may be associated with a perceived impending danger, concerns about death and dying, missing close family and yearning to be with them, and a preoccupation with feeling trapped, embarrassed, rejected, or intense loneliness. Sometimes patients were not aware of how sick they were and what their symptoms were.
It has also been postulated that there is a correlation between Catatonia and intense fear associated with trauma. Several case studies have described the association of Catatonia with PTSD. In one case study, a 12-year old female patient had two life-threatening experiences. She presented with four of the 12 specified criteria for Catatonia in the DSM-5 prior to treatment with ECT and was discharged with complete improvement. Of note, there has been some discussion of whether refugees who have fled war torn countries and are diagnosed with resignation syndrome may have Catatonia.
Fear in patients with Catatonia and autism has also been mentioned in the literature. While no empirical studies have been done, it has been noted that sometimes Catatonia develops after severe psychological trauma or stressful events. It has been postulated that Catatonia may be an extreme motor reaction to fear in the autistic population and that they may be particularly vulnerable to Catatonia due to social, cognitive, and sensory deficits.
What’s the prevalence of Catatonia?
Based on reviews of the literature, statistics regarding the prevalence of Catatonia are highly variable. It is difficult to determine prevalence because of the lack of awareness and education of how to diagnose Catatonia.
A Dutch study found that clinicians identified Catatonia in only 2% of 139 patients, whereas a research team identified Catatonia in 18%.
This study looked at the number of patients in a specific group who were identified as having Catatonia by clinicians versus the number of patients in the same group who were identified as having Catatonia by a research team educated on the diagnostic criteria for making a diagnosis of Catatonia. In this study, clinicians identified Catatonia in only 2% of 139 patients, whereas an educated research team identified Catatonia in 18% of the same 139 patients.
We believe it’s important to try to accurately identify the prevalence of Catatonia as best as possible to address the commonly held belief that Catatonia is rare and therefore, not worthy of consideration as a possible diagnosis.
"14% of patients in the general hospital setting had signs of Catatonia."
- Dr. Max Fink
Prevalence
Note: There may be variations in statistical prevalence due to lack of awareness and education about Catatonia.