catatonia catatonia catatonia is a complex neuropsychiatric behavioral syndrome that is characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal. the onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during episodes. it has historically been related to schizophrenia (catatonic schizophrenia), catatonia is most often seen in mood disorders. it is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurological, and medical conditions. catatonia is not a stand-alone diagnosis (although some experts disagree), and the term is used to describe a feature of the underlying disorder. not to be confused with katatonia, cataplexy, catalepsy, catalonia, or cataonia. catatoniaother namescatatonic syndromea patient in catatonic stuporspecialtypsychiatry, neurologysymptomsimmobility, mutism, staring, posturing, rigidity, low consciousness, etc.complicationsphysical trauma, malignant catatonia (autonomic instability, life-threatening), dehydration, pneumonia, pressure ulcers due to immobility, muscle contractions, dvt, pecausesunderlying illness (psychiatric, neurologic, or medical), brain injury/damage, certain drugs/medicationsdiagnostic methodclinical, lorazepam challengetreatmentbenzodiazepines (lorazepam challenge), ect there are several subtypes of catatonia: akinetic catatonia, excited catatonia, malignant catatonia, delirious mania, and self-injurious behaviors in autism. recognizing and treating catatonia is very important as failure to do so can lead to poor outcomes and can be potentially fatal. treatment with benzodiazepines or ect can lead to remission of catatonia. there is growing evidence of the effectiveness of the nmda receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia. antipsychotics are sometimes employed, but they can worsen symptoms and have serious adverse effects. signs and symptoms the presentation of a patient with catatonia varies greatly depending on the subtype and underlying cause, and can be acute or subtle. because most patients with catatonia have an underlying psychiatric illness, the majority will present with worsening depression, mania, or psychosis followed by catatonia symptoms. catatonia presents as a motor disturbance in which patients will display marked reduction in movement, marked agitation, or a mixture of both despite having the physical capacity to move normally. these patients may be unable to start an action or stop one. movements and mannerisms may be repetitive, or purposeless. the most common signs of catatonia are immobility, mutism, withdrawal and refusal to eat, staring, negativism, posturing (rigidity), rigidity, waxy flexibility/catalepsy, stereotypy (purposeless, repetitive movements), echolalia or echopraxia, verbigeration (repeat meaningless phrases). it should not be assumed that patients presenting with catatonia are unaware of their surroundings as some patients can recall in detail their catatonic state and their actions. there are several subtypes of catatonia and they are characterized by the specific movement disturbance and associated features. although catatonia can be divided into various subtypes, the natural history of catatonia is often fluctuant and different states can exist within the same individual. subtypes withdrawn catatonia: this form of catatonia is characterized by decreased response to external stimuli, immobility or inhibited movement, mutism, staring, posturing, and negativism. patients may sit or stand in the same position for hours, may hold odd positions, and may resist movement of their extremities. excited catatonia: excited catatonia is characterized by odd mannerisms/gestures, performing purposeless or inappropriate actions, excessive motor activity, restlessness, stereotypy, impulsivity, agitation, and combativeness. speech and actions may be repetitive or mimic another person's. people in this state are extremely hyperactive and may have delusions and hallucinations. catatonic excitement is commonly cited as one of the most dangerous mental states in psychiatry. malignant catatonia: malignant catatonia is a life-threatening condition that may progress rapidly within a few days. it is characterized by fever, abnormalities in blood pressure, heart rate, respiratory rate, diaphoresis (sweating), and delirium. certain lab findings are common with this presentation; however, they are nonspecific, which means that they are also present in other conditions and do not diagnose catatonia. these lab findings include: leukocytosis, elevated creatine kinase, low serum iron. the signs and symptoms of malignant catatonia overlap significantly with neuroleptic malignant syndrome (nms) and so a careful history, review of medications, and physical exam are critical to properly differentiate these conditions. for example, if the patient has waxy flexibility and holds a position against gravity when passively moved into that position, then it is likely catatonia. if the patient has a "lead-pipe rigidity" then nms should be the prime suspect. other forms: periodic catatonia is an inconsistently defined entity. in the wernicke-kleist-leonhard school, it is a distinct form of "non-system schizophrenia" characterized by recurrent acute phases with hyperkinetic and akinetic features and often psychotic symptoms, and the build-up of a residual state in between these acute phases, which is characterized by low-level catatonic features and aboulia of varying severity. the condition has a strong hereditary component. according to modern classifications, this may be diagnosed as a form of bipolar disorder, schizoaffective disorder or schizophrenia. independently, the term periodic catatonia is sometimes used in modern literature to describe a syndrome of recurrent phases of acute catatonia (excited or inhibited type) with full remission between episodes, which resembles the description of "motility psychosis" in the wernicke-kleist-leonhard school. system catatonias or systematic catatonias are only defined in the wernicke-kleist-leonhard school. these are chronic-progressive conditions characterized by specific disturbances of volition and psychomotricity, leading to a dramatic decline of executive and adaptive functioning and ability to communicate. they are considered forms of schizophrenia but distinct from other schizophrenic conditions. affective flattening and apparent loss of interests are common but may be related to reduced emotional expression rather than lack of emotion. heredity is low. of the 21 different forms (6 "simple" and 15 "combined" forms) that have been described, most overlap only partially - if at all - with current definitions of either catatonia or schizophrenia, and thus are difficult to classify according to modern diagnostic manuals. early childhood catatonias are also a diagnosis exclusive to the wernicke-kleist-leonhard school, and refers to system catatonias that manifest in young children. clinically, these conditions resemble severe regressive forms of autism. chronic catatonia-like breakdown or autistic catatonia refers to a functional decline seen in some patients with pre-existing autism spectrum disorder and/or intellectual disability which usually runs a chronic-progressive course and encompasses attenuated catatonic symptoms as well as mood and anxiety symptoms that increasingly interfere with adaptive functioning. onset is typically insidious and often mistaken for background autistic symptoms. slowing of voluntary movement, reduced speech, aboulia, increased prompt dependency and obsessive-compulsive symptoms are frequently seen; negativism, (auto-)aggressive behaviors and ill-defined hallucinations have also been reported. both the causes of this disorder as well as its prognosis appear to be heterogenous, with most patients showing partial recovery upon treatment. it seems to be related to chronic stress as a result of life transitions, loss of external time structuring, sensory sensitivities and/or traumatic experiences, co-morbid mental disorders, or other unknown causes. since clinical catatonia can not always be diagnosed, this condition has also been renamed to the more general term "late regression". complications patients may experience several complications from being in a catatonic state. the nature of these complications will depend on the type of catatonia being experienced by the patient. for example, patients presenting with withdrawn catatonia may have refusal to eat which will in turn lead to malnutrition and dehydration. furthermore, if immobility is a symptom the patient is presenting with, then they may develop pressure ulcers, muscle contractions, and are at risk of developing deep vein thrombosis (dvt) and pulmonary embolus (pe). patients with excited catatonia may be aggressive and violent, and physical trauma may result from this. catatonia may progress to the malignant type which will present with autonomic instability and may be life-threatening. other complications also include the development of pneumonia and neuroleptic malignant syndrome. causes catatonia is almost always secondary to another underlying illness, often a psychiatric disorder. mood disorders such as a bipolar disorder and depression are the most common etiologies to progress to catatonia. other psychiatric associations include schizophrenia and other primary psychotic disorders. it also is related to autism spectrum disorders. psychodynamic theorists have interpreted catatonia as a defense against the potentially destructive consequences of responsibility, and the passivity of the disorder provides relief. catatonia is also seen in many medical disorders, including infections (such as encephalitis), autoimmune disorders, meningitis, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia). pathogenesis the pathophysiology that leads to catatonia is still poorly understood and a definite mechanism remains unknown. neurologic studies have implicated several pathways; however, it remains unclear whether these findings are the cause or the consequence of the disorder. abnormalities in gaba, glutamate signaling, serotonin, and dopamine transmission are believed to be implicated in catatonia. furthermore, it has also been hypothesized that pathways that connect the basal ganglia with the cortex and thalamus is involved in the development of catatonia. diagnosis there is not yet a definitive consensus regarding diagnostic criteria of catatonia. in the american diagnostic and statistical manual of mental disorders, fifth edition (dsm-5) and the world health organization's eleventh edition of the international classification of disease (icd-11) the classification is more homogeneous than in earlier editions. prominent researchers in the field have other suggestions for diagnostic criteria. dsm-5 classification the dsm-5 does not classify catatonia as an independent disorder, but rather it classifies it as catatonia associated with another mental disorder, due to another medical condition, or as unspecified catatonia. catatonia is diagnosed by the presence of three or more of the following 12 psychomotor symptoms in association with a mental disorder, medical condition, or unspecified: stupor: no psycho-motor activity; not actively relating to the environment catalepsy: passive induction of a posture held against gravity waxy flexibility: allowing positioning by an examiner and maintaining that position mutism: no, or very little, verbal response (exclude if known aphasia) negativism: opposition or no response to instructions or external stimuli posturing: spontaneous and active maintenance of a posture against gravity mannerisms that are odd, circumstantial caricatures of normal actions stereotypy: repetitive, abnormally frequent, non-goal-directed movements agitation, not influenced by external stimuli grimacing: keeping a fixed facial expression echolalia: mimicking another's speech echopraxia: mimicking another's movements. other disorders (additional code 293.89 to indicate the presence of the co-morbid catatonia): catatonia associated with autism spectrum disorder catatonia associated with schizophrenia spectrum and other psychotic disorders catatonia associated with brief psychotic disorder catatonia associated with schizophreniform disorder catatonia associated with schizoaffective disorder catatonia associated with a substance-induced psychotic disorder catatonia associated with bipolar and related disorders catatonia associated with major depressive disorder catatonic disorder due to another medical condition if catatonic symptoms are present but do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered. icd-11 classification in icd-11 catatonia is defined as a syndrome of primarily psychomotor disturbances that is characterized by the simultaneous occurrence of several symptoms such as stupor; catalepsy; waxy flexibility; mutism; negativism; posturing; mannerisms; stereotypies; psychomotor agitation; grimacing; echolalia and echopraxia. catatonia may occur in the context of specific mental disorders, including mood disorders, schizophrenia or other primary psychotic disorders, and neurodevelopmental disorders, and may be induced by psychoactive substances, including medications. catatonia may also be caused by a medical condition not classified under mental, behavioral, or neurodevelopmental disorders. assessment/physical catatonia is often overlooked and under-diagnosed. patients with catatonia most commonly have an underlying psychiatric disorder, for this reason, physicians may overlook signs of catatonia due to the severity of the psychosis the patient is presenting with. furthermore, the patient may not be presenting with the common signs of catatonia such as mutism and posturing. additionally, the motor abnormalities seen in catatonia are also present in psychiatric disorders. for example, a patient with mania will show increased motor activity that may progress to exciting catatonia. one way in which physicians can differentiate between the two is to observe the motor abnormality. patients with mania present with increased goal-directed activity. on the other hand, the increased activity in catatonia is not goal-directed and often repetitive. catatonia is a clinical diagnosis and there is no specific laboratory test to diagnose it. however, certain testing can help determine what is causing the catatonia. an eeg will likely show diffuse slowing. if seizure activity is driving the syndrome, then an eeg would also be helpful in detecting this. ct or mri will not show catatonia; however, they might reveal abnormalities that might be leading to the syndrome. metabolic screens, inflammatory markers, or autoantibodies may reveal