Catatonia: causes, symptoms and treatment of this syndrome

It is possible that we have ever seen in a movie, read in a book or even seen in real life some psychiatric patients who remain in a state of absence, rigid and immobile, mute and unreactive, being able to be placed by third parties in any imaginable posture and remaining in said posture like a doll of wax.

This state is what is called catatonia, a mainly motor syndrome of various causes and that affects patients with different types of mental and medical disorders.

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Catatonia as a syndrome: concept and symptoms

Catatonia is a neuropsychological syndrome in which a series of psychomotor symptoms are produced, often accompanied by cognitive, consciousness and perception alterations.

The most characteristic symptoms of this syndrome are the presence of catalepsy or inability to move due to a state of muscular rigidity that prevents muscle contraction, waxy flexibility (a state of passive resistance in which the subject does not flex the joints by himself, remaining as it is if he is placed in a certain way with the same posture and position to unless it is changed and in which the members of the body remain in any position in which another person leaves them), mutism, negativism before the attempt to make the subject perform any action, ecosymptoms (or automatic repetition / imitation of the actions and words carried out by the interlocutor), stereotypes, perseverance, agitation, lack of response to the environment or stupor.

Its diagnosis requires at least three of the aforementioned symptoms, for at least twenty-four hours. As a general rule, it is presented anosognosia regarding motor symptoms.

Some psychological symptoms

Subjects with this alteration often have intense emotionality, difficult to control, both positively and negatively. Although motor immobility is characteristic, patients occasionally emerge from it in an emotional state of great intensity and with a high level of movement and agitation that can lead to self-harm or assault others. Despite their anosognosia regarding their motor symptoms, they are nonetheless aware of their emotions and the intensity with which they occur.

Catatonia can occur in different degrees of greater or lesser severity, producing alterations in the vital functioning of the patient that can make it difficult to adapt to the environment.

Yes OK the prognosis is good if it begins to be treated soonIn some cases it can be chronic and can even be fatal in certain circumstances.

Presentation patterns

Two typical presentation patterns can be observed, one called stuporous or slow catatonia and another called agitated or delusional catatonia.

The first one is characterized by a state of stupor in which there is an absence of functions related to the environment; the individual remains paralyzed and absent from the environment, the common symptoms being catalepsy, waxy flexibility, mutism, and negativism.

With regard to agitated or delusional catatonia, it is characterized by symptoms more linked to arousal such as ecosymptoms, the performance of stereotyped movements and states of agitation.

Possible causes of catatonia

The causes of catatonia can be very diverse. Considered as a neuropsychological syndrome the presence of alterations in the nervous system must be taken into account.

Research shows that patients with catatonia have some type of dysfunction in part of the right posterior parietal cortex, which is consistent with the fact that people with catatonia are able to initiate movements correctly (in a that the supplementary motor area usually remains preserved) and the fact that there is anosognosia with respect to the symptoms engines. The prefrontal The lower lateral side of these subjects also tends to present alterations, as well as the medial orbitofrontal, which also explains the presence of occasional raptus and emotional alterations.

At the hormonal level, the role of GABA, which has been revealed altered in patients with catatonia by presenting a lower level of attachment to brain structures. Glutamate, serotonin and the dopamine also seem to play a role in this disorder, but a higher level of research is needed as to how exactly they influence.

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Potential organic causes

One of the first causes that should be explored in the first place is the organic type, as catatonia is a symptom present in a large number of neurological disorders. In this sense we can find that temporal lobe epilepsy, encephalitis, brain tumors, and strokes there are possible causes of this syndrome that should be treated immediately.

In addition to this, infections such as septicemia or those produced by tuberculosis, malaria, syphilis or HIV can also cause this state. Liver and kidney failure, hypothyroidism, severe complications of diabetes such as ketoacytosis or even severe hypothermia are other conditions that have been linked to the appearance of catatonia

Other biological causes can be derived from the consumption and / or abuse of psychoactive substances, be they drugs or psychotropic drugs. For example, catatonia is common in neuroleptic malignant syndrome, severe and life-threatening syndrome that in some cases appears after administration of antipsychotics.

Causes from psychodynamics

In addition to the above causes, some authors related to the Freudian tradition have proposed that in some cases catatonia may have symbolic psychological aspects as a cause.

Specifically, it has been proposed that catatonia may appear as a regression to a primitive state as a defense mechanism against traumatic or terrifying stimuli. Also used is the explanation that it can also occur as a dissociation response (which is actually seen in some patients with PTSD).

However, it must be borne in mind that these explanations start from an epistemology far from the scientific, and therefore are no longer considered valid.

Mental disorders in which it appears

Catatonia has long been a syndrome that has been identified with a subtype of schizophrenia, catatonic schizophrenia. However, the presence of this syndrome has also been observed in numerous disorders, both mental and organic in origin.

Some of the different disorders to which it has been linked are the following.

1. Schizophrenia and other psychotic disorders

It is the type of condition to which catatonia has traditionally been linked, to the point that catatonia has been considered a specific subtype of schizophrenia. On the fringes of schizophrenia may appear in other disorders such as Brief Psychotic Disorder.

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2. Mood disorders

Although it has been linked to schizophrenia almost since its inception, the different studies carried out regarding the catatonia seem to indicate that a high number of catatonic patients present some type of disorder of the state of the cheer up, especially in manic or depressive episodes. It can be specified both in depressive disorder and in bipolar.

3. Post Traumatic Stress Disorder

Post-Traumatic Stress Disorder has also been occasionally associated with catatonic states.

4. Substance use, intoxication or withdrawal

Uncontrolled administration or cessation of certain substances with effect on the brain, it can cause catatonia.

5. Autism spectrum disorder

Some children with developmental disorders such as autism may have catatonia comorbidly.

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Consideration today

Today the latest revision of one of the main diagnostic manuals in psychology, the DSM-5, has removed this label as a subtype of schizophrenia to make catatonia an indicator or modifier of the diagnosis of both this and other disorders (such as mood disorders). Likewise, the classification as a neuropsychological syndrome has been added separately from other disorders.

Treatment to apply

Because the etiology (causes) of catatonia can be diverse, the treatments to be applied will depend largely on what causes it. Its origin must be analyzed and act differently depending on what it is.. Apart from this, the symptoms of catatonia can be treated in different ways.

At the pharmacological level the high utility of benzodiazepines, which act as GABA agonists in acute cases. The effects of this treatment can reverse the symptoms of most patients. One of the most effective ones is lorazepam, which is in fact the first-line treatment.

Although it may seem due to its link with schizophrenia that the application of antipsychotics can be useful, the truth is that it can be harmful (remember that catatonia can appear in neuroleptic malignant syndrome that is precisely caused by the administration of said drugs).

Another therapy used is electro-convulsive therapy, although it is usually applied if treatment with benzodiazepines does not provoke a response. The possibility of jointly using benzodiazepines and electro-convulsive therapy is also considered, since the effects can be enhanced.

On a psychological level occupational therapy can be performed to stimulate the patient, as well as psychoeducation for the patient and her environment in order to provide them with information and strategies for action and prevention. The treatment of affective symptoms is also of great help, especially in cases derived from psychiatric disorders.

Bibliographic references:

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. DSM-V. Masson, Barcelona.

• Arias, S. and Arias, M. (2008) Catatonia: Darkness, Dilemma, Contradiction. Spanish Journal of Movement Disorders; 9: 18-23.

• Crespo, M.L. & Pérez, V. (2005). Catatonia: a neuropsychiatric syndrome. Colombian Journal of Psychiatry. vol. XXXIV, 2. Bogota