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

This state is called catatonia , a mainly motor syndrome of various causes and affecting patients with different types of both mental and medical disorders.

Catatonia as a syndrome: concept and symptoms

Catatonia is a syndrome of neuropsychological type in which a series of psychomotor symptoms are produced, often accompanied by cognitive, consciousness and perception alterations.

The most characteristic symptoms of this syndrome are the presence of catalepsy or impossibility of movement due to a state of muscular rigidity that prevents muscular contraction, waxy flexibility (a state of passive resistance in which the subject does not flex the joints by himself, staying as it is if it is placed in a certain way with the same posture and position unless it is changed and in which the members of the body remain in any posture in which another person leaves them), mutism, negativism in the face of the attempt to make the subject perform any action, eco-symptoms (or automatic repetition/imitation of the actions and words carried out by the interlocutor), stereotypes, perseverance, agitation, absence of response to the environment or stupor.

Your diagnosis requires at least three of the above-mentioned symptoms , for at least twenty-four hours. Anosognosia regarding motor symptoms is usually present.

Some psychological symptoms

Subjects with this alteration often present intense emotion , which is difficult to control, both in the positive and the negative. Although motor immobility is characteristic, sometimes patients leave it in a very intense emotional state with a high level of movement and agitation that may lead them to self-harm or to attack others. Despite their anosognosy regarding their motor symptoms, they are nevertheless aware of their emotions and the intensity with which they present themselves.

Catatonia can present in different degrees of greater or lesser severity , producing alterations in the vital functioning of the patient that can make it difficult to adapt to the environment.

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

Presentation patterns

Two typical presentation patterns can be observed, one called stuporous or slowed down catatonia and another known as agitated or delirious catatonia .

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

With regard to agitated or delirious catatonia, it is characterized by symptoms more linked to activation such as echoes, the performance of stereotyped movements and states of agitation.

Possible causes of catatonia

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

Research shows that patients with catatonia have some type of dysfunction in part of the right posterior parietal cortex , which is consistent with the fact that people with catatonia are able to initiate movement correctly (so that the extra motor area is usually preserved) and that there is anosognosy regarding motor symptoms.The lower lateral prefrontal of these subjects also tends to present alterations, as well as the medial orbitofrontal, which also explains the presence of occasional raptus and emotional alterations.

At the hormonal level, the role of GABA is explored, which has been shown to be altered in patients with catatonia by presenting a lower level of attachment to brain structures. Glutamate, serotonin and dopamine also appear to play a role in this disorder, but more research is needed into exactly how they influence it .

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 tumours and strokes are possible causes of this syndrome which should be treated immediately.

In addition, infections such as sepsis, tuberculosis, malaria, syphilis and 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 development of catatonia.

Other biological causes may derive from the use and/or abuse of psychoactive substances , whether drugs or psychotropic drugs. For example, catatonia is common in severe, life-threatening neuroleptic malignant syndrome, which in some cases occurs with the administration of antipsychotics.

Causes from Psychodynamics

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

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

However, it should be borne in mind that these explanations are based on an epistemology that is far removed from the scientific, and therefore are 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, the 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 been 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

Despite the fact that it has been linked almost from the beginning with schizophrenia, the different studies carried out regarding 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 disorder.

3. Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder has also been seen at times to be associated with catatonic states.

4. Substance use, intoxication or withdrawal

The uncontrolled administration or cessation of certain substances with an 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 fashion.

Consideration to date

Today, the latest revision of one of the main diagnostic manuals in psychology, the DSM-5, has eliminated this label as a subtype of schizophrenia in order to convert the catatonia into a diagnostic indicator or modifier of both this and other disorders (such as mood disorders). Classification as a neuropsychological syndrome has also been added separately from other disorders.

Treatment to be applied

Because the etiology (causes) of catatonia can be diverse, the treatments to be applied will depend largely on what produces it. Its origin must be analysed and it must act in a differentiated way according to what it is . Apart from this, the symptoms of catatonia can be treated in different ways.

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

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

Another therapy used is electroconvulsive therapy , although it is usually applied if treatment with benzodiazepines does not cause a response. The possibility of using benzodiazepines and electroconvulsive therapy together is also considered, as the effects can be enhanced.

On a psychological level , occupational therapy can be carried out to stimulate the patient, as well as psychoeducation for the patient and his/her environment in order to provide them with information and strategies for action and prevention. The treatment of affective symptoms is also very helpful, especially in cases derived from psychiatric disorders.

Bibliographic 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.