Catatonic Schizophrenia

Catatonic Schizophrenia was common many decades ago in North America and Europe but has now become rare. The core feature in is motor dysfunction.

The presentation of catatonia is varied. Commonly the patient presents with staring, not responding (mute), little or no movement for hours, poor nutrition and lack of self care.

He can also present with an opposite clinical picture ie repetitive, hyperactive non-goal directed activity. In this case, the patient is in danger of collapse through extreme fatigue.

Other symptoms include:

  • staring
  • muteness - no verbal communication
  • echolalia - repeating what is said to them
  • posturing - assuming an awkward posture for long periods
  • waxy flexibility - patients posture can be 'moulded' often in awkward positions which they hold for long periods
  • negativism - they are resistive to being physically moved
  • rigidity - their posture is rigid
  • echopraxia - they copy movements
  • stupor - this is when they are absolutely non responsive or minimally responsive with non sensical speech
  • excitement - this is non directed, disorganised and repetitive
  • immobility - maintaining the same posture for long periods
  • grimacing
  • stereotypy - repetitive non-goal directed movmements

Typically there is poor self care with poor oral intake and poor self care. If patients are looking after themselves, then this diagnosis is unlikely.

Autonomic dysfunction is also possible. This means that blood pressure, pulse, temperature can be erratic and dangerously high.

Patients are at danger from self inflicted injuries and malnutrition.

If there is inadequate response to medication, then catatonia is an indication for urgent ECT (electro-convulsive therapy).



Catatonia
As we see above, catatonic schizophrenia presents with catatonia, of which there are varied patterns of motor presenations. But catatonic schizophrenia is not the only disorder that presents with catatonia or catatonic symptoms. In fact only about 10% of patients will have psychiatric disorders and only a minority of these will have schizpohrenia. A far larger proportion of patients with catatonia will have medical and neurological disorders.

Patients with catatonia could have a range of possible diagnoses which include bipolar disorder, schizophrenia, schizo-affective disorder, neurological or medical disorders (such as non convulsive status epilepticus, encephalitis), and benzodiazapine withdrawal. There is a view that catatonia should have its own diagnostic category as a separate disorder, unrelated to schizophrenia.

This view is based on the observation that catatonia associated with bipolar disorder and schizo-affective disorder responded much better to a benzodiazepine than catatonia associated with schizophrenia. The vast majority will experience a dramatic improvement within 3 hours from being mute, non-responsive and immobile to almost normality.

The presence of catatonia has been recognised as being a risk factor for the development of neuroleptic malignant syndrome if patients are initially exposed to antipsychotic drugs while still catatonic.

Electroconvulsive therapy (ECT) may be considered if there is no response to benzodiazepines and there is an emergency. Emergencies occur when patients are not eating and drinking and in danger of starving themselves to death. The post partum period is also an emergency because this is the key period in which mother and the new born baby bond. In these cases, the mental health legislation will dictate the course to obtain consent for this, since the patient will be incapable of providing consent.

In patients receiving benzodizapines, always be aware of risk of patients developing respiratory arrest, sedation and falls.



Reference
Schiz Bull 36(2)239-242

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