Comprehensive Catatonia Guideline Released
Abstract
The guideline offers more insight into this underappreciated psychomotor syndrome that can arise from a range of psychiatric and other medical disorders.
A multinational expert group has developed a comprehensive clinical guideline for the management of patients with catatonia—a severe neuropsychiatric condition marked by abnormal speech and movement. The guideline was published earlier this year in the Journal of Psychopharmacology.
The new catatonia guideline developed by the British Association for Psychopharmacology provides guidance and resources for conducting a thorough patient evaluation for a syndrome that has a wide range of psychomotor manifestations. DSM-5 defines catatonia as the presence of three or more of the following: Catalepsy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerisms, stereotypies, grimacing, echolalia, and echopraxia.
“Catatonia is a fascinating and underrecognized condition,” said Jonathan Rogers, M.B.B.Chir., a Wellcome Trust Clinical Training Fellow at University College London Division of Psychiatry and co-author of the new guideline.
Up to 10% of hospitalized psychiatric patients may experience catatonia, according to some estimates. Yet, many psychiatrists miss the signs of the disorder—which can range from immobility and not speaking to excitability, stupor, and/or psychomotor disturbances, explained Mark Oldham, M.D., who co-authored the guideline. He is an assistant professor of psychiatry at the University of Rochester Medical Center in New York.
Guideline Highlights Causes, Treatment Options
While several catatonia guidelines predate this guideline, Oldham said that most of the guidelines focused on the occurrence of catatonia in specific patient populations, such as people with schizophrenia. “This is the first generic guideline that looks at catatonia across all possible etiologies,” he said.
While catatonia is a neuropsychiatric syndrome, in many cases the underlying cause is not due to a psychiatric disorder. —Jonathan Rogers, M.B.B.Chir.
Catatonia is associated with a host of psychiatric disorders, including mood disorders, autism spectrum disorder, and substance use disorders, Rogers said. Other illnesses may also increase the risk of catatonia, he added. “Data suggest that 20% of catatonia cases overall and 50% of those in an acute medical setting, like an ICU, involve no psychiatric comorbidity,” Rogers added. Catatonia has been linked with encephalitis, medication withdrawal, endocrine problems, and more.
In addition to describing the clinical features of catatonia, the guideline offers recommendations about how to narrow in on potential causes of catatonia, including when to seek guidance from other physicians, such as a neurologist.
Taking the time to uncover catatonia with a thorough assessment is satisfying, however, as catatonia can readily be treated, Rogers continued. Most patients will respond quickly to either benzodiazepines (preferably lorazepam) or electroconvulsive therapy, he noted. In cases of no or limited response to either of these, the NMDA-receptor medications amantadine and memantine are recommended.
Knowledge Gaps Remain
The guideline emphasizes several groups of patients who might benefit from a more targeted treatment approach. For instance, if a patient has periodic catatonia (a rare type characterized by the rapid onset of motor disturbances that last a few weeks and then disappear for weeks, months, or even years), he or she might be most responsive to treatment with lithium.
Psychiatrists often miss the signs of the catatonia—which can range from immobility and not speaking to excitability, stupor, and/or psychomotor disturbances. —Mark Oldham, M.D.
“Another circumstance is catatonia due to clozapine withdrawal,” Oldham continued. “If that is suspected, then restart the patient on clozapine if there are no safety concerns.”
He noted that there is some debate over whether to administer antipsychotics in individuals with catatonia and schizophrenia (since these drugs can induce movement problems).
“A common refrain is that antipsychotics are an absolute no-no for catatonia, but these guidelines say judicious prescribing can be beneficial when catatonia is accompanied by psychosis,” he said. The guidelines recommend using second-generation antipsychotics and regular checking of a patient’s iron levels. (Low iron is a risk factor for neuroleptic malignant syndrome, a potentially life-threating disorder characterized by extreme muscle rigidity, elevated heart rate, and hyperthermia.) Co-administration of a benzodiazepine with the antipsychotic is also suggested.
Both Rogers and Oldham cautioned that while these guidelines offer many recommendations, the underlying clinical evidence is still sparse, and many knowledge gaps remain.
More education is needed about this serious syndrome to generate awareness about the disease, Oldham said, noting that he hopes the publication of the guideline helps. “People with catatonia are in a mental prison; they are often aware of their inability to speak or act in the way they should, and that causes tremendous anguish.” ■
