Catatonia DSM-5

What is catatonia?

Catatonia is a complex neuropsychiatric syndrome characterized by unusual physical and behavioral symptoms. It was first described in the late 19th century by German psychiatrist Karl Ludwig Kahlbaum, who originally named it "catatonic stupor." The word "catatonia" comes from the Greek words kata (meaning down) and tonos (meaning tension or tone), reflecting the state of reduced movement and increased muscle tone seen in affected individuals.

Types of catatonia

There are several types of catatonia, each with its own set of symptoms and characteristics. These include:

Malignant catatonia

Malignant catatonia is a severe and life-threatening form of catatonia. It can develop rapidly and is often associated with acute psychiatric illnesses or severe medical conditions. Symptoms of malignant catatonia include fever, autonomic instability, and delirium.

Akinetic catatonia

Akinetic catatonia, or retarded catatonia, is characterized by a state of immobility and unresponsiveness. It can be caused by various factors, including psychiatric disorders like schizophrenia or medical conditions like Parkinson's disease.

Excited catatonia

Excited catatonia is also known as "agitated" or "stuporous" catatonia. This type of catatonia is often associated with manic episodes in individuals with bipolar disorder. Symptoms may include rapid movements, agitation, and aggressive behaviors.

Note that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not recognize these subtypes; instead, it classifies catatonia into three categories.

Causes and symptoms

Some theorize that catatonia may be caused by an imbalance in the brain's dopamine and serotonin levels, which are neurotransmitters responsible for regulating mood, movement, and cognition (Daniels, 2009; Burrow et al., 2021). Others suggest that it may be related to dysfunction in the gamma-aminobutyric acid (GABA) system, which helps regulate muscle tone and movement (Northoff et al., 1999).

The symptoms of catatonia can vary greatly depending on the underlying cause and individual factors. However, some common symptoms include:

• Stupor or immobility: A person with catatonia may remain in a rigid, motionless state for extended periods of time.
• Mutism: Some individuals with catatonia may not speak at all or may only speak in short phrases.
• Waxy flexibility: In this symptom, a person's body can be easily moved into different positions and will remain in that position until moved again.
• Catenation: This refers to the tendency for a person with catatonia to move their limbs in specific patterns repeatedly.
• Agitation: On the other end of the spectrum, some individuals may display repetitive, purposeless movements or agitation.
• Echolalia and echopraxia: These symptoms involve repeating words or phrases spoken by others (echolalia) or mimicking their movements (echopraxia).
• Negativism: Some individuals with catatonia may display opposition to all instructions or attempts to move them.
• Grimacing: Catatonic individuals may also make facial expressions that do not match their emotions or the situation.
• Inappropriate or unusual postures: This can include holding the body in a twisted position or assuming a bizarre posture for extended periods of time.

Risk factors

Several factors can increase the risk of developing catatonia, including:

• A history of psychiatric disorders such as schizophrenia, bipolar disorder, or major depressive disorder.
• A history of neurological conditions such as Parkinson's disease or epilepsy.
• Substance use disorders, particularly long-term and heavy alcohol or sedative use.
• Medical illnesses that can affect brain function, such as infections or autoimmune disorders.

What are the DSM-5 criteria for catatonia?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders outlines criteria for catatonia distinguished into three categories (American Psychiatric Association, 2013-a):

• Catatonia associated with another mental disorder (catatonia specifier): This involves significant psychomotor disturbances found in conditions such as neurodevelopmental disorders, psychosis, bipolar disorder, depression, and other mental illnesses.
• Catatonic disorder due to another medical condition: Causes can include encephalitis, traumatic brain injury, and other medical issues.
• Unspecified catatonia: Cases that do not fit into the aforementioned categories.

Differences between DSM-IV and DSM-5 criteria

Various changes were made in the DSM-5 regarding the criteria for catatonia compared to the fourth edition (DSM-IV). Some of these changes include (American Psychiatric Association, 2013-b):

• The same criteria are used to diagnose catatonia regardless of whether the context is a psychotic, bipolar, depressive, or other medical disorder or an unidentified medical condition.
• In DSM-IV, two out of five symptom clusters were required if the context was a psychotic or mood disorder. Only one symptom cluster was needed if the context was a general medical condition.
• In DSM-5, all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms).
• Catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders, a separate diagnosis in the context of another medical condition or another specified diagnosis.

Treatments for catatonia

The treatment of catatonia depends on the underlying cause and severity of symptoms. Treatment options may include:

• Benzodiazepines: These medications can be used to help alleviate acute catatonic symptoms, such as agitation and muscle rigidity.
• Electroconvulsive therapy (ECT): This procedure involves using electrical currents to stimulate the brain in order to trigger a seizure.
• Antipsychotic medications: These medications may be used to treat underlying psychotic symptoms and can help alleviate catatonic symptoms as well.
• Zolpidem: This medication has been found to be effective in treating catatonia in some cases.
• Glutamate antagonists: These medications have shown promising results in treating catatonia, particularly in those with comorbid medical conditions.
• Supportive care: For individuals with severe catatonia, supportive care in a hospital setting may be necessary. This can include monitoring vital signs, providing nutrition and hydration, and ensuring safety.

References

American Psychiatric Association. (2013-a). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychiatric Association. (2013-b). Highlights of changes from DSM-IV-TR to DSM-5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf

Ariza-Salamanca, D. F., Corrales-Hernández, M. G., Pachón-Londoño, M. J., & Hernández-Duarte, I. (2022). Molecular and cellular mechanisms leading to catatonia: An integrative approach from clinical and preclinical evidence. Frontiers in Molecular Neuroscience, 15. https://doi.org/10.3389/fnmol.2022.993671

Burrow, J. P., Spurling, B. C., & Marwaha, R. (2023). Catatonia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430842/

Daniels, J. (2009). Catatonia: Clinical aspects and neurobiological correlates. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(4), 371–380. https://doi.org/10.1176/jnp.2009.21.4.371

Northoff, G., Steinke, R., Czcervenka, C., Krause, R., Ulrich, S., Danos, P., Kropf, D., Otto, H., & Bogerts, B. (1999). Decreased density of GABA-A receptors in the left sensorimotor cortex in akinetic catatonia: Investigation of in vivo benzodiazepine receptor binding. Journal of Neurology, Neurosurgery, and Psychiatry, 67(4), 445–450. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1736556/