Catatonia

This article is about the catatonic state. For other uses, see Catatonia (disambiguation).

Not to be confused with Katatonia, cataplexy, catalepsy, Catalonia, or Cataonia.

Catatonia
Other names	Catatonic syndrome
A patient in catatonic stupor
Specialty	Psychiatry, neurology
Symptoms	Immobility, mutism, staring, posturing, rigidity, low consciousness, etc.
Complications	Physical trauma, malignant catatonia (autonomic instability, life-threatening), dehydration, pneumonia, pressure ulcers due to immobility, muscle contractions, deep vein thrombosis (DVT) [1] and pulmonary embolism (PE) [1]
Causes	Underlying illness (psychiatric, neurologic, or medical), brain injury/damage, certain drugs/medications
Diagnostic method	Clinical, lorazepam challenge
Treatment	Benzodiazepines (lorazepam challenge), electroconvulsive therapy (ECT) [1]

Catatonia is a complex syndrome, most commonly seen in people with underlying mood (e.g major depressive disorder) or psychotic disorders (e.g schizophrenia). ^{[2] [3]} People with catatonia have abnormal movement and behaviors, which vary from person to person and fluctuate in intensity within a single episode. ^[4] People with catatonia appear withdrawn, meaning that they do not interact with the outside world and have difficulty processing information. ^[5] They may be nearly motionless for days on end or perform repetitive purposeless movements. Two people may exhibit very different sets of behaviors and both still be diagnosed with catatonia. Treatment with benzodiazepines or ECT are most effective and lead to remission of symptoms in most cases. ^[3]

There are different subtypes of catatonia, which represent groups of symptoms that commonly occur together. These include stuporous/akinetic catatonia, excited catatonia, malignant catatonia, and periodic catatonia. ^[6]

Catatonia has historically been related to schizophrenia (catatonic schizophrenia), but is most often seen in mood disorders. ^[3] It is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurological, and medical conditions.

Classification

Modern Classifications

The ICD-11 is the most common manual used globally to define and diagnose illness, including mental illness. ^[7] It diagnoses catatonia in someone who has three different symptoms associated with catatonia at one time. These symptoms are called stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia. ^[8] It divides catatonia into three groups based on the underlying cause; Catatonia associated with another mental disorder, catatonia induced by psychoactive substance, and secondary catatonia.

The DSM-5 is the most common manual used by mental health professionals in the United States to define and diagnose different mental illnesses. The DSM-5 defines catatonia as, “a syndrome characterized by lack of movement and communication, along with three or more of the following 12 behaviors; stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, or echopraxia.” ^[9] As a syndrome, catatonia can only occur in people with an existing illness. The DSM-5 divides catatonia into 3 diagnoses. The most common of the three diagnoses is Catatonia Associated with Another Mental Disorder. Around 20% of cases are caused by an underlying medical condition, and known as Catatonic Disorder Due to Another Medical Condition. ^[10] When the underlying condition is unknown it is considered Unspecified Catatonia.

Signs and symptoms

As discussed previously, the ICD-11 and DSM-5 both require 3 or more of the symptoms defined in the table below in order to diagnose Catatonia. However, each person can have a different set of symptoms may worsen, improve, and change in appearance throughout a single episode. ^[4] Symptoms may develop over hours or days to weeks.

Symptom	Definition
Stupor	A marked lack of psychomotor activity; the individual appears immobile and unresponsive
Catalepsy	Passive induction of a posture held against gravity
Waxy Flexibility	Slight resistance to positioning by the examiner, allowing limbs to remain in imposed positions
Mutism	Lack of verbal response despite apparent alertness
Negativism	Resistance or no response to external instructions or stimuli
Posturing	Voluntary assumption of inappropriate or bizarre postures
Mannerism	Odd, exaggerated movements or behaviors
Stereotypy	Repetitive, non-goal-directed movements or gestures
Agitation	Restlessness or excessive motor activity without external stimulus
Grimacing	Facial contortions or expressions unrelated to emotional context
Echolalia	Mimicking or repeating another person’s speech
Echopraxia	Mimicking or imitating another person’s movements

Because most patients with catatonia have an underlying psychiatric illness, the majority will present with worsening depression, mania, or psychosis followed by catatonia symptoms. ^[3] Even when unable to interact, It should not be assumed that patients presenting with catatonia are unaware of their surroundings as some patients can recall in detail their catatonic state and their actions. ^[11]

Subtypes

There are several subtypes of catatonia which are used currently; Stuporous Catatonia, Excited Catatonia, Malignant Catatonia and Periodic Catatonia. Subtypes are defined by the group of symptoms and associated features that a person is experiencing or displaying. Notably, while catatonia can be divided into various subtypes, the appearance of catatonia is often dynamic and the same individual may have different subtypes at different times. ^[12]

Stuporous Catatonia: This form of catatonia is characterized by immobility, mutism, and a lack of response to the world around them. ^{[2] [3]} They may appear frozen in one position for long periods of time unable to eat, drink, or speak.

Excited Catatonia: This form of catatonia is characterized by odd mannerisms and gestures, purposeless or inappropriate actions, excessive motor activity, restlessness, stereotypy, impulsivity, agitation, and combativeness. Speech and actions may be repetitive or mimic another person's. ^{[2] [3] [11]} People in this state are extremely hyperactive and may have delusions and hallucinations. ^[13]

Malignant Catatonia: This form of catatonia is life threatening. It is characterized by fever, dramatic and rapid changes in blood pressure, increased heart rate and respiratory rate, and excessive sweating. ^{[2] [3]} Laboratory tests may be abnormal.

Periodic Catatonia: This form of catatonia is characterized by only by a person having recurrent episodes of catatonia. Individuals will experience multiple episodes over time, without signs of catatonia in between episodes. Historically, the Wernicke-Kleist-Leonhard School considered periodic catatonia a distinct form of "non-system schizophrenia" characterized by recurrent acute phases with hyperkinetic and akinetic features and often psychotic symptoms, and the build-up of a residual state in between these acute phases, which is characterized by low-level catatonic features and aboulia of varying severity.

Causes

Catatonia can only exist if a person has another underlying illness, and can be associated with a wide range of illnesses including psychiatric disorders, medical conditions, and substance use.

Psychiatric Conditions

Mood disorders such as a bipolar disorder and depression are the most common conditions underlying catatonia. ^[3] Other psychiatric conditions that can cause catatonia include schizophrenia and other primary psychotic disorders, ^[14] autism spectrum disorders, ADHD, ^[15] and Post-traumatic Stress Disorder. ^[16] In autism, people tend to present with catatonia during periods of regression. ^[17]

Psychodynamic theorists have interpreted catatonia as a defense against the potentially destructive consequences of responsibility, and the passivity of the disorder provides relief. ^[18]

Medical Conditions

Catatonia is also seen in many medical disorders, encephalitis, meningitis, autoimmune disorders, ^[19] focal neurological lesions (including strokes), ^[20] alcohol withdrawal, ^[21] abrupt or overly rapid benzodiazepine withdrawal, ^{[22] [23] [24]} cerebrovascular disease, neoplasms, head injury, ^[9] and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia). ^[9]

Neurological Disorders

Catatonia can occur due to a number of neurological conditions. For instance, certain types of encephalitis can cause catatonia. Anti-NMDA receptor encephalitis is a form of autoimmune encephalitis which is known to cause catatonia in some people. Additionally encephalitis has been reported to cause catatonia in people who have encephalitis due to HIV and Herpes Simplex Virus (HSV). The research is limited, but some evidence suggests that people can develop catatonia after traumatic brain injury without a primary psychiatric disorder. ^[25] Similarly, there are several case reports suggesting that people have experienced catatonia after a stroke, with some people having catatonia-associated symptoms that were unexplainable by their stroke itself, and which improved after treatment with benzodiazepines. ^{[26] [27]} Parkinson disease can cause catatonia for some people by impairing their ability to produce and secrete dopamine, a neurotransmitter which is thought to contribute to motor dysfunction in people with catatonia.

Metabolic and Endocrine Disorders

Abnormal thyroid function can cause catatonia when the thyroid overproduces or underproduces thyroid hormones. This is thought to occur due to thyroid hormones impact on metabolism including in the cells of the nervous system. Abnormal electrolyte levels have also been shown to cause catatonia in rare cases. Most notably low levels of sodium in the blood can cause catatonia in some people. ^{[28] [29] [30] [31]}

Autoimmune Disorders

As discussed previously, Anti-NMDA receptor encephalitis is a form of autoimmune encephalitis which can cause catatonia. Additionally, autoimmune diseases that are not exclusively neurological can cause neurological and psychiatric symptoms including catatonia. For instance, systemic lupus erythematosus can cause catatonia and is thought to do by causing inflammation in the blood vessels of the brain or possibly by the body's own antibodies damaging neurons.

Infectious Diseases

Certain types of infections are known to cause catatonia either through directly impairing brain function or by making a person more likely to contract diseases that impair brain function. HIV and AIDS can cause catatonia, most likely by predisposing one to infections in the brain, including different types of viral encephalitis. ^{[32] [33]} Borrelia burgdorferi causes Lyme disease, which has been shown to cause catatonia by infecting the brain and causing encephalitis. ^{[19] [34] [35] [36]}

Pharmacological Causes

Use of NMDA receptor antagonists including ketamine and phencyclidine (PCP) can lead to catatonia-like states. Information about these effects has improved scientific understanding of the role of glutamate in catatonia. High dose and chronic use of stimulants like Cocaine and Amphetamines can lead to cases of catatonia, typically associated with psychosis. This is thought to be due to changes in the function of circuits of the brain associated with dopamine release.

Pathogenesis

The mechanisms in the brain that cause catatonia are poorly understood. ^{[11] [37]} Currently, there are two main categories of explanations for what may be happening in the brain to cause catatonia. The first, is that there is disruption of normal neurotransmitter production or release in certain areas of the brain prevents normal function of those areas of the brain leading to behavioral and motor symptoms associated with catatonia. The second, claims that disruption of communication between different areas of the brain cause catatonia.

Neurotransmitters

The neurotransmitters that are most strongly associated with catatonia are GABA, dopamine, and glutamate. GABA is the main inhibitory neurotransmitter of the brain, meaning that it slows down the activity of the systems of the brain it acts on. In catatonia, people have low levels of GABA which causes them to be overly activated, especially in the areas of the brain that cause inhibition. This is thought to cause the behavioral symptoms associated with catatonia including withdrawal. Dopamine can increase or decrease the activity of the area of the brain it acts on depending on where in the brain it is. dopamine is lower than normal in people with catatonia, which is thought to cause a lot of the motor symptoms, because dopamine is the main neurotransmitter which activates the parts of the brain responsible for movement. Glutamate is an excitatory neurotransmitter, meaning that it increases the activity of the areas of the brain it acts on. Notably, glutamate increases tells the neuron it acts on to fire, by binding to the NMDA receptor. People with Anti-NMDA receptor encephalitis can develop catatonia, because their own antibodies attack the NMDA receptor, which reduces the ability of the brain to activate different areas of the brain using glutamate.

Neurological Pathways

Several pathways in the brain have been studied which seem to contribute to catatonia when they aren't functioning properly. ^[38] However, these studies were unable to determine if the abnormalities they observed were the cause of catatonia or if the catatonia caused the abnormalities. Furthermore, it has also been hypothesized that pathways that connect the basal ganglia with the cortex and thalamus is involved in the development of catatonia. ^[39]

Diagnosis

There is not yet a definitive consensus regarding diagnostic criteria of catatonia. In the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) and the World Health Organization's eleventh edition of the International Classification of Diseases ( ICD-11, 2022), the classification is more homogeneous than in earlier editions. Prominent researchers in the field have other suggestions for diagnostic criteria. ^[40] Still, diagnosing catatonia can be challenging. Evidence suggests that there is as high as a 15 day average delay to diagnosis for people with catatonia.

DSM-5 classification

The DSM-5 does not classify catatonia as an independent disorder, but rather it classifies it as catatonia associated with another mental disorder, due to another medical condition, or as unspecified catatonia. ^{[41] [42] : 134–5}

Catatonia is diagnosed by the presence of three or more of the following 12 psychomotor symptoms in association with a mental disorder, medical condition, or unspecified: ^{[41] : 135}

• stupor: no psycho-motor activity; not actively relating to the environment
• catalepsy: passive induction of a posture held against gravity
• waxy flexibility: allowing positioning by an examiner and maintaining that position
• mutism: no, or very little, verbal response (exclude if known aphasia)
• negativism: opposition or no response to instructions or external stimuli
• posturing: spontaneous and active maintenance of a posture against gravity
• mannerisms that are odd, circumstantial caricatures of normal actions
• stereotypy: repetitive, abnormally frequent, non-goal-directed movements
• agitation, not influenced by external stimuli
• grimacing: keeping a fixed facial expression
• echolalia: mimicking another's speech
• echopraxia: mimicking another's movements.

Other disorders (additional code 293.89 [F06.1] to indicate the presence of the co-morbid catatonia):

• Catatonia associated with autism spectrum disorder ^{[41] : 57}
• Catatonia associated with schizophrenia spectrum and other psychotic disorders
  • Catatonia associated with brief psychotic disorder ^{[41] : 109}
  • Catatonia associated with schizophreniform disorder ^{[41] : 111}
  • Catatonia associated with schizoaffective disorder ^{[41] : 121}
  • Catatonia associated with a substance-induced psychotic disorder
• Catatonia associated with bipolar and related disorders ^{[41] : 142}
• Catatonia associated with major depressive disorder ^{[41] : 185}
• Catatonic disorder due to another medical condition ^{[41] : 136–7}

If catatonic symptoms are present but do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered. ^[43]

ICD-11 classification

In ICD-11 catatonia is defined as a syndrome of primarily psychomotor disturbances that is characterized by the simultaneous occurrence of several symptoms such as stupor; catalepsy; waxy flexibility; mutism; negativism; posturing; mannerisms; stereotypies; psychomotor agitation; grimacing; echolalia and echopraxia. Catatonia may occur in the context of specific mental disorders, including mood disorders, schizophrenia or other primary psychotic disorders, and Neurodevelopmental disorders, and may be induced by psychoactive substances, including medications. Catatonia may also be caused by a medical condition not classified under mental, behavioral, or neurodevelopmental disorders.

Assessment/Physical

Catatonia is often overlooked and under-diagnosed. ^[44] Patients with catatonia most commonly have an underlying psychiatric disorder, for this reason, physicians may overlook signs of catatonia due to the severity of the psychosis the patient is presenting with. Furthermore, the patient may not be presenting with the common signs of catatonia such as mutism and posturing. Additionally, the motor abnormalities seen in catatonia are also present in psychiatric disorders. For example, a patient with mania will show increased motor activity and may not be considered for a diagnosis of Excited Catatonia, even if symptoms are developing that are not associated with mania. One way in which physicians can differentiate between the two is to observe the motor abnormality. Patients with mania present with increased goal-directed activity. On the other hand, the increased activity in catatonia is not goal-directed and often repetitive. ^[3]

Catatonia is a clinical diagnosis and there is no specific laboratory test to diagnose it. However, certain testing can help determine what is causing the catatonia. An EEG will likely show diffuse slowing. If seizure activity is driving the syndrome, then an EEG would also be helpful in detecting this. CT or MRI will not show catatonia; however, they might reveal abnormalities that might be leading to the syndrome. Metabolic screens, inflammatory markers, or autoantibodies may reveal reversible medical causes of catatonia. ^[3]

Vital signs should be frequently monitored as catatonia can progress to malignant catatonia which is life-threatening. Malignant catatonia is characterized by fever, hypertension, tachycardia, and tachypnea. ^[3]

Rating scale

Various rating scales for catatonia have been developed, however, their utility for clinical care has not been well established. ^[45] The most commonly used scale is the Bush-Francis Catatonia Rating Scale (BFCRS) (external link is provided below). ^[46] The scale is composed of 23 items with the first 14 items being used as the screening tool. If 2 of the 14 are positive, this prompts for further evaluation and completion of the remaining 9 items.

A diagnosis can be supported by the lorazepam challenge ^[47] or the zolpidem challenge. ^[48] While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT.

Laboratory Findings

Certain lab findings are common with this malignant catatonia that are uncommon in other forms of catatonia. These lab findings include: leukocytosis, elevated creatine kinase, low serum iron. The signs and symptoms of malignant catatonia overlap significantly with neuroleptic malignant syndrome (NMS). Therefore the results of laboratory tests need to be considered in the context of clinical history, review of medications, and physical exam findings.

Differential diagnosis

The differential diagnosis of catatonia is extensive as signs and symptoms of catatonia may overlap significantly with those of other conditions. Therefore, a careful and detailed history, medication review, and physical exam are key to diagnosing catatonia and differentiating it from other conditions. Furthermore, some of these conditions can themselves lead to catatonia. The differential diagnosis is as follows:

• Neuroleptic malignant syndrome (NMS) and catatonia are both life-threatening conditions that share many of the same characteristics including fever, autonomic instability, rigidity, and delirium. ^[49] Lab values of low serum iron, elevated creatine kinase, and white blood cell count are also shared by the two disorders further complicating the diagnosis. There are features of malignant catatonia (posturing, impulsivity, etc.) that are absent from NMS and the lab results are not as consistent in malignant catatonia as they are in NMS. Some experts consider NMS to be a drug-induced condition associated with antipsychotics, particularly, first generation antipsychotics, ^[49] but it has not been established as a subtype. ^[50] Therefore, discontinuing antipsychotics and starting benzodiazepines is a treatment for this condition, and similarly it is helpful in catatonia as well.
• Anti-NMDA receptor encephalitis is an autoimmune disorder characterized by neuropsychiatric features and the presence of IgG antibodies. ^[51] The presentation of anti-NMDAR encephalitis has been categorized into 5 phases: prodromal phase, psychotic phase, unresponsive phase, hyperkinetic phase, and recovery phase. The psychotic phase progresses into the unresponsive phase characterized by mutism, decreased motor activity, and catatonia. ^[51]
• Both serotonin syndrome and malignant catatonia may present with signs and symptoms of delirium, autonomic instability, hyperthermia, and rigidity. Again, similar to the presentation in NMS. However, patients with Serotonin syndrome have a history of ingestion of serotonergic drugs (Ex: SSRI). These patients will also present with hyperreflexia, myoclonus, nausea, vomiting, and diarrhea. ^[52]
• Malignant hyperthermia and malignant catatonia share features of autonomic instability, hyperthermia, and rigidity. However, malignant hyperthermia is a hereditary disorder of skeletal muscle that makes these patients susceptible to exposure to halogenated anesthetics and/or depolarizing muscle relaxants like succinylcholine. ^[53] Malignant hyperthermia most commonly occurs in the intraoperative or postoperative periods. Other signs and symptoms of malignant hyperthermia include metabolic and respiratory acidosis, hyperkalemia, and cardiac arrhythmias.
• Akinetic mutism is a neurological disorder characterized by a decrease in goal-directed behavior and motivation; however, the patient has an intact level of consciousness. ^[54] Patients may present with apathy, and may seem indifferent to pain, hunger, or thirst. Akinetic mutism has been associated with structural damage in a variety of brain areas. ^[55] Akinetic mutism and catatonia may both manifest with immobility, mutism, and waxy flexibility. Differentiating both disorders is the fact that akinetic mutism does not present with echolalia, echopraxia, or posturing. Furthermore, it is not responsive to benzodiazepines as is the case for catatonia.
• Elective mutism has an anxious etiology but has also been associated with personality disorders. ^[56] Patients with this disorder fail to speak with some individuals but will speak with others. Likewise, they may refuse to speak in certain situations; for example, a child who refuses to speak at school but is conversational at home. This disorder is distinguished from catatonia by the absence of any other signs/symptoms.
• Nonconvulsive status epilepticus is seizure activity with no accompanying tonic-clonic movements. ^[57] It can present with stupor, similar to catatonia, and they both respond to benzodiazepines. Nonconvulsive status epilepticus is diagnosed by the presence of seizure activity seen on electroencephalogram (EEG). ^[58] Catatonia on the other hand, is associated with normal EEG or diffuse slowing.
• Delirium is characterized by fluctuating disturbed perception and consciousness in the ill individual. ^[59] It has hypoactive and hyperactive or mixed forms. People with hyperactive delirium present similarly to those with excited catatonia and have symptoms of restlessness, agitation, and aggression. Those with hypoactive delirium present with similarly to retarded catatonia, withdrawn and quiet. However, catatonia also includes other distinguishing features including posturing and rigidity as well as a positive response to benzodiazepines.
• Patients with locked-in syndrome present with immobility and mutism; however, unlike patients with catatonia who are unmotivated to communicate, patients with locked-in syndrome try to communicate with eye movements and blinking. Furthermore, locked-in syndrome is caused by damage to the brainstem. ^[60]
• Stiff-person syndrome and catatonia are similar in that they may both present with rigidity, autonomic instability and a positive response to benzodiazepines. ^[61] However, stiff-person syndrome may be associated with anti-glutamic acid decarboxylase (anti-GAD) antibodies ^{[62] [63]} and other catatonic signs such as mutism and posturing are not part of the syndrome.
• Untreated late-stage Parkinson's disease may present similarly to retarded catatonia with symptoms of immobility, rigidity, and difficulty speaking. Further complicating the diagnosis is the fact that many patients with Parkinson's disease will have major depressive disorder, which may be the underlying cause of catatonia. Parkinson's disease can be distinguished from catatonia by a positive response to levodopa. Catatonia on the other hand will show a positive response to benzodiazepines.
• Extrapyramidal side effects of antipsychotic medication, especially dystonia and akathisia, can be difficult to distinguish from catatonic symptoms, or may confound them in the psychiatric setting. Extrapyramidal motor disorders usually do not involve social symptoms like negativism, while individuals with catatonic excitement typically do not have the physically painful compulsion to move that is seen in akathisia. ^[64]
• Certain stimming behaviors and stress responses in individuals with autism spectrum disorders can present similarly to catatonia. In autism spectrum disorders, chronic catatonia is distinguished by a lasting deterioration of adaptive skills from the background of pre-existing autistic symptomatology that cannot be easily explained. Acute catatonia is usually clearly distinguishable from autistic symptoms. ^[65]
• The diagnostic entities of obsessional slowness and psychogenic parkinsonism show overlapping features with catatonia, such as motor slowness, gegenhalten (oppositional paratonia), mannerisms, and reduced or absent speech. However, psychogenic parkinsonism involves tremor which is unusual in catatonia. ^[66] Obsessional slowness is a controversial diagnosis, with presentations ranging from severe but common manifestations of obsessive compulsive disorder to catatonia. ^[67]
• Down Syndrome Disintegrative Disorder (or Down Syndrome Regression Disorder, DSDD / DSRD) is a chronic condition characterized by loss of previously acquired adaptive, cognitive and social functioning occurring in persons with Down Syndrome, usually during adolescence or early adulthood. The clinical picture is variable, but often includes catatonic signs, which is why it was called "catatonic psychosis" in initial reports in 1946. ^[68] DSDD seems to phenotypically overlap with obsessional slowness (see above) ^[69] and catatonia-like regression occurring in ASD. ^[70]

Treatment

Treating catatonia effectively requires treating the catatonia itself, treating the underlying condition, and helping them with their basic needs, like eating, drinking, and staying clean and safe, while they are withdrawn and incapable of caring for themselves.

Catatonia-Specific Treatments

The specifics of treating catatonia itself can vary from region to region, hospital to hospital, and individual to individual, but typically involves the use of benzodiazepines. In fact, in some cases it is unclear whether a person has catatonia or another condition which may present similarly. In these cases a "benzodiazepine challenge" is often done. During a "benzodiazepine challenge" a healtchare provider will give a moderate dose of a benzodiazepine to the patient and monitor them. If a person has catatonia they will often have improvements in their symptoms within 15 to 30 minutes. If the person doesn't improve within 30 minutes they're given a second dose and the process is repeated once more. If the person responds to either of the doses then they can be given benzodiazepines at a consistent dose and timing until their catatonia resolves. Depending on the person, a person may need to reduce their dosing slowly over time in order to prevent reoccurrence of their symptoms.

ECT is also commonly used to treat catatonia in people who don't improve with medication alone or whose symptoms reoccur whenever the dose of medications are reduced. ECT is usually administered with multiple sessions per week over two to four weeks. ^[71] ECT has a success rate of 80% to 100%. ^[72] ECT is effective for all subtypes of catatonia, however people who have catatonia with an underlying neurological condition show less improvement with ECT treatment. ^{[72] [47]}

Excessive glutamate activity is believed to be involved in catatonia; ^[73] when first-line treatment options fail, NMDA antagonists such as amantadine or memantine may be used. Amantadine may have an increased incidence of tolerance with prolonged use and can cause psychosis, due to its additional effects on the dopamine system. Memantine has a more targeted pharmacological profile for the glutamate system, reduced incidence of psychosis and may therefore be preferred for individuals who cannot tolerate amantadine. Topiramate is another treatment option for resistant catatonia; it produces its therapeutic effects by producing glutamate antagonism via modulation of AMPA receptors. ^[74]

Non-Specific Aspects of Treatment

Treating the Underlying Condition

There are many medications that are known to cause catatonia in some people including steroids, stimulants, anticonvulsants, neuroleptics or dopamine blockers. ^[3] If a person has catatonia and is on these medications, they should be considered as a potential cause if another cause is not apparent and discontinued if possible.

Antipsychotics are sometimes used in those with a co-existing psychosis, however they should be used with care as they may worsen catatonia and have a risk of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate discontinuation of the antipsychotic. ^{[14] [4]} There is evidence that clozapine works better than other antipsychotics to treat catatonia. ^{[73] [4]}

Supportive Care

Supportive care is required in those with catatonia. This includes monitoring vital signs and fluid status, and in those with chronic symptoms; maintaining nutrition and hydration, medications to prevent a blood clot, and measures to prevent the development of pressure ulcers. ^[4]

Prognosis

Twenty-five percent of psychiatric patients with catatonia will have more than one episode throughout their lives. ^[4] Treatment response for patients with catatonia is 50–70%, with treatment failure being associated with a poor prognosis. Many of these patients will require long-term and continuous mental health care. The prognosis for people with catatonia due to schizophrenia is much worse compared to other causes. ^[3] In cases of catatonia that develop into malignant catatonia, the mortality rate is as high as 20%. ^[75]

Complications

Patients may experience several complications from being in a catatonic state. The nature of these complications will depend on the type of catatonia being experienced by the patient. For example, patients presenting with withdrawn catatonia may have refusal to eat which will in turn lead to malnutrition and dehydration. ^[44] Furthermore, if immobility is a symptom the patient is presenting with, then they may develop pressure ulcers, muscle contractions, and are at risk of developing deep vein thrombosis (DVT) and pulmonary embolus (PE). ^[44] Patients with excited catatonia may be aggressive and violent, and physical trauma may result from this. Catatonia may progress to the malignant type which will present with autonomic instability and may be life-threatening. Other complications also include the development of pneumonia and neuroleptic malignant syndrome. ^[3]

Epidemiology

Catatonia has been historically studied in psychiatric patients. ^[76] Catatonia is under-recognized because the features are often mistaken for other disorders including delirium or the negative symptoms of schizophrenia. The prevalence has been reported to be as high as 10% in those with acute psychiatric illnesses, and 9–30% in the setting of inpatient psychiatric care. ^{[4] [77] [11]} The incidence of catatonia is 10.6 episodes per 100 000 person-years, which essentially means that in a group of 100,000 people, the group as a whole would experience 10 to 11 episodes of catatonia per year. ^[78] Catatonia can occur at any age, but is most commonly seen in adolescence or young adulthood or in older adults with existing medical conditions. It occurs in males and females in approximately equal numbers. ^{[79] [78]} Around 20% of all catatonia cases can be attributed to a general medical condition. ^{[10] [44]}

Underlying Condition	Proportion of Catatonia Cases
Mood Disorders	20–40%
Major Depressive Disorder	15–20%
Bipolar Disorder	15–20%
Psychotic Disorders	20–30%
Schizophrenia	10–15%
Schizoaffective Disorder	5–10%
Autism Spectrum Disorder	5–10%
Medical Conditions	~20%

History

Ancient History

There have been reports of stupor-like and catatonia-like states in people throughout the history of psychiatry. ^[80] In ancient Greece, the first physician to document stupor-like or catatonia-like states was Hippocrates, in his Aphorisms. ^{[81] [82]} He never defined the syndrome, but seemingly observed these states in people he was treating for melancholia. In ancient China, the first descriptions of people that appear in the Huangdi Neijing (The Yellow Emperor's Inner Canon), ^[83] which the book which forms the basis of Traditional Chinese Medicine. It is thought to have been compiled by many people over the course of centuries during the Warring States Period (475-221 BCE) and the early Han Dynasty (206 BCE-220 CE).

Modern History

The term “catatonia” was first used by, German psychiatrist, Karl Ludwig Kahlbaum in 1874, in his book Die Katatonie oder das Spannungsirresein, which translates to "Catatonia or Tension Insanity". ^[84] He viewed catatonia as its own illness, which would get worse over time in stages of mania, depression, and psychosis leading to dementia. This work heavily influenced another German psychiatrist, Emil Kraeplin, who was the first to classify catatonia as a syndrome. Kraeplin associated catatonia with a psychotic disorder called dementia praecox, which is no longer used as a diagnosis, but heavily informed the development of the concept of schizophrenia.

Kraeplin’s work influenced two other notable German psychiatrists Karl Leonhard and Max Fink and their colleagues to expand the concept of catatonia as a syndrome which could occur in the setting of many mental illnesses not just psychotic disorders. They also laid the groundwork to describe different subtypes of catatonia still used today, including Stuporous Catatonia, Excited Catatonia, Malignant Catatonia, and Periodic Catatonia. Additionally, Leonhard and his colleagues categorized catatonia as either systematic or unsystematic, based on whether or not symptoms happened according to consistent and predictable patterns. These ways of thinking shaped the way that psychologists and psychiatrists thought of catatonia well into the 20th century. In fact, catatonia was a subtype of schizophrenia as recently as the DSM-III, and wasn't revised to be able to be applied to mood disorders until 1994 with the release of the DSM-IV.

In the latter half of the 20th century, clinicians observed that catatonia occurred in various psychiatric and medical conditions, not exclusively in schizophrenia. Max Fink and colleagues advocated for recognizing catatonia as an independent syndrome, highlighting its frequent association with mood disorders and responsiveness to treatments like benzodiazepines and ECT.

Society and Culture

Popular Conceptions and Origins

Catatonia, historically misunderstood, has been subject to shifting perceptions in society. As discussed previously, since the 19th century it was often linked exclusively to schizophrenia, perpetuating misconceptions. These historical misunderstandings have shaped the public opinions on catatonia. This has contributed to a lack of understanding about catatonia and its broader association with other mental disorders and medical conditions.

Popular culture and media have played a significant role in shaping societal perceptions of catatonia. In many cases, media portrayals reduce it to a stereotypical "frozen state," similar to a coma, failing to capture the complexity of symptoms like stupor, agitation, and mutism. Such oversimplifications contribute to public misperceptions and get in the way of people receiving the care they need.

See also

• Acquiescence
• Akinetic mutism
• Autistic catatonia
• Awakenings (1990 biopic about catatonic patients, based on Oliver Sacks's book of the same name)
• Blank expression
• Botulism
• Clouding of consciousness
• Disorganized schizophrenia
• Homecoming (features catatonia as a main plot point)
• Karolina Olsson
• Oneiroid syndrome
• Paranoid schizophrenia
• Persistent vegetative state
• Resignation syndrome
• Sensory overload
• Tonic immobility
• Sleep paralysis

References

1. Balaguer AP, Rivero IS (22 December 2021). "Electroconvulsive therapy, catatonia, deep vein thrombosis and anticoagulant treatment: a case report". General Psychiatry. 34 (6): e100666. doi:10.1136/gpsych-2021-100666. ISSN   2517-729X. PMC   8705197 . PMID   35028525.
2. Fink M, Taylor MA (1 November 2009). "The Catatonia Syndrome: Forgotten but Not Gone". Archives of General Psychiatry. 66 (11): 1173–7. doi:10.1001/archgenpsychiatry.2009.141. PMID   19884605.
3. Burrow JP, Spurling BC, Marwaha R (2022). "Catatonia". StatPearls. StatPearls Publishing. PMID   28613592.
4. Heckers S, Walther S (9 November 2023). "Catatonia". New England Journal of Medicine. 389 (19): 1797–1802. doi:10.1056/NEJMra2116304. PMID   37937779. S2CID   265673511.
5. Edinoff AN, Kaufman SE, Hollier JW, Virgen CG, Karam CA, Malone GW, Cornett EM, Kaye AM, Kaye AD (8 November 2021). "Catatonia: Clinical Overview of the Diagnosis, Treatment, and Clinical Challenges". Neurology International. 13 (4): 570–586. doi: 10.3390/neurolint13040057 . ISSN   2035-8385. PMC   8628989 . PMID   34842777.
6. "Catatonia treatment and prognosis". UpToDate. Retrieved 22 November 2024.
7. Harrison JE, Weber S, Jakob R, Chute CG (November 2021). "ICD-11: an international classification of diseases for the twenty-first century". BMC Medical Informatics and Decision Making. 21 (S6): 206. doi: 10.1186/s12911-021-01534-6 . ISSN   1472-6947. PMC   8577172 . PMID   34753471.
8. Reed GM, First MB, Kogan CS, Hyman SE, Gureje O, Gaebel W, Maj M, Stein DJ, Maercker A, Tyrer P, Claudino A, Garralda E, Salvador-Carulla L, Ray R, Saunders JB (2 January 2019). "Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders". World Psychiatry. 18 (1): 3–19. doi:10.1002/wps.20611. PMC   6313247 . PMID   30600616.
9. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp.  119–121. ISBN   978-0-89042-555-8.
10. Oldham MA (1 July 2018). "The Probability That Catatonia in the Hospital has a Medical Cause and the Relative Proportions of Its Causes: A Systematic Review". Psychosomatics. 59 (4): 333–340. doi:10.1016/j.psym.2018.04.001. ISSN   0033-3182. PMID   29776679.
11. Rasmussen SA, Mazurek MF, Rosebush PI (2016). "Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology". World Journal of Psychiatry. 6 (4): 391–8. doi: 10.5498/wjp.v6.i4.391 . PMC   5183991 . PMID   28078203.
12. Shorter E, Fink M (2018). The Madness of Fear: A History of Catatonia. Oxford University Press. ISBN   978-0-19-088119-1.
13. Nolen-Hoeksema S (2014). Abnormal Psychology. McGraw-Hill Education. p. 224. ISBN   978-1-259-06072-4.
14. Fink M, Taylor MA (2003). Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge University Press. ISBN   978-0-521-82226-8.^{[ page needed ]}
15. Dhossche DM, Rout U (2006). "Are Autistic and Catatonic Regression Related? A Few Working Hypotheses Involving Gaba, Purkinje Cell Survival, Neurogenesis, and ECT". International Review of Neurobiology. Vol. 72. pp. 55–79. doi:10.1016/S0074-7742(05)72004-3. ISBN   978-0-12-366873-8. PMID   16697291.
16. Ahmed GK, Elbeh K, Karim AA, Khedr EM (2021). "Case Report: Catatonia Associated With Post-traumatic Stress Disorder". Frontiers in Psychiatry. 12: 740436. doi: 10.3389/fpsyt.2021.740436 . ISSN   1664-0640. PMC   8688766 . PMID   34950066.
17. SafeMinds (29 November 2021). "Catatonia Associated with Late Regression in Autism". SafeMinds. Retrieved 22 November 2024.
18. Arieti S (1994). Interpretation of schizophrenia. Jason Aronson. ISBN   1-56821-209-7. OCLC   472906047.
19. Rogers JP, Pollak TA, Blackman G, David AS (July 2019). "Catatonia and the immune system: a review". The Lancet Psychiatry. 6 (7): 620–630. doi:10.1016/S2215-0366(19)30190-7. PMC   7185541 . PMID   31196793.
20. Haroche A, Rogers J, Plaze M, Gaillard R, Williams SC, Thomas P, Amad A (July 2020). "Brain imaging in catatonia: systematic review and directions for future research". Psychological Medicine. 50 (10): 1585–97. doi:10.1017/S0033291720001853. PMID   32539902. S2CID   219704600.
21. Geoffroy PA, Rolland B, Cottencin O (1 May 2012). "Catatonia and Alcohol Withdrawal: A Complex and Underestimated Syndrome". Alcohol and Alcoholism. 47 (3): 288–290. doi: 10.1093/alcalc/agr170 . PMID   22278315.
22. Rosebush PI, Mazurek MF (August 1996). "Catatonia after benzodiazepine withdrawal". Journal of Clinical Psychopharmacology. 16 (4): 315–9. doi:10.1097/00004714-199608000-00007. PMID   8835707.
23. Deuschle M, Lederbogen F (January 2001). "Benzodiazepine withdrawal-induced catatonia". Pharmacopsychiatry. 34 (1): 41–42. doi:10.1055/s-2001-15188. PMID   11229621. S2CID   260241781.
24. Kanemoto K, Miyamoto T, Abe R (September 1999). "Ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal". Seizure. 8 (6): 364–6. doi: 10.1053/seiz.1999.0309 . PMID   10512781. S2CID   17454162.
25. Berthelot J, Cambre J, Erwin M, Phan J (6 March 2024). Inada T (ed.). "Catatonia as a Result of a Traumatic Brain Injury". Case Reports in Psychiatry. 2024: 1–3. doi: 10.1155/2024/5184741 . ISSN   2090-6838. PMC   10937075 . PMID   38482162.
26. Koprucki S, Morcos R (18 September 2024). "Acute Catatonia Following a Cerebellar Stroke: A Case Report". Cureus. 16 (9): e69645. doi: 10.7759/cureus.69645 . ISSN   2168-8184. PMC   11488475 . PMID   39429282.
27. Hasan H, Abdo M, Rabei S (March 2023). "Post Cerebrovascular Stroke Catatonic Psychosis: A Case Report". European Psychiatry. 66 (S1): S1058. doi:10.1192/j.eurpsy.2023.2245. ISSN   0924-9338. PMC   10479261 .
28. McGuire E, Yohanathan M, Lally L, McCarthy G (14 July 2017). "Hyponatraemia-associated catatonia". BMJ Case Reports: bcr–2017–219487. doi:10.1136/bcr-2017-219487. ISSN   1757-790X. PMC   5534696 . PMID   28710304.
29. Peritogiannis V, Rizos DV (24 May 2021). "Catatonia Associated with Hyponatremia: Case Report and Brief Review of the Literature". Clinical Practice & Epidemiology in Mental Health. 17 (1): 26–30. doi:10.2174/1745017902117010026. ISSN   1745-0179. PMC   8227445 . PMID   34249136.
30. Mehta V, Sharma A, Sharma CB, Guria RT (December 2021). "Cerebral Salt Wasting Induced Hyponatraemia Presenting as Catatonia". Journal of the Royal College of Physicians of Edinburgh. 51 (4): 377–9. doi:10.4997/jrcpe.2021.413. ISSN   1478-2715. PMID   34882138.
31. Krueger A, Shebak SS, Kavuru B (12 November 2015). "Catatonia in the Setting of Hyponatremia". The Primary Care Companion for CNS Disorders. 17 (6): 26803. doi:10.4088/PCC.15l01808. ISSN   2155-7780. PMC   4805406 . PMID   27057405.
32. Volkow ND, Harper A, Munnisteri D, Clother J (1 January 1987). "AIDS and catatonia". Journal of Neurology, Neurosurgery & Psychiatry. 50 (1): 104. doi:10.1136/jnnp.50.1.104-a. ISSN   0022-3050. PMC   1033262 . PMID   3819740.
33. Hisamoto Y, Gabriel G, Verma S, Karakas C, Chari G (18 April 2017). "Catatonia as a rare manifestation of HIV associated psychosis in adolescents. (P6.208)". Neurology. 88 (16_supplement). doi:10.1212/WNL.88.16_supplement.P6.208. ISSN   0028-3878.
34. Pfister HW, Preac-Mursic V, Wilske B, Rieder G, Förderreuther S, Schmidt S, Kapfhammer HP (February 1993). "Catatonic syndrome in acute severe encephalitis due to Borrelia burgdorferi infection". Neurology. 43 (2): 433–5. doi:10.1212/WNL.43.2.433. ISSN   0028-3878. PMID   8437717.
35. Neumärker KJ, Dudeck U, Plaza P (February 1989). "[Borrelia encephalitis and catatonia in adolescence]". Der Nervenarzt. 60 (2): 115–9. ISSN   0028-2804. PMID   2716930.
36. Ford L, Tufts DM (15 June 2021). "Lyme Neuroborreliosis: Mechanisms of B. burgdorferi Infection of the Nervous System". Brain Sciences. 11 (6): 789. doi: 10.3390/brainsci11060789 . ISSN   2076-3425. PMC   8232152 . PMID   34203671.
37. Walther S, Stegmayer K, Wilson JE, Heckers S (July 2019). "Structure and neural mechanisms of catatonia". The Lancet Psychiatry. 6 (7): 610–9. doi:10.1016/S2215-0366(18)30474-7. PMC   6790975 . PMID   31196794.
38. Dhossche DM, Stoppelbein L, Rout UK (December 2010). "Etiopathogenesis of Catatonia: Generalizations and Working Hypotheses". The Journal of ECT. 26 (4): 253–8. doi:10.1097/YCT.0b013e3181fbf96d. PMID   21076339.
39. Northoff G (October 2002). "What catatonia can tell us about 'top-down modulation': A neuropsychiatric hypothesis". Behavioral and Brain Sciences. 25 (5): 555–577. doi:10.1017/s0140525x02000109. PMID   12958742. S2CID   20407002.
40. Fink M (2003). Catatonia : a clinician's guide to diagnosis and treatment. Michael Alan Taylor. Cambridge: Cambridge University Press. ISBN   0-511-06198-6. OCLC   57254202.^{[ page needed ]}
41. American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association. doi:10.1176/appi.books.9780890425787. ISBN   978-0-89042-575-6. S2CID   249488050.
42. Jeste DV, Lieberman JA, Benson RS, Young ML, Akaka J, Bernstein CA, Crowley B, Everett AS, Geller J, Graff MD, Greene JA, Kashtan JF, Mcvoy MK, Nininger JE, Oldham JM, Schatzberg AF, Widge AS, Vanderlip ER (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5^TM. American Psychiatric Association . Retrieved 8 December 2023.
43. Michael B. First (2013). DSM-5® Handbook of Differential Diagnosis. American Psychiatric Publishing. p. 49. ISBN   978-1-58562-998-5.
44. Serra-Mestres J, Jaimes-Albornoz W (29 June 2018). "Recognizing Catatonia in Medically Hospitalized Older Adults: Why It Matters". Geriatrics. 3 (3): 37. doi: 10.3390/geriatrics3030037 . PMC   6319219 . PMID   31011075.
45. Sienaert P, Rooseleer J, De Fruyt J (December 2011). "Measuring catatonia: A systematic review of rating scales". Journal of Affective Disorders. 135 (1–3): 1–9. doi:10.1016/j.jad.2011.02.012. PMID   21420736.
46. Bush G, Fink M, Petrides G, Dowling F, Francis A (February 1996). "Catatonia. I. Rating scale and standardized examination". Acta Psychiatrica Scandinavica. 93 (2): 129–136. doi:10.1111/j.1600-0447.1996.tb09814.x. PMID   8686483. S2CID   20752576.
47. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G (9 December 2014). "A Clinical Review of the Treatment of Catatonia". Frontiers in Psychiatry. 5: 181. doi: 10.3389/fpsyt.2014.00181 . PMC   4260674 . PMID   25538636.
48. "Catatonia in French Psychiatry: Implications of the Zolpidem Challenge Test". Psychiatric Annals. 37 (1): 00485713–20070101–02. January 2007. doi:10.3928/00485713-20070101-02.
49. Simon LV, Hashmi MF, Callahan AL (2022). "Neuroleptic Malignant Syndrome". StatPearls. StatPearls Publishing. PMID   29489248.
50. Northoff G (1 December 2002). "Catatonia and neuroleptic malignant syndrome: psychopathology and pathophysiology". Journal of Neural Transmission. 109 (12): 1453–67. CiteSeerX   10.1.1.464.9266 . doi:10.1007/s00702-002-0762-z. PMID   12486486. S2CID   12971112.
51. Samanta D, Lui F (2022). "Anti-NMDA Receptor Encephalitis". StatPearls. StatPearls Publishing. PMID   31869136.
52. Foong AL, Grindrod KA, Patel T, Kellar J (October 2018). "Demystifying serotonin syndrome (or serotonin toxicity)". Canadian Family Physician. 64 (10): 720–7. PMC   6184959 . PMID   30315014.
53. Watt S, McAllister RK (2022). "Malignant Hyperthermia". StatPearls. StatPearls Publishing. PMID   28613578.
54. Arnts H, van Erp WS, Lavrijsen JC, van Gaal S, Groenewegen HJ, van den Munckhof P (May 2020). "On the pathophysiology and treatment of akinetic mutism". Neuroscience & Biobehavioral Reviews. 112: 270–8. doi: 10.1016/j.neubiorev.2020.02.006 . hdl: 11245.1/c438b878-4d5b-4f13-887c-7f01df095324 . PMID   32044373.
55. Ackermann H, Ziegler W (February 1995). "Akinetischer Mutismus – eine Literaturübersicht". Fortschritte der Neurologie · Psychiatrie. 63 (2): 59–67. doi:10.1055/s-2007-996603. PMID   7705740. S2CID   260156218.
56. Holka-Pokorska J, Piróg-Balcerzak A, Jarema M (30 April 2018). "The controversy around the diagnosis of selective mutism – a critical analysis of three cases in the light of modern research and diagnostic criteria". Psychiatria Polska. 52 (2): 323–343. doi: 10.12740/PP/76088 . PMID   29975370.
57. Wylie T, Sandhu DS, Murr N (2022). "Status Epilepticus". StatPearls. StatPearls Publishing. PMID   28613459.
58. Sutter R, Kaplan PW (August 2012). "Electroencephalographic criteria for nonconvulsive status epilepticus: Synopsis and comprehensive survey: EEG Criteria for NCSE". Epilepsia. 53: 1–51. doi:10.1111/j.1528-1167.2012.03593.x. PMID   22862158. S2CID   24014621.
59. Delirium: prevention, diagnosis and management. National Institute for Health and Care Excellence: Guidelines. National Institute for Health and Care Excellence (NICE). 2019. ISBN   978-1-4731-2992-4. PMID   31971702.
60. M Das J, Anosike K, Asuncion RM (2022). "Locked-in Syndrome". StatPearls. StatPearls Publishing. PMID   32644452.
61. Balint B, Meinck HM (July 2018). "Pragmatic Treatment of Stiff Person Spectrum Disorders: Pragmatic Treatment of SPSD". Movement Disorders Clinical Practice. 5 (4): 394–401. doi:10.1002/mdc3.12629. PMC   6174384 . PMID   30363317.
62. Baizabal-Carvallo JF, Jankovic J (August 2015). "Stiff-person syndrome: insights into a complex autoimmune disorder". Journal of Neurology, Neurosurgery & Psychiatry. 86 (8): 840–8. doi:10.1136/jnnp-2014-309201. PMID   25511790. S2CID   19981869.
63. Sarva H, Deik A, Ullah A, Severt WL (4 March 2016). "Clinical Spectrum of Stiff Person Syndrome: A Review of Recent Reports". Tremor and Other Hyperkinetic Movements. 6: 340. doi:10.7916/D85M65GD (inactive 14 November 2024). PMC   4790195 . PMID   26989571.
64. Rasmussen SA, Mazurek MF, Rosebush PI (2016). "Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology". World Journal of Psychiatry. 6 (4): 1875–9. doi: 10.5498/wjp.v6.i4.391 . PMC   5183991 . PMID   8078203.
65. Vaquerizo-Serrano J, Salazar De Pablo G, Singh J, Santosh P (2022). "Catatonia in autism spectrum disorders: A systematic review and meta-analysis". European Psychiatry. 65 (1): e4. doi:10.1192/j.eurpsy.2021.2259. PMC   8792870 . PMID   34906264.
66. Thenganatt M, Jankovic J (2016). "Psychogenic (Functional) parkinsonism". Functional Neurologic Disorders. Handbook of Clinical Neurology. Vol. 139. pp. 259–262. doi:10.1016/B978-0-12-801772-2.00022-9. ISBN   978-0-12-801772-2. PMID   27719845.
67. Ganos C, Kassavetis P, Cerdan M, Erro R, Balint B, Price G, Edwards MJ, Bhatia KP (June 2015). "Revisiting the Syndrome of "Obsessional Slowness"". Movement Disorders Clinical Practice. 2 (2): 163–9. doi:10.1002/mdc3.12140. PMC   6353487 . PMID   30713890. S2CID   73414098.
68. Rosso M, Fremion E, Santoro SL, Oreskovic NM, Chitnis T, Skotko BG, Santoro JD (2020). "Down Syndrome Disintegrative Disorder: A Clinical Regression Syndrome of Increasing Importance". Pediatrics. 145 (6): e20192939. doi: 10.1542/peds.2019-2939 . PMID   32471843. S2CID   219104019.
69. Chicoine B (December 2022). "Obsessional Slowness". Adult Down Syndrome Center, Advocate Medical Group.
70. Lyons A, Allen NM, Flanagan O, Cahalane D (2020). "Catatonia as a feature of down syndrome: An under-recognised entity?". European Journal of Paediatric Neurology. 25: 187–190. doi: 10.1016/j.ejpn.2020.01.005 . PMID   31959555. S2CID   210841869.
71. "Catatonia treatment and prognosis: Search". UpToDate. Retrieved 15 November 2024.
72. Luchini F, Medda P, Mariani MG, Mauri M, Toni C, Perugi G (June 2015). "Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response". World J Psychiatry. 5 (2): 182–92. doi: 10.5498/wjp.v5.i2.182 . PMC   4473490 . PMID   26110120.
73. Saini A, Begum N, Matti J, Ghanem DA, Fripp L, Pollak TA, Zandi MS, David A, Lewis G, Rogers J (15 September 2022). "Clozapine as a treatment for catatonia: A systematic review" (PDF). Schizophrenia Research. 263: 275–281. doi: 10.1016/j.schres.2022.09.021 . ISSN   0920-9964. PMID   36117082. S2CID   252276294.
74. Carroll BT, Goforth HW, Thomas C, Ahuja N, McDaniel WW, Kraus MF, Spiegel DR, Franco KN, Pozuelo L, Muñoz C (October 2007). "Review of Adjunctive Glutamate Antagonist Therapy in the Treatment of Catatonic Syndromes". The Journal of Neuropsychiatry and Clinical Neurosciences. 19 (4): 406–412. doi:10.1176/jnp.2007.19.4.406. PMID   18070843.
75. Smith AC, Holmes EG (1 December 2023). "Catatonia: A Narrative Review for Hospitalists". American Journal of Medicine Open. 10: 100059. doi:10.1016/j.ajmo.2023.100059. ISSN   2667-0364. PMC   11256243 . PMID   39035239.
76. American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders. doi:10.1176/appi.books.9780890425787. ISBN   978-0-89042-578-7. S2CID   249488050.^{[ page needed ]}
77. Solmi M, Pigato GG, Roiter B, Guaglianone A, Martini L, Fornaro M, Monaco F, Carvalho AF, Stubbs B, Veronese N, Correll CU (20 August 2018). "Prevalence of Catatonia and Its Moderators in Clinical Samples: Results from a Meta-analysis and Meta-regression Analysis". Schizophrenia Bulletin. 44 (5): 1133–50. doi:10.1093/schbul/sbx157. PMC   6101628 . PMID   29140521.
78. Rogers JP, Pollak TA, Begum N, Griffin A, Carter B, Pritchard M, Broadbent M, Kolliakou A, Ke J, Stewart R, Patel R, Bomford A, Amad A, Zandi MS, Lewis G, Nicholson TR, David AS (2 November 2021). "Catatonia: demographic, clinical and laboratory associations". Psychological Medicine. 53 (6): 2492–2502. doi: 10.1017/S0033291721004402 . PMC   10123832 . PMID   35135642. S2CID   242076501.
79. Parsanoglu Z, Balaban OD, Gica S, Atay OC, Altin O (May 2022). "Comparison of the Clinical and Treatment Characteristics of Patients Undergoing Electroconvulsive Therapy for Catatonia Indication in the Context of Gender". Clinical EEG and Neuroscience. 53 (3): 175–183. doi:10.1177/15500594211025889. PMID   34142904. S2CID   235471133.
80. Berrios GE (1981). "Stupor: A conceptual history". Psychological Medicine. 11 (4): 677–688. doi:10.1017/s0033291700041179. PMID   7034030. S2CID   26932116.
81. Roccatagliata G (1985), Pichot P, Berner P, Wolf R, Thau K (eds.), "The Idea of Melancholia in Classical Culture", Psychiatry The State of the Art: Volume 8 History of Psychiatry, National Schools, Education, and Transcultural Psychiatry, Boston, MA: Springer US, pp. 89–93, doi:10.1007/978-1-4757-1853-9_12, ISBN   978-1-4757-1853-9 , retrieved 18 November 2024
82. Scholtz M (December 1940). "Hippocrates' Aphorisms". California and Western Medicine. 53 (6): 272. ISSN   0093-4038. PMC   1634189 . PMID   18745795.
83. Veith I (15 December 2015). The Yellow Emperor's Classic of Internal Medicine. University of California Press. doi:10.1525/9780520963245. ISBN   978-0-520-96324-5.
84. "Zur Entwicklung der Psychiatrie - ein Internet-Atlas von Dr. Hans-Peter Haack" (in German). Archived from the original on 9 February 2008. Retrieved 29 June 2017.

External links

• Catatonia in DSM-5
• Encyclopedia of Mental Disorders — Catatonic Disorders
• "Schizophrenia: Catatonic Type" video by Heinz Edgar Lehmann, 1952
• Bush-Francis Catatonia Rating Scale