Approach to Catatonia and NMS

1. P R E S E N T E R : D R . M E L A K U . Y ( Y E A R I
M E D I C A L R E S I D E N T )
M O D E R A T O R : D R . M E S A L I
J E M A L ( P S Y C H I A T R I S T , A S S I S T A N T
P R O F E S S O R O F P S Y C H I A T R Y )
Adama Hospital Medical College
Department of Psychiatry
Seminar On
Neuroleptic malignant
syndrome and Catatonic disorders
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2. Outline
 Introduction
 NMS
 Catatonia
 Take-Home Messages
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3. Introduction
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 Catatonia is a neuropsychiatric syndrome that
appears in medical, neurological or psychiatric
conditions.
 There are presentation variants: “malignant
catatonia” (MC) subtype shares many characteristics
with the neuroleptic malignant syndrome(NMS)

4. Neuroleptic Malignant Syndrome(NMS)
Introduction:
 The neuroleptic malignant syndrome, or NMS, may have
been first described in 1959 by Walker
 Reported a case of what appeared to be tetanus in a 19-
year-old man
 After given trifluoperazine—fever and profound
parkinsonian rigidity that was partially relieved by
trihexyphenidyl
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5. NMS…
Epidemiology :
 About 0.01 to 0.02 percent of patients treated with
antipsychotics develop neuroleptic malignant syndrome.
 Men are affected more frequently than women, and
young patients are affected more commonly than elderly
patients.
 The mortality rate can reach 10 to 20 percent or even
higher when depot antipsychotic medications are
involved
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6. NMS…
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Proposed Pathophysiology:
 The precise cause of NMS is not well elucidated.
 The most enduring proposal for the mechanism underlying the
symptoms observed during NMS is an excessive dopamine
blockade, most prominently at the D 2 receptor.
 Antagonizing this receptor within the nigrostriatal, hypothalamic,
and mesolimbic/cortical pathways likely explains the rigidity,
hyperthermia, and AMS, respectively,
 Furthermore, this proposed mechanism is supported by resolution
of symptoms on discontinuation of neuroleptics that cause
dopamine blockade, specifically those with potent D 2 affinity.

7. NMS…
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Proposed…
 Moreover, removal of dopamine agonists can induce
NMS symptoms.
 Atypical antipsychotics with less D 2 antagonist activity
can also cause NMS, which suggests that dopamine
blockade may not be the sole precipitator of NMS.
 Increased catecholamines in the urine and plasma
support the sympathoadrenal hyperactivity hypothesis.

8. NMS…
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Proposed…
 Abnormalities in this system would explain the lack of
tonic inhibition as well as autonomic instability, though
downstream effects of dopamine blockade may also
explain the sympathoadrenal dysfunction.
 Unregulated sympathetic outflow can account for nearly
all the symptoms commonly seen in NMS.
 Another possible mechanism that could contribute to
NMS presentation could be predisposition of the
patient’s musculoskeletal fiber, as seen in the
pathophysiology of malignant hyperthermia

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10. NMS…
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Risk factors:
 Pharmacologic
 Patient specific
 Environmental

11. NMS…
Clinical features:
 The motor and behavioral symptoms include
muscular rigidity and dystonia, akinesia, mutism,
obtundation, and agitation.
 The autonomic symptoms include hyperthermia,
diaphoresis, and increased pulse and blood pressure
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12. NMS…
Laboratory findings:
 increased white blood cell count
 increased levels of creatinine phosphokinase,
 liver enzymes, plasma myoglobin,
 and myoglobinuria, occasionally associated with renal failure
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13. NMS…
Levenson’s diagnostic criteria:
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14. NMS…
Diagnosis:
 Diagnosed if a patient had three or more major criteria,
or two of the major criteria and four of the minor criteria
 Other criterion sets, including one proposed by APA,
fever and rigidity as essential to the diagnosis and add
dysphagia, incontinence, mutism, and tremor to the
minor criteria.
 The APA criteria require both severe rigidity and fever
(rather than accepting just one of the two if there is an
elevated creatine kinase); only two minor criteria must
be present
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15. NMS…
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Diagnosis:
DSM-V Criteria for NMS
Major criteria(all are required)
 Exposure to dopamine blocking agent
 Severe muscle rigidity
 Fever

16. NMS…
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Other Criteria(at least two are required)
 Diaphoresis
 Dysphagia
 Tremor
 Incontinence
 Altered level of consciousness
 Mutism
 Tachycardia
 Elevated labile blood pressure
 Leucocytosis
 Elevated creatine phosphokinase

17. NMS…
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18. NMS…
Course and Prognosis :
 The symptoms usually evolve over 24 to 72 hours,
and the untreated syndrome lasts 10 to 14 days.
 The diagnosis is often missed in the early stages, and
the withdrawal or agitation may mistakenly be
considered to reflect an exacerbation of the psychosis
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19. NMS…
Treatment:
 Supportive medical treatment,
 the most commonly used medications for the
condition are dantrolene and bromocriptine ,
although amantadine is sometimes used.
 Bromocriptine and amantadine pose direct DRA
effects and may serve to overcome the antipsychotic
induced dopamine receptor blockade.
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20. NMS…
Treatment:
 The lowest effective dosage of the antipsychotic drug
should be used to reduce the chance of neuroleptic
malignant syndrome.
 High potency drugs, such as haloperidol, pose the
greatest risk.
 Antipsychotic drugs with anticholinergic effects seem
less likely to cause neuroleptic malignant syndrome.
 Electroconvulsive therapy (ECT) has been used
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21. NMS…
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22. NMS…
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24. Catatonia
Introduction:
 Catatonia was first described by German psychopathologist Karl Kahlbaum
1874 as a motor syndrome in patients with behavioral disorders
 Catatonia is a complex neuropsychiatric syndrome characterized by a broad
range of motor, speech and behavioural abnormalities
 It is seen in the setting of psychiatric disorders, medical, neurological and
surgical conditions, as well as in the setting of certain drugs and toxins
 Although it may become life-threatening, catatonia has an excellent
prognosis if recognized and treated early
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25. Catatonia…
Epidemiology :
 Catatonia is an uncommon condition mostly seen in advanced
primary mood or psychotic illnesses.
 Among inpatients with catatonia, 25 to 50 percent are related to
mood disorders (e.g., major depressive episode, recurrent, with
catatonic features), and approximately 10 percent are associated
with schizophrenia.
 The percentage of catatonia due to a general medical condition is
reported to range from 20% to 39%.
.
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26. Catatonia…
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Pathophysiology:
 The specific pathophysiological mechanisms underlying
catatonia are not well understood.
 Neurochemical studies have focused on the inhibitory
neurotransmitter γ-aminobutyric acid (GABA) A
 The role of GABA in catatonia is supported by the observation
of a dramatic response to treatment with benzodiazepines and
zolpidem
 The GABAergic hypothesis is also supported by the
observation that ECT

27. Catatonia…
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Clinical features:
 The catatonic syndrome is seen in two principal forms
 hypokinetic (withdrawn type) or hyperkinetic (excited
type)
 Some patients, however, may display features of both
types during the course of the illness
 There is no difference in the expression of catatonic
symptoms based on the underlying cause, whether it is
psychiatric or medical

28. Catatonia…
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Clinical… hypokinetic
 typically appear awake and watchful,
 minimal spontaneous speech and movement.
 It is commonly associated with mutism, stupor,
negativism, obsessional slowness and posturing

29. Catatonia…
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Clinical…Hyperkinetic:
 agitation,
 combativeness,
 disorganized overproductive speech (verbigeration),
 stereotypies,
 grimacing and
 echophenomena

30. Catatonia…
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Clinical…Subtypes
 Malignant catatonia
 Periodic catatonia

31. Catatonia…
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Clinical …Malignant catatonia
 Malignant catatonia is characterized by sudden development
of intense excitement, delirium, high fever, hypertension,
catalepsy, mutism, rigidity, stereotypies and posturing.
 Because of accompanying marked autonomic instability and
hyperthermia this form of catatonia is potentially fatal.
 Numerous medical conditions leading to malignant catatonia
have been reported.
 Although randomised clinical trials are lacking,
electroconvulsive therapy (ECT) is effective in the treatment
of malignant catatonia

32. Catatonia…
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Clinical …Periodic Catatonia
 Periodic catatonia has a rapid onset and consists of brief,
recurrent hypokinetic or hyperkinetic abnormalities with
episodes lasting 4–10 days which recur over a period of
weeks to years.
 Patients are generally asymptomatic between episodes, but
may exhibit inter-ictal facial grimacing, stereotypies and
negativism, particularly late in the course of the illness.
 Overall, periodic catatonia is considered to have a better
prognosis than the malignant form of catatonia

33. Catatonia…
Diagnosis:
 There are no pathognomonic laboratory findings in
catatonia.
 Appropriate medical tests may include complete blood
counts, electrolytes, brain imaging, and
electroencephalography (if seizures are suspected).
 In addition, serum creatinine phosphokinase, white
blood cell count, and serum transaminases should be
checked because the results of laboratory tests are
elevated in patients with neuroleptic malignant
syndrome.
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34. Catatonia…
Diagnosis(DSM V):
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35. Catatonia…
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36. Catatonia
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Assessment:
 Several rating scales have been developed for the
assessment of catatonia.
 The Bush-Francis Catatonia Rating Scale (BFCRS) is
the most widely used scale.
 This includes 23 items and up to 30 signs

37. Catatonia
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Assessment:
 There is also a screening version of BFCRS known as Bush-Francis
Catatonia Rating Screening Instrument (BFCSI), which contains 14
most common catatonic signs
 (excitement, immobility/stupor, mutism, staring gaze,
posturing/catalepsy, grimacing, echopraxia/echolalia, stereotypes,
mannerisms, verbigeration, rigidity, negativism, waxy flexibility and
withdrawal).
 If two or more of the BFCSI signs are present for 24 h or longer,
catatonia should be considered as a possible diagnosis.
 To avoid overdiagnosis, signs such as ‘impulsiveness’ and
‘combativeness’ were excluded from the screening instrument

38. Catatonia…
Differential Diagnosis (DDX):
 Hypoactive delirium,
 End-stage dementia,
 Akinetic mutism,
 Catatonia due to a primary psychiatric disorder.
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39. Catatonia…
Course and Treatment:
 Catatonia impairs a person’s ability to care for himself or
herself and therefore requires hospitalization.
 In an excited state, the catatonic patient may represent a
danger to others; hence, close supervision is needed.
 Fluid and nutrient intake must be maintained, often
with intravenous lines or feeding tubes.
 The catatonic individual must be assisted with hygiene.
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40. Catatonia…
Course and Treatment:
 The primary treatment modality is identifying and
correcting the underlying medical or pharmacological
cause.
 Benzodiazepines can provide temporary improvement in
symptoms, and their use may improve patients’ ability to
communicate and to care for themselves.
 ECT is appropriate for catatonia due to a general medical
condition, especially if the catatonia is life threatening
(e.g., inability to eat) or has developed into lethal
(malignant) catatonia.
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41. Take-home Messages
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42. References
 Kaplan and Sadock’s Synopsis of Pyschiatry,11th edition
 European Journal of Psychiatry, Volume 33
 British medical journal of neuropsychiatry
 WWW.thelancet.com
 WWW.researchgate.net
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43. Thank You…!!!
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