Editores: Sadock, Benjamin J.; Sadock, Virginia A.

; Ruiz, Pedro
Título: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th Edition
Copyright ©2017 Lippincott Williams & Wilkins

> Table of Contents > Volume I > 12 - Schizophrenia and Other Psychotic Disorders > 12.17 - Other Psychotic Disorders > Catatonia

Catatonia

History
Catatonia was originally described by the German psychiatrist Karl Kahlbaum in 1870s as a distinct mental disorder with
psychiatric, motor, and behavioral symptoms. Although, originally, Kahlbaum considered catatonia to have an overall
benign course, reports of chronic catatonia led later psychiatrists, including Kraepelin, to reconsider and view catatonia
as a chronic disorder similar to hebephrenia. This view of catatonia contributed to Kraepelin's proposal that catatonia be
viewed as a subtype of dementia praecox. While Kraepelin recognized that catatonic symptoms could occur in mood
disease and organic disorders, he distinguished between catatonic dementia praecox and catatonic symptoms occurring
in other disorders.

This view of catatonia as a distinct subtype of schizophrenia dominated modern classification systems including the
DSM and ICD. Multiple editions of DSM through DSM-IV-TR and ICD-10 discussed catatonia as a subtype of
schizophrenia. DSM-III-R introduced the catatonic features specifier for mood disorders when the clinical picture of a
mood disorder episode is dominated by two or more catatonic symptoms. The category of catatonic disorder due to a
general medical condition was introduced in DSM-IV. Furthermore, the ICD-10 recognized a category of organic catatonic
disorder in addition to catatonic schizophrenia.

In a clear break from the Kraepelinian conception of catatonia as subtype of schizophrenia, DSM-5 introduced a separate
rubric for catatonia. This change was motivated by evidence regarding the occurrence of catatonia in a number of other
psychiatric and medical disorders besides schizophrenia and mood disorders and evidence of under-recognition of
catatonia in current psychiatric practice. The manual recognized three types of catatonia: (1) catatonia associated with
another mental disorder, (2) catatonic disorder due to another medical condition, and (3) unspecified catatonia. Although
DSM-5 did not recognize catatonia as an “independent class,” many scholars view catatonia as a discrete entity that is
distinct from the psychotic disorders.

Epidemiology
Epidemiologic research on prevalence, incidence, and correlates of catatonia has been hampered by differences in
definition and method of assessment of catatonia. A review of 20th century studies found that catatonia was reported in
7 to 17 percent of patients hospitalized with acute psychotic disorders and 13 to 31 percent of patients with mood
disorders. There is some evidence that the prevalence of catatonic type of schizophrenia may have declined over the 20th
century and that catatonia may be more common in developing countries than industrialized countries. Catatonia may be
seen in individuals of all ages, including children and adolescents. Gender and age distributions of patients with catatonia
likely reflect the epidemiology of the underlying disorder.

Etiology
The etiology of catatonia is unknown. The long and growing list of medical conditions associated with catatonia
underscores the potential heterogeneity in the etiology of catatonia. The list includes major neurologic disorders such as
epilepsy, encephalitis and trauma, endocrine disorders including thyroid disease, metabolic disturbances
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such as uremia and hypercalcemia, paraneoplastic disorders, folate deficiency, and autoimmune diseases. Catatonia can
also occur in the context of a number of mental disorders, including psychotic and mood disorders and
neurodevelopmental disorders including autism spectrum disorder.

It is plausible that these different conditions are the distal causes that work through a common mechanism to produce
catatonic symptoms. The favorable response of the disorder to GABAergic treatments (e.g., benzodiazepines) points to a
role of GABA system in catatonia. There is also a growing interest in the role of the NMDA receptors in catatonia based
on numerous case reports associating anti-NMDA receptor antibody encephalitis with catatonic symptoms.

Diagnostic and Clinical Features

The essential feature of catatonia is a psychomotor disturbance that may involve decreased engagement with the
interviewer during clinical interview or physical examination, decreased motor activity, or excessive and peculiar motor
activity. The psychomotor disturbance may range from marked unresponsiveness to environmental stimuli (stupor) to
marked agitation. In some cases, the individual's symptoms may quickly switch between decreased motor activity and
excessive motor activity, making the diagnosis difficult. Some of the peculiar motor and verbal symptoms such as
catalepsy (holding a posture induced by the examiner), posturing (active adoption of often awkward postures by the
patient), waxy flexibility (slight resistance when the examiner tries to position the patient's body parts), mannerism (odd
or caricature-like mimicking of normal actions), grimacing, echolalia, and echopraxia (mimicking another person's speech
or behavior) are more pathognomonic and helpful for the diagnosis of a catatonic syndrome. During severe stages of
immobility or increased activity, the individual may need careful supervision to prevent dehydration, malnutrition,
exhaustion, hyperpyrexia, aspiration, embolic events, decubiti, or contractures of extremities. Self-inflicted injuries and
harm to others can also occur, particularly during periods of increased activity.

The DSM-5 diagnosis of catatonia requires that the clinical picture be dominated by at least 3 of the 12 characteristic
symptoms including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation,
grimacing, echolalia, and echopraxia. The diagnosis of catatonia associated with another medical condition also requires
evidence from clinical history, physical examination, or laboratory examinations findings (including imaging studies) that
the catatonic symptoms are caused by another medical condition, that they are not better explained by another mental
disorder and do not occur exclusively during the course of delirium, and that the symptoms cause significant distress or
impairment in social or occupational functioning.

In coding catatonia associated with another mental disorders or medical disorder, the name of the associated mental or
medical disorder is recorded first, followed by the specifiers “catatonia associated with…” in the case of mental disorders
(e.g., “major depressive disorder; catatonia associated with major depressive disorder”) or “catatonic disorder due to…” in
the case of medical conditions (e.g., “hypothyroidism; catatonic disorder due to hypothyroidism”).

The residual category of unspecified catatonia is reserved for situations in which the catatonic symptoms are present
and cause clinically significant distress or impairment. However, either the number of symptoms does not reach the
minimum required of three symptoms, the underlying medical or mental disorder is not clear or there is insufficient
information regarding the underlying cause (e.g., in the emergency department settings).

Differential Diagnosis
Movement disturbances are common during the course of a delirium or neuroleptic malignant syndrome and a separate
diagnosis of catatonic disorder due to another medical condition is not justified in these cases. Catatonia-like symptoms
are not uncommon among patients treated with antipsychotic medication (e.g., neuroleptic-induced acute dystonia).
History of recent exposure to medications, especially first-generation antipsychotic medications, may help in
distinguishing these diagnostic possibilities. Generalized rigidity is a cardinal feature of neuroleptic malignant syndrome,
in which significant increases in creatine kinase levels are common. Autonomic instability and increases in temperature
can be seen in individuals with catatonia, but these findings are typically more severe in neuroleptic malignant syndrome
and can be potentially life-threatening.

Course and Prognosis

Catatonic symptoms sometimes remit with the management of the underlying psychiatric or medical condition. However,
many individuals will also require specific treatment of the catatonic syndrome. Although a rare type of remitting and
relapsing catatonia, known as “periodic catatonia” has been described in classic European literature, the majority of
cases of catatonia do not have a recurring course. Catatonic symptoms are especially responsive to treatment with high
doses of benzodiazepines and ECT, which may be indicated as the main or adjunctive treatment in the acute
management of psychiatric patients presenting with severe catatonic symptoms. Use of antipsychotic medications,
particularly high-potency first-generation antipsychotic medications, in individuals with catatonia may worsen outcomes.