Management of Catatonia

Introduction to Catatonia

Catatonia is a syndrome characterized by psychomotor disturbances, including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia, according to the American Academy of Child and Adolescent Psychiatry 1, 2
Key diagnostic features include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, and stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia 1, 2

Underlying psychiatric disorders, such as mood disorders and schizophrenia, medical conditions affecting brain function, medication effects, and genetic/neurobiological vulnerabilities are primary risk factors for developing catatonia 3
Mood disorders, such as bipolar disorder and severe depression, are associated with an increased risk of developing catatonia 3
Pre-existing functional neurological disorders, dementia, neurodegenerative diseases, multiple sclerosis, demyelinating diseases, cerebrovascular events, and traumatic brain injury are also risk factors for catatonia 3, 4, 5, 6, 7
Viral infections affecting the central nervous system, such as encephalitis, and post-viral syndromes can increase the risk of developing catatonia 6, 8
Severe psychological stress, significant adverse life events, interpersonal conflicts, hypervigilance, excessive self-monitoring, and fear-avoidance behaviors are associated with an increased risk of catatonia 3
Genetic vulnerabilities and neurobiological predispositions affecting GABA and glutamate systems, as well as lower stress resilience and emotional inhibition, may contribute to the development of catatonia 3

Midazolam 2.5-5 mg IV or SC may be used as an alternative to lorazepam for the treatment of catatonia 9
Electroconvulsive therapy (ECT) is a treatment option for various psychiatric conditions, including catatonia, as indicated by the American Academy of Child and Adolescent Psychiatry 10
ECT is indicated when benzodiazepines fail or in severe cases, according to the American Academy of Child and Adolescent Psychiatry 10, 11
ECT is particularly effective in elderly patients with catatonia and should be administered in a specialized setting with appropriate monitoring, as recommended by the American Academy of Child and Adolescent Psychiatry 2, 11

The American Academy of Emergency Medicine recommends ruling out underlying medical causes, including infections, medication effects, metabolic disturbances, neurological conditions, and autoimmune disorders, particularly in elderly patients 12
Patients receiving ECT should be monitored for cognitive side effects and assessed for tardive seizures within 24 hours post-ECT, as recommended by the American Academy of Child and Adolescent Psychiatry 11

ECT requires a second opinion from a psychiatrist knowledgeable about ECT, and anesthesia should be administered by qualified personnel, according to the American Academy of Child and Adolescent Psychiatry 11
ECT procedure specifics for elderly patients include the use of methohexital for anesthesia, succinylcholine for muscle relaxation, and atropine or glycopyrrolate to prevent vagal bradycardia, with close monitoring for adverse effects, as recommended by the American Academy of Child and Adolescent Psychiatry 11

Patients with bipolar disorder or schizophrenia experiencing acute exacerbation, those recently started on or with dosage changes in antipsychotic medications, patients with autoimmune disorders affecting the central nervous system, and patients experiencing abrupt discontinuation of benzodiazepines or clozapine are at high risk of developing catatonia, according to the American Academy of Child and Adolescent Psychiatry 3