Catatonic depression

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A patient that is diagnosed with catatonic depression. Catatonia following an attack of melancholia.jpg
A patient that is diagnosed with catatonic depression.
Image showing patients with depressive disorder exemplifying catatonic features Precis de psychiatrie 42.jpg
Image showing patients with depressive disorder exemplifying catatonic features

Catatonic depression is characterized as a spectrum of mood disorders and is distinguished by the co-occurrence of catatonia and Major depressive disorder (MDD). [1] Catatonic symptoms involve a variety of motor abnormalities and behavioral disturbances, such as stupor, immobility, mutism, negativism, posturing, rigidity, and repetitive or purposeless movements. [1] Individuals suffering from catatonic depression frequently demonstrate a significant decline in their capacity to engage in voluntary behaviors and communicate effectively. [1] These symptoms can significantly impair daily functioning and pose challenges in their personal and professional lives. [1]

Contents

The exact cause of catatonic depression is not fully understood. [1] However, it is believed to arise from a complex interplay of genetic, biochemical, and environmental factors. Some research suggests that disturbances in neurotransmitters like dopamine and gamma-aminobutyric acid (GABA) may contribute to the development of catatonic symptoms. [2] Furthermore, stressful life events, trauma, and certain medical disorders can raise the risk of developing this condition. Diagnosing catatonic depression requires a comprehensive evaluation by a qualified mental health professional. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has specific criteria for diagnosing catatonic symptoms associated with depression. [2]  

Catatonic depression is often treated using a multimodal approach. Antidepressants, mood stabilizers, and antipsychotics may be prescribed to manage depression symptoms and underlying neurotransmitter imbalances. Electroconvulsive therapy (ECT) has also shown effectiveness in treating catatonic depression, particularly in cases where immediate intervention is required if other therapies have been unsuccessful. [2] Individuals can benefit from supportive psychotherapy, cognitive-behavioral therapy (CBT), and psychosocial therapies to cope with symptoms and create management strategies for their illness. [2] Catatonic depression is a debilitating and chronic condition that requires early intervention for optimal treatment. Individuals suffering from catatonic depression can benefit from appropriate treatment and support, resulting in symptom reduction and an improved overall quality of life. [1] Seeking expert help and support is critical to ensuring the patient's accurate diagnosis and treatment. [2]

Signs and Symptom

Catatonic depression is a complex psychiatric condition which involves both major depressive disorder and catatonia. Catatonic depression is characterised by a mix of symptoms and indications that overlap with major depressive disorder and catatonia. [1]

Stupor and mutism are the two most common symptoms. [1] Although symptoms of catatonic depression can vary by individual, common signs of catatonia include grimacing (making a facial expression of pain), negativism, posturing, rigidity, and wavy flexibility. [1]

Major depressive symptoms are also experienced by a person suffering from catatonic depression. [1] These symptoms can include hopelessness, irritability, a loss of interest in or enjoyment from normal activities, sleep disturbances (insomnia or excessive sleeping), exhaustion, anxiety, psychomotor retardation, feelings of worthlessness, difficulty concentrating, remembering things, and suicidal thoughts. [1]

Physiological Mechanism

The pathophysiology of catatonic depression is not currently well understood and mainly shrouded in mystery, but researchers have suggested possible pathophysiology explaining the major depressive disorder coupled with catatonic features. [3]

Gamma-aminobutyric acid (GABA), a vital neurotransmitter of the central nervous system which is known to inhibit nerve transmission. Gamma-Aminobuttersaure - gamma-aminobutyric acid.svg
Gamma-aminobutyric acid (GABA), a vital neurotransmitter of the central nervous system which is known to inhibit nerve transmission.

Reduced gamma-aminobutyric acid (GABA) activity

GABA-A (GABA type A) receptor activation in the right lateral orbitofrontal and right posterior parietal cortex is suggested to be a plausible cause of catatonia syndrome dysfunction, which helps explain the motor and affective symptoms seen in catatonic individuals. [3] Reduced GABA-A receptor density is found on imaging in cortical regions such as the left sensorimotor cortex, which suggests malfunctioning GABA-A signalling in catatonia. [3]

Dopamine Dysfunction

Dopamine, a neurotransmitter which plays an important role in emotion and movement regulation within the brain. Dopamin - Dopamine.svg
Dopamine, a neurotransmitter which plays an important role in emotion and movement regulation within the brain.

There is some evidence that blockage of dopamine D2 receptor has led to reduced risk of exacerbating catatonia. [3] This can be seen in neuroleptic malignant syndrome, which has similar symptoms to catatonia.

An alternative idea suggests that the mesostriatal and mesocorticolimbic systems, and the hypothalamus need to maintain a balance between GABA-A and dopamine. [3]

Diagram showcasing activation of NMDA receptor upon binding of excitatory neurotransmitter, glutamate. Activated NMDAR.svg
Diagram showcasing activation of NMDA receptor upon binding of excitatory neurotransmitter, glutamate.

Glutamate Dysfunction

Glutamate anomalies have been observed in the basal ganglia (clusters of neurones located in subcortical region) as such excitatory glutamatergic N-methyl-D-aspartate receptors (NMDARs) within this brain region appear to be associated with catatonia. [3] Catatonic symptoms are thought to be caused by glutamate hyperactivity.

There is a high correlation between catatonia and NMDAR encephalitis. (NMDARs are internalised into cells during this inflammatory process, resulting in a drop in the receptor's total abundance.) [3]

Abnormalities of the brain and brainstem pathway

The disruption of the following three motor pathways is hypothesised to be associated with catatonia. [3]

The first pathway involves the primary motor cortex (M1), putamen, internal and external palladium and thalamus. [3]

The second pathway runs between the M1, thalamus, cerebellum, and pontine nuclei. [3]

The third pathway is composed of the M1, supplementary motor area (SMA), posterior parietal cortex, and medial prefrontal cortex. [3]

It has been shown that individuals with catatonia have more blood flow to the M1 and SMA than those without catatonia. [3] This implies a relation between catatonic depression and elevated neuronal activity in the M1 and SMA.

Autoimmune disorders

Catatonia is also associated with autoimmune encephalopathies that involves anti-neuronal antibodies (acting on neurones over pathogens). [3] These antibodies become internalised within neurones and cause its dysfunction, leading to catatonic symptoms.

Causes

Genetic susceptibility of an individual has been extensively supported in the case of major depressive disorders. In 2023, the genome-wide association studies (GWAS) have identified 178 genetic risk loci with more than 200 candidate genes. [4] Based on the stress diathesis theory, people with a family history of mood disorder are more prone to developing depression due to stressful life events. [5] However, it is to be noted that major depressive disorder is not entirely dependent on genetics and is influenced by other factors.

Research has indicated that there is a 27% chance of a patient developing catatonic symptoms if a first-degree relative has the disorder. [3] Catatonia is also highly heritable. One gene linked to the heredity of catatonia is CNP, which codes for the enzyme cyclic nucleotide phosphodiesterase, which is necessary for myelination and oligodendrocyte function. [3] Depletion of this gene causes the affected mice to develop catatonic depression. [3]

Environmental Factors

Traumatic events and immense stress are well-documented factors of major depressive disorders. Early life trauma is strongly correlated with the onset of mood disorder such as depression as well as the severity and duration of the malady. [5]

However, people with such experience may or may not develop depression while those without impactful life events may also develop major depressive disorder. This could be explained by the gene-environment interaction which influences the impact of life events on the development of a disease. [5] A functional polymorphism of the promoter region of the serotonin transporter gene (5-HTT) was found to moderate the influence of stressful life events on depression. [5]

Intense terror

Catatonic depression has been possibly associated with extreme fear. Catatonia may be an end-state reaction to emotions of impending doom stemming from early experiences with predators whose attack instincts were focused on movements. [3] A 2020 study on an older population discovered that hyperactivity and nervousness were more common in catatonic patients. [3]

Diagnosis

In order to identify catatonic symptoms in individuals with major depressive disorder, a comprehensive physical and psychological evaluation is part of a diagnostic catatonic depression assessment. Often, people with catatonic depression cannot respond to questions in which case the person's closed ones could be inquired. [1]

Clinical Assessment

It is important for the physician to rule other medical conditions which mimic symptoms of catatonic depression. [1] The physician may take the patient's medical history, including details about symptoms and current medications, perform a thorough physical examination by observing the patient's posture and movements, perform a neurological examination, and order an electroencephalogram (EEG) or magnetic resonance imaging (MRI) to rule out other neurological conditions. [1]

DCM and ICD criteria

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) together with the International Classification of Disease (ICD-11) are generally used to diagnose catatonic depression. [6] Although definitive diagnostic criteria for catatonic depression is still in debate, the two classifications is in agreement for catatonic depression diagnostics. [6]

DCM-5 and ICD-11 classification

To diagnose catatonic depression, it requires the presence of 3 of the following 12 clinical signs, which includes stupor (impaired responsiveness indicated by a lack of movement and speech), catalepsy (a lack of response to external stimuli due to muscular rigidity), waxy flexibility (resistance to repositioning after being moved), mutism (being unable or unwilling to speak), negativism (resistance to suggestions or instructions), posturing (holding an abnormal position for an extended period), mannerisms (involve an unusual, exaggerated, or peculiar way of performing a normal action like movement or speech), stereotypies (these behaviors include repetitive, non-goal-directed movements and speech, disrupting normal functioning), psychomotor agitation (increased movement, restlessness, and irritability coupled with enhanced responsiveness to internal and external stimuli), grimacing (making a facial expression of pain), echolalia (mimicking another person's speech) and echopraxia (mimicking another person's movements or behaviors for no reason).

Misdiagnosis

Major depressive disorder subtype catatonia can be easily overlooked which could result in misdiagnosis and thus worsen the patient's condition. [7] Therefore, physicians ought to be cautious when diagnosing major depressive disorder and consider the possible subtypes.

Managements

Lorazepam, belongs to group of medicine named benzodiazepines. It is a commonly used medicine to treat anxiety disorders. 3 boites de lorazepam 2,5.jpg
Lorazepam, belongs to group of medicine named benzodiazepines. It is a commonly used medicine to treat anxiety disorders.

Catatonic depression is a severe but manageable subtype of depression. Benzodiazepines, such as lorazepam, are often prescribed as the first-line treatment for catatonia. These medications contain anxiety-relieving and muscle relaxing characteristics. [1]

Combination therapy

Antipsychotic medications can be combined with benzodiazepines to treat catatonic depression. Combination therapy can help relieve symptoms and enhance overall function. [1] When medication alone is ineffective, the use of electroconvulsive therapy (ECT) is recommended. ECT is the use of electrical currents to produce a seizure while under general anesthesia. It is thought to reset brain chemistry and may be beneficial in treating severe mental illnesses, including catatonia. [1]

Exercising is shown to be beneficial to reduce symptoms of catatonic depression. Workout 7th Brigade Park Chermside P1070570.jpg
Exercising is shown to be beneficial to reduce symptoms of catatonic depression.

Lifestyle

It is suggested to create a scheduled daily regimen that includes consistent sleep, meals, and activities that can provide a sense of stability and manage symptoms better. [3] It is also recommended to engage in regular physical activity, such as walking, yoga, or swimming, as exercise has been demonstrated to elevate mood and lessen symptoms of depression. [3]

Psychotherapies

Supportive treatment can be effective in resolving underlying depression and assisting patients in coping with symptoms. [1] A person suffering from catatonic depression requires acute psychiatric care, which includes contacting an inpatient mental facility or seeking emergency medical attention to ensure that the person receives therapy as soon as possible. [1]

Epidemiology

Catatonic depression is underdiagnosed and may impact up to 38% of acute psychiatric patients, as it creates particular symptoms as indicated above and necessitates a specific treatment approach with an emphasis on medications to relieve symptoms. [1] Catatonia affects over 10% of all persons hospitalized to psychiatric facilities. Catatonia may be associated with depression, although it also affects approximately 20% of persons with autism spectrum disorder, and up to 50% of catatonia instances are caused by medical difficulties. [2]

Catatonic depression is frequently associated with other mental health illnesses, including bipolar disorder, schizophrenia, major depressive disorder, mood disorders, personality disorders, and anxiety disorders. [1]

See also

Related Research Articles

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Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes. Typically, these manic episodes can last at least 7 days for most of each day to the extent that the individual may need medical attention. Also, the depressive episodes will be approximately 2 weeks long.

<span class="mw-page-title-main">Catatonia</span> Psychiatric behavioural syndrome

Catatonia is a complex neuropsychiatric behavioral syndrome that is characterized by abnormal movements, immobility, abnormal behaviors, and withdrawal. The onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during episodes. It has historically been related to schizophrenia, but catatonia is most often seen in mood disorders. It is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurological, and medical conditions. Catatonia is now a stand-alone diagnosis, and the term is used to describe a feature of the underlying disorder.

<span class="mw-page-title-main">Major depressive disorder</span> Mental disorder involving persistent low mood, low self-esteem, and loss of interest

Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introduced by a group of US clinicians in the mid-1970s, the term was adopted by the American Psychiatric Association for this symptom cluster under mood disorders in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and has become widely used since.

<span class="mw-page-title-main">Mood disorder</span> Mental disorder affecting the mood of an individual, over a long period of time

A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature. The classification is in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD).

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia (psychosis) and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. many people with schizoaffective disorder have other mental disorder including anxiety disorders

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual, causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.

Dysthymia, also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longer-lasting symptoms. The concept was used by Robert Spitzer as a replacement for the term "depressive personality" in the late 1970s.

Atypical depression is defined in the DSM-IV as depression that shares many of the typical symptoms of major depressive disorder or dysthymia but is characterized by improved mood in response to positive events. In contrast to those with atypical depression, people with melancholic depression generally do not experience an improved mood in response to normally pleasurable events. Atypical depression also often features significant weight gain or an increased appetite, hypersomnia, a heavy sensation in the limbs, and interpersonal rejection sensitivity that results in significant social or occupational impairment.

A major depressive episode (MDE) is a period characterized by symptoms of major depressive disorder. Those affected primarily exhibit a depressive mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities. Other symptoms can include feelings of emptiness, hopelessness, anxiety, worthlessness, guilt, irritability, changes in appetite, difficulties in concentration, difficulties remembering details, making decisions, and thoughts of suicide. Insomnia or hypersomnia and aches, pains, or digestive problems that are resistant to treatment may also be present.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

<span class="mw-page-title-main">Waxy flexibility</span> Catatonia psychomotor symptom

Waxy flexibility is one of the twelve symptoms that can lead to the diagnosis of catatonia. It is a psychomotor symptom that results in a decreased response to stimuli and a tendency to remain in an immobile posture. If one were to move the arm of someone with waxy flexibility, the patient would keep that arm where it had been positioned until moved again as if positioning malleable wax. Attempts to reposition the patient are met by "slight, even resistance".

Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experienced a full manic episode. Otherwise, one manic episode meets the criteria for bipolar I disorder (BP-I).

Minor depressive disorder, also known as minor depression, is a mood disorder that does not meet the full criteria for major depressive disorder but at least two depressive symptoms are present for a long time. These symptoms can be seen in many different psychiatric and mental disorders, which can lead to more specific diagnoses of an individual's condition. However, some of the situations might not fall under specific categories listed in the Diagnostic and Statistical Manual of Mental Disorders. Minor depressive disorder is an example of one of these nonspecific diagnoses, as it is a disorder classified in the DSM-IV-TR under the category Depressive Disorder Not Otherwise Specified (DD-NOS). The classification of NOS depressive disorders is up for debate. Minor depressive disorder as a term was never an officially accepted term, but was listed in Appendix B of the DSM-IV-TR. This is the only version of the DSM that contains the term, as the prior versions and the most recent edition, DSM-5, does not mention it.

Mixed anxiety–depressive disorder (MADD) is a diagnostic category that defines patients who have both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some autonomic nervous system features. Autonomic features are involuntary physical symptoms usually caused by an overactive nervous system, such as panic attacks or intestinal distress. The World Health Organization's ICD-10 describes Mixed anxiety and depressive disorder: "...when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."

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<span class="mw-page-title-main">Melancholic depression</span> Medical condition

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<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

Autistic catatonia is a term used to describe the occurrence of catatonia in autistic people. Catatonia occurs in roughly 10 percent of people diagnosed with an autism spectrum disorder. In addition to the common sign of catatonia, autistic people with catatonia are more likely to stim and self-harm.

Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses, which can be misdiagnosed. Misdiagnosis may involve erroneously assigning a BPD diagnosis to individuals not meeting the specific criteria or attributing an incorrect alternate diagnosis in cases where BPD is the accurate condition.

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