The catatonia It is a psychomotor syndrome characterized by an apparent lack of responses to environmental stimuli, while the person is awake. These patients adopt a rigid posture, appear immobile and barely speak, being able to remain that way for hours, days and even weeks.
It occurs in children, adolescents and adults; and is associated with a wide variety of signs and symptoms related to the absence of voluntary movements and expression of thoughts.
It has traditionally been linked to schizophrenia, although it also appears in a wide variety of disorders, such as depression.
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Catatonia has a very diverse set of causes. Throughout history, several hypotheses have been established about its possible origin:
It seems that there is a relationship between poor fetal development of the cerebral cortex and schizophrenia or other developmental disorders.
These developmental problems can cause a malfunction in the glutamatergic pathways (of the neurotransmitter glutamate, very important in the central nervous system) causing the typical symptoms of catatonia..
Patients with mental retardation, autism, or other developmental disorders are more vulnerable to catatonia; since brain function is altered.
It seems that alterations in the connections between the spinal cord and the brainstem can produce this condition..
Links have been found between the administration of drugs that block postsynaptic dopamine receptors and the development of catatonia. While drugs that produce the opposite effect serve as treatment.
They have also found alterations in the neurotransmission of serotonin and norepinephrine associated with catatonia.
Some patients with catatonia appear to have a GABA deficiency in one of the areas of the brain that controls movement; since, when they take drugs that potentiate GABA (such as benzodiazepines) they improve their catatonia symptoms.
In a postmortem study, Kahlbaum found damage to the Silvio fissure and the frontal sulcus in human patients who died with catatonia. Precisely these areas are responsible for executive functions, as well as voluntary behaviors. However, it is difficult to draw conclusions from these investigations since the injury could have been produced after the appearance of catatonia..
More research is needed to gradually get closer to a more accurate explanation of catatonia, and, therefore, to a better prevention and treatment.
Not all patients with catatonia react in the same way. Three different presentation subtypes of catatonia can be distinguished:
The patient is in an apathetic, immobile state, without reacting to the stimuli of his environment. They stare blankly, without making eye contact. They are usually in rigid positions and do not speak, being able to remain that way for long periods of time.
These people are excited, active and energetic. However, all his movements seem to have no purpose. It is also common for them to experience delusions or hallucinations.
It is the most serious case, and it can lead to death. It arises when the syndrome is complicated by various reasons and there is a metabolic decompensation. Fever, rhabdomyolysis, kidney failure, heart failure, etc. may appear.
A good way to know what the symptoms of a person with catatonia are like is through real cases. You will then be able to better understand what this condition is like with these two cases taken from Wilcox and Reid Duffy (2015) (names are fictitious).
Pablo suffered from chronic bipolar disorder, so he had times when he was extremely energetic and active, while in others he was down and sad.
It all started at age 37 through a period of depression. He did not want to eat, he did not speak and he refused to get out of bed. His family took him to the hospital, and there he only got up from his chair with physical help. Still, he was passively resisting any change in movement.
Another characteristic that it presented was that when they managed to change the position of his arms, he could keep them immobile for 5 or 10 minutes, even if the posture was uncomfortable..
Sonia is 52 years old and had suffered from schizoaffective disorder for 30 years. It is typical of this disorder to have symptoms of both schizophrenia and depression or bipolarity. He had already suffered three episodes of catatonia in the past.
For a week she began to feel very nervous, with a huge increase in purposeless activity. According to the family, he had been walking rapidly from one part of the house to another incessantly. In addition, he was repeating unintelligible words and phrases for hours.
Upon arriving at the emergency room, he spent several hours shouting "peanut butter, ice cream, peanut butter, ice cream ...". The repetition of incoherent words or phrases is very typical of catatonia and is known as "verbigeration.".
After four days, this patient calmed down and remained immobilized, with a rigid posture, and stopped speaking.
There are a wide variety of neurological disorders, psychiatric, psychological and medical conditions that are related to catatonia. Here are some of them:
- Schizophrenia, in fact, it has been estimated that 35% of schizophrenics have presented catatonia.
- Neuroleptic malignant syndrome, that produced by starting or changing a neuroleptic medication. These drugs act on the nervous system by modifying dopamine levels, which, as we mentioned, its alteration can induce catatonia.
- Affective disorders such as depression and bipolar disorder.
- Mental retardation
- Autism
- Generalized development issue
- Encephalitis
- Temporal lobe epilepsy
- Multiple sclerosis
- Parkinsonism
- Subarachnoid hemorrhage
- Wilson disease
- HIV
- Tumors (in the corpus callosum or subthalamic), etc..
Once catatonia has been diagnosed, the most widely used treatments are drugs and electroconvulsive therapy. A quick start is essential, as these patients may not eat or suffer complications from exhaustion. Parenteral feeding may be necessary if patient refuses to eat.
It is important to first assess for neuroleptic malignant syndrome, encephalitis, epilepsy or acute psychosis to treat these conditions as soon as possible because they are a medical emergency.
The most commonly used medications in people with catatonia are benzodiazepines such as clonazepam and lorazepam, carbamazepine, tricyclic antidepressants, muscle relaxants, reserpine (antipsychotic), lithium carbonate, bromocriptine, thyroid hormone, and neuroleptics (as a last resort, for the possible development of neuroleptic malignant syndrome).
In the first 48-72 hours after starting treatment with lorazepam, approximately 70 or 80% of patients show improvement (Crespo and Pérez, 2005).
On the other hand, if patients do not respond well to the mentioned medications or develop malignant catatonia, electroconvulsive therapy is chosen. Mainly very effective for teenagers with catatonic schizophrenia.
However, it is necessary to ensure that the patient abandons the consumption of alcohol and other drugs, since they reduce the effectiveness of the treatment..
In general, the prognosis for catatonia is good if it is intervened quickly. Although if more than four days pass without changes or improvement in symptoms, the risk of mortality increases significantly. In the long term, the progression of catatonia depends on the condition that caused it..
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