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Catatonia balaji
- 1. Features ■ Motor – posturing, catalepsy, stereotypy, mannerism, rigidity, waxy flexibility, echopraxia, echolalia ■ Behavioural & Emotional – withdrawal, excitement*, grimace, stupor, mutism, staring, negativism, verbigeration, perseveration, automatic obedience, mitgehen, gegenhalten, ambitendency, impulsivity, combativeness
- 2. Don’t miss! ■ ambitendency ■ mitgehen ■ gegenhalten ■ automatic obedience ■ in speech- whispered, odd accent, robotic ■ walking tiptoe, other mannerisms ■ stereotypies
- 3. Examination ■ Observe pt while trying to converse ■ Scratch head in exaggerated manner ■ Examine for cogwheeling ■ Activity level Abnormal movements Abnormal speech ■ Echopraxia ■ Negativism
- 4. Examination ■ Check pulse by supporting hand, then leave it ■ Ask patient to follow simple commands ■ Rapidly touch palm and withdraw finger ■ Posturing ■ Active/ Passive Negativism ■ Magnet reaction
- 5. Examination ■ Attempt to reposture after instr to ‘keep arm loose’ use alt light and heavy force ■ Try to raise arm with finger pressure after instruction ‘NOT TO ALLOW’ ■ Waxy flexibility Gegenhalten ■ Mitgehen
- 6. Examination ■ Offer hand and say ‘DO NOT SHAKE MY HAND’ ■ Reach your pocket and ask to show the tongue ‘I want to stick a pin in it’ ■ Ambitendence ■ Automatic obedience
- 7. Examination ■ Stroke the palm of the hand gently ■ Oral intake, output monitoring, temp, pulse and blood pressure charts, any incidents ■ Indirect observation ■ Grasp reflex ■ Autonomic signs Combativeness Withdrawal
- 8. DSM IV • Mutism: refusal to speak • Immobility: lack or paucity of movement • Stereotypies: purposeless, repetitive movements • Negativism: active or passive refusal to follow commands • Mannerisms: repetitive, purposeful movements • Posturing: maintenance of bizarre postures • Grimacing: repetitive facial posturing • Catalepsy or Waxy Flexibility: maintenance of posture • Echopraxia or Echolalia: repetition of words or the imitation of actions • Excitement: purposeless, excessive movement
- 9. DSM IV ■ 1 criterion needed for general medical condition or substance induced catatonia ■ 2 criteria for catatonia that is associated with a psychiatric condition ICD 10 ■ Only under psychotic disorders ■ NO ORGANIC CATATONIA DESCRIBED !!
- 10. A Syndrome ■ Multiple etiologies ■ Organic – Neurological, Infectious, Metabolic, Nutritional, Drug related, Misc ■ Functional – Mood ds (mania commonly), Schizophrenia, other Ψ, OCD, PTSD etc
- 11. Treatment of Catatonia ■ Benzodiazepines – Lorazepam ■ LZM (p.o./ i.v./ i.m.) 4 – 8 mg/d for upto 5 d ■ Resolution by day 3, in most ■ Failures respond to ECT by 3rd ECT ■ Same treatment for NMS/ lethal catatonia ■ Also, STOP ANY OFFENDING DRUGS !
- 12. Organic catatonia - Neurological ■ Brain stem, diencephalic, basal ganglia, lesions near III ventricle, amygdala ■ Frontal lobe ds. (apallic syn.), SMA ■ Parietal lobe ds. ■ Limbic & temporal lobe ds. ■ Head injury, dementia, MS, atrophy ■ Encephalitis & other infections ■ Epilepsy
- 13. Organic catatonia - Metabolic ■ Periodic catatonia ■ DM, in DKA ■ Thyroid dysfunction ■ Hepatic failure ■ Renal failure ■ Porphyrias ■ Nutritional- Wernickes, pellagra, B12 def
- 14. Organic catatonia – Drugs ■ Neuroleptics ■ Alcohol ■ Opioids ■ Cannabis ■ BZDs ■ Disulfiram ■ SSRI, TCA
- 15. Lethal catatonia ■ physical and mental agitation, chorea, stupor, rigidity, mutism ■ fever, hypotension, sweating (like NMS) ■ convulsions, delirium, coma, death ■ prodrome of a few days exists in most cases ■ no elevations in CPK, WBC count etc
- 16. Serotonin syndrome ■ hyperthermia, diaphoresis, excitement/ confusion, hyperreflexia, jerks/ seizures, tremors, hypotension ■ DIC ■ rhabdomyolysis ■ cardiovascular compromise
- 17. NMS • Triad of fever, rigidity, confusion • Autonomic symptoms – fever, sweating, labile BP, tachypnea, cardiac arrythmias • Extrapyramidal symptoms – rigidity, tremor, dystonia, chorea, ocular flutter • Confusion – disorientation, delirium, seizures, coma • Lab – leukocytosis, raised CPK
- 18. NMS ■ Predisposing factors – young male, exhaustion, iron def, affective ds, brain ds, thyrotoxicosis ■ Precipitating causes – dopamine receptor antagonists (HPL, TFP), esp with Li; levodopa, other dopamine receptor agonists, SSRIs
- 19. NMS ■ Treatment – Supportive- cooling, fluid and electrolyte balance, ventilation, dialysis Specific- Bromocriptine- 2.5 mg tid Dantrolene- 2-3 mg/kg tid Levodopa, Pergolide BZDs , ECT
- 20. Differential diagnosis ■ Elective mutism ■ Locked-in syndrome ■ Stiff-person syndrome ■ Malignant hyperthermia ■ Akinetic Parkinsonism ■ Stupor ■ Manic excitement