Background
- Independent Dx (but often erroneously Dx "schizophrenia")
- Variable from transient subtle behavioural abnormalities to malignant ±lethal
- Fluctuate from stupor to mutism to severe agitation
- Hx/Ex may be difficult as patients with catatonia do not interact with surroundings or people
Clinical
Onset of catatonia, in EM stetting, usually acute (hours).
| Sign | Psychomotor Activity |
Definition |
|---|---|---|
| Staring | Mildly ↓ | Fixed gaze, ↓ blinking |
| Stupor | ⇓⇓ | No motor activity, not responsive to external stimuli |
| Mutism | ⇓⇓ | Incomprehensible speech or none |
| Posturing | AbN. | Spontaneous maintenance of a posture for minutes or hours |
| Less common | ||
| Ambitendency | ↓ | Indecisive, hesitant movements due to conflicting goals; patient appears to be stuck |
| Negativism | AbN. | Contrary behaviour to that requested |
| Stereotypy | AbN. | Repetitive, non–goal-directed motor behaviour |
| Rigidity | Moderately AbN. | Resistance through ↑muscle tone (varies mild to lead-pipe rigidity) |
| Agitation | ⇑⇑⇑ | Nonpurposeful movements, hyperactivity, or uncontrollable emotional Rxns |
| Grimacing | AbN. | Distorted facial expressions, inappropriate to the situation |
| Mannerisms | AbN. | Odd, purposeful movements, inappropriate to the patient |
| Rare | ||
| Echolalia | Severe AbN. | Imitating examiner's words |
| Echopraxia | Severe AbN. | Imitating examiner's actions |
| Verbigeration | Severe AbN. | Continuous and directionless repetition of words, phrases, or sentences |
| Waxy flexibility | Severe AbN. | Slight and even resistance to positioning by examiner |
| Catalepsy | Severe AbN. | Passive induction of a posture, which remains held against gravity |
DDx
- Intoxication (cannabis, cocaine)
- Withdrawal (alcohol, opioids, benzodiazepines)
- NMS
- Serotonin synd.
- Acute psychosis
- Epilepsy
- Delirium
- Encephalopathy/encephalitis
ED hints
- Commonest in the ED are mutism and stupor
- DDx quiet delirium (fluctuating alertness and cognition)
- Actively seek/exclude other causes of poor interaction (anger, language difficulties, trauma related dissociation)
- Rapidly fluctuating levels of psychomotor behaviour usually drug (e.g. cocaine) related
- If muscle rigidity consider:
- Serotonin synd.:
- Serotonergic drugs, sweat, ↑T°, ↑reflexes
- NMS:
- Dopamine antags., ↑T°, autonomic dysFxn)
- Serotonin synd.:
- Lorazepam (1-2mg IV) challenge effective in 90%
- Remission after Lorazepam wears off confirms catatonia Dx
Investigations
Management
- Lorazepam (1-2mg IV) challenge
- Hold dopamine antagonist
- Adequate hydration
- Regular Lorazepam
- If persistent, admit medical:
- Hydration, BP, thromboprophylaxis etc
- ECT is effective in >60%
- NMDA antagonists (amantadine/memantine)