Catatonia: causes, symptoms and treatment of this syndrome.

This strange physical and mental state has been associated with schizophrenia and other disorders.

It is possible that we have seen in a movie, read in a book or even seen in real life some psychiatric patients who remain in a state of absence, rigid and immobile, mute and retentive, being able to be placed by third parties in any imaginable position and remaining in that position like a wax doll.

This state is what is called catatonia, a mainly motor syndrome of diverse causes.This state is what is called catatonia, a syndrome mainly motor of diverse causes and that affects patients with different types of disorder as much mental as medical.

The catatonia as a syndrome: concept and symptoms

The catatonia is a syndrome of neuropsychological type in which a series of psychomotor symptoms occur, often accompanied by cognitive, consciousness and perceptual disturbances.

The most characteristic symptoms of this syndrome are the presence of catalepsy or impossibility of movement due to a state of muscle rigidity that prevents muscle contraction, often which prevents muscle contraction, waxy flexibility (a state of passive resistance in which the subject does not flex the joints on his own, remaining as he is if placed in a certain way with the same posture and position unless changed and in which the limbs of the body remain in whatever posture another person leaves them in), mutism, negativism at the attempt to make the subject perform any action, echo symptoms (or automatic repetition/imitation of the actions and words performed by his interlocutor), stereotypies, perseveration, agitation, absence of response to the environment or stupor.

Its diagnosis requires at least three of the above-mentioned symptomsThe diagnosis requires at least three of the above-mentioned symptoms, for about twenty-four hours. As a general rule, anosognosia is present with respect to the motor symptomatology.

Some psychological symptoms

Subjects with this disorder often present an intense emotionalityThis is difficult to control, both positively and negatively. Although motor immobility is characteristic, sometimes patients come out of it in an emotional state of great intensity and with a high level of movement and agitation that can lead them to self-injury or aggression towards others. Despite their anosognosia with respect to their motor symptoms, they are nevertheless aware of their emotions and the intensity with which they present themselves.

Catatonia can present itself in different degrees of greater or lesser severity, producing alterations in the functioning of the patient.It can produce alterations in the patient's vital functioning that can make it difficult for him/her to adapt to the environment.

Although the prognosis the prognosis is good if it begins to be treated early, in some cases it can be chronic.In some cases it can be chronic and can even be fatal in certain circumstances.

Patterns of presentation

Two typical presentation patterns may be observed, one called stuporous or slowed catatonia and the other known as agitated or delirious catatonia..

The first one is characterized by a state of stupor in which there is an absence of functions of relationship with the environment; the individual remains paralyzed and absent with respect to the environment, the common symptoms being catalepsy, waxy flexibility, mutism and negativism.

As for agitated or delirious catatonia, it is characterized by more activation-related symptoms such as Echosymptoms, the performance of stereotyped movements and agitated states.

Possible causes of catatonia

The causes of catatonia can be very diverse. When considering catatonia as a neuropsychological syndrome the presence of alterations in the nervous system must be taken into account..

Research shows that patients with catatonia have some kind of dysfunction in part of the right posterior parietal cortex.This is consistent with the fact that people with catatonia are able to initiate movements correctly (so that the supplementary motor area usually remains preserved) and the fact that there is anosognosia with respect to motor symptoms. The lateral inferior prefrontal of these subjects also tends to be altered, as well as the medial orbitofrontal, which also explains the presence of occasional abductions and emotional disturbances.

At the hormonal level, the role of GABA is explored, which has been shown to be altered in patients with catatonia as it has a lower level of binding to brain structures. Glutamate, serotonin and dopamine also seem to play a relevant role in this disorder, but further research is needed regarding the more research is needed into exactly how they play a role..

Potential organic causes

One of the first causes to be explored is the organic type, as catatonia is a symptom present in a large number of neurological disorders. In this sense we can find that temporal lobe epilepsy, encephalitis, brain tumors and cerebrovascular accidents are possible causes of this syndrome that should be explored. are possible causes of this syndrome that should be treated immediately.

In addition, infections such as septicemia or those caused by tuberculosis, malaria, syphilis or HIV can also cause this condition. Liver and kidney failure, hypothyroidism, severe complications of Diabetes such as ketoacitosis or even severe hypothermia are other conditions that have been linked to the onset of catatonia.

Other biological causes may derive from the consumption and/or abuse of psychoactive substances, whether drugs or psychotropic drugs.drugs or psychotropic drugs. For example, catatonia frequently appears in neuroleptic malignant syndrome, a severe and potentially fatal syndrome that in some cases appears after the administration of antipsychotics.

Psychodynamic causes

In addition to the previous causes, some authors close to the Freudian tradition have proposed that in some cases the have proposed that in some cases catatonia may have psychological aspects of a symbolic nature as a cause.

Specifically, it has been proposed that catatonia may appear as a regression to a primitive state. as a regression to a primitive state as a defense mechanism against traumatic or frightening stimuli. The explanation that it can also occur as a dissociation response (which in fact is observed in some patients with post-traumatic stress disorder) is also used.

However, it should be borne in mind that these explanations are based on an epistemology far removed from the scientific, and are therefore no longer considered valid.

Mental disorders in which it appears

Catatonia has long been a syndrome that has been identified with a subtype of schizophrenia, catatonic schizophrenia. However, the presence of this syndrome has also been observed in numerous disorders, both mental and of organic origin.

Some of the different disorders to which it has appeared linked are the following.

1. Schizophrenia and other psychotic disorders

This is the type of condition to which catatonia has traditionally been linked, to the extent that catatonia has been considered a specific subtype of schizophrenia. Apart from schizophrenia it can appear in other disorders such as brief psychotic disorder..

2. Mood disorders

Although it has been linked almost from the beginning with schizophrenia, the different studies carried out on catatonia seem to indicate that a high number of catatonic patients present some kind of mood disorder, especially in manic or depressive episodes.. It can be specified in both depressive and bipolar disorders.

3. Post-traumatic Stress Disorder

Post Traumatic Stress Disorder has also been sometimes associated with catatonic states.

4. Substance use, intoxication or abstinence

The uncontrolled administration or cessation of certain substances with effects on the brain. with effect on the brain can generate catatonia.

5. Autism spectrum disorder

Some children with developmental disorders such as autism may manifest catatonia in a comorbid manner.

Consideration today

Today the latest revision of one of the major diagnostic manuals of psychology, the DSM-5, has eliminated this label as a subtype of schizophrenia in order to to make catatonia a diagnostic indicator or modifier for both schizophrenia and other disorders (such as mood disorders). The classification as a neuropsychological syndrome separate from other disorders has also been added.

Treatment to be applied

Because the etiology (causes) of catatonia can be diverse, the treatments to be applied will depend to a great extent on what produces it. The origin of the catatonia should be analyzed and different actions should be taken depending on the origin of the catatonia.. Apart from this, the symptoms of catatonia can be treated in different ways.

At the pharmacological level the high usefulness of benzodiazepines has been proved, which act as GABA agonists in acute cases. agonists in acute cases. The effects of this treatment can reverse the symptoms of most patients. One of the most effective has been lorazepam, which is in fact the treatment of first choice.

Although it may seem, due to its association with schizophrenia, that the application of antipsychotics can be useful, the truth is that it can be harmful (remember that catatonia can appear in neuroleptic malignant syndrome, which is precisely caused by the administration of these drugs).

Another therapy used is the electro-convulsive therapyalthough it is usually applied if treatment with benzodiazepines does not elicit a response. The possibility of using benzodiazepines and electro-convulsive therapy together is also considered, as the effects can be potentiated.

At the psychological level occupational therapy can be used to stimulate the patient, as well as psychoeducation. for the patient and his or her environment in order to provide them with information and strategies for action and prevention. The treatment of affective symptoms is also of great help, especially in cases derived from psychiatric disorders.

Bibliographical references:

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Fifth edition. DSM-V. Masson, Barcelona.

• Arias, S. and Arias, M. (2008) Catatonia: Darkness, Dilemma, Contradiction. Spanish Journal of Movement Disorders; 9: 18-23.

• Crespo, M.L. & Pérez, V. (2005). Catatonia: a neuropsychiatric syndrome. Revista Colombiana de Psiquiatría. vol. XXXIV, 2. Bogotá.