Catatonia Associated with Another Mental Disorder (Catatonia Specifier)

Introduction

Catatonia is a state of neurogenic motor immobility. In its severe form, it involves the absence of movement and speech, and imposed postures. The most common symptoms are stupor, mutism and negativism. Other symptoms include staring, withdrawal, rigidity, echolalia and echopraxia. The individual may be in an excited, agitated and possibly aggressive state.

Catatonia is not classified as a separate disorder under DSM-5 but rather as a state associated with a number of disorders including schizophrenia, bipolar disorder, autism spectrum disorder and depression. The major characteristic of catatonia is stupor. Stupor is a condition in which a person lacks critical cognitive functioning and is unresponsive to stimuli other than pain. In addition to psychological disorders, stupor may present in infectious diseases, hypothermia, neoplasms, and drug abuse. Catatonia is featured in schizophrenia, depression, mania, and acute psychosis.

An improved classification of catatonia under DSM-5 is expected to make it easier to diagnose. Under DSM-4, catatonia was a subtype of schizophrenia, episode specifier of mood disorders, and a feature of medical conditions. Different characteristics were used to define catatonia in the latter. Under DSM-5, catatonia is a specifier of schizophrenia, mood disorders and other psychotic disorders, including schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. A catatonia-not otherwise specified category has also been added. The same criteria is now used to diagnose catatonia across all of these conditions. Thus, catatonic schizophrenia has been eliminated, together with four other subtypes, as a subtype of schizophrenia.

Under DSM-5, three of the following twelve characteristic symptoms of catatonia must be present for a diagnosis (American Psychiatric Association, 2013):

1. stupor
2. negativism
3. waxy flexibility
4. posturing
5. mimicking others’ speech or movement
6. lack of response
7. agitation
8. grimacing
9. catalepsy
10. repetitive movements
11. echolalia
12. echopraxia

Impact of Catatonia on Daily Life

The symptoms of catatonia can pose challenges and create social stigma in daily life. An episode may involve the individual afflicted staring in a daze and not responding to noise or normal touch, or he/she may talk in a quick, excited manner. A student with catatonia may fail to respond to teachers and peers or talk in a hyperactive manner and disturb the class. Impairments in mobility, speech and hearing can limit daily activities.

Catatonia can create social stigma in daily life. As many as 10 to 15% of psychiatric ward patients have catatonia. In individuals with autism, catatonia has been reported to be as high as 14 to 17%. Engagement in repetitive actions can be a source of stigma. Echophenomenon involves repetitive actions (echopraxia) and repetitive vocalizations (echolalia). Even with these challenges, many individuals with catatonia learn to control their symptoms and enjoy a good quality of life.

Catatonia is usually diagnosed when one or a cluster of symptoms interferes with daily functioning. A study of catatonia in those with autism spectrum disorder provides a useful classification of its effect on various degrees of daily functioning (Wing and Shah 2000).

• Least severe symptoms – mobile, slow carrying out self-care activities, freezing during an activity, participated in daily activities with help from staff.
• Severely affected – slow, unable to cross thresholds, locked into one repetitive activity, daily program severely impacted.
• Most severely affected - stiff, immobile, unable to cross demarcation lines, may walk long distance when prompted. Lives significantly disrupted by symptoms.

Catatonia Treatment

The main treatments for catatonia include pharmacotherapy and electro-convulsive therapy (ECT) (Bartolommei et al,2012). The main medication used is benzodiazepine, a drug with high addictive potential that is used in the treatment of anxiety, anterograde amnesia, sedation, seizures and convulsion. However, its use for more than four weeks is not recommended by the FDA. It is recommended that ECT be used to provide short-term improvements to severe symptoms, or in life-threatening situations. Although the treatment options for catatonia are limited, medications can have significant positive effects. Treatment outcomes, however, vary greatly depending on whether the catatonia is related to schizophrenia, depression, or autism. Other therapeutic approaches, such as behavioral therapy and speech therapy, have been applied as part of the treatment for disorders in which catatonia is a symptom. For example, the use of behavioral therapy has shown to improve the catatonic symptoms of repetitive vocalizations and behaviors in individuals with autism. Catatonia has been widely studied as a symptom of schizophrenia and autism.

Many interventions are focused on adaptive strategies. Occupational, individual and family therapy are often pursued to help individuals cope with the substantial changes to daily life that can be caused by catatonic symptoms. Occupational therapy may start with an assessment to evaluate the individual’s level of daily functioning. The two main areas of focus are physical and mental adaptation and development to help the individual adjust to daily life. For example, an individual may receive speech therapy and behavioral therapy to address repetitive vocalisations (echolalia) with a view to integrating them into a classroom environment. Echoic training is an example of therapy that incorporates both speech and behavioral therapy (Valentino et al, 2012).

Individual and family therapies are an important part of the adaptation process and maintenance of quality of life. A large number of children with autism engaging in echophenomena, self-injury, and aggressive behavior have hospital visits before adulthood. Problems with emotion regulation are often behind these externalizing behaviors. Psychotherapy can help these individuals cope with the additional pressures and resultant emotions they may experience in daily life. Most therapy today incorporates behavioral therapy. Family counselling plays an important role in the success of adoption and coping strategies since the responses of family members to catatonic symptoms will affect the individual’s development and coping strategies.

Novel therapies used in the treatment of echolalia that may have the potential to treat other catatonia symptoms include horse therapy (equine) (Holm et al, 2013) and music therapy.

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References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Wing, L., & Shah, A. (2000). Catatonia in autistic spectrum disorders. The British Journal of Psychiatry, 176(4), 357-362.

Bartolommei, N., Lattanzi, L., Callari, A., Cosentino, L., Luchini, F., & Mauri, M. (2012). Catatonia: a critical review and therapeutic recommendations. Journal of Psychopathology, 18, 234-246.

Valentino, A. L., Shillingsburg, M. A., Conine, D. E., & Powell, N. M. (2012). Decreasing Echolalia of the Instruction “Say” During Echoic Training Through Use of the Cues-Pause-Point Procedure. Journal of Behavioral Education, 21(4), 315-328.

Holm, M. B., Baird, J. M., Kim, Y. J., Rajora, K. B., D’Silva, D., Podolinsky, L., ... & Minshew, N. (2013). Therapeutic Horseback Riding Outcomes of Parent-Identified Goals for Children with Autism Spectrum Disorder: An ABA′ Multiple Case Design Examining Dosing and Generalization to the Home and Community. Journal of autism and developmental disorders, 1-11.

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