A case of adolescent catatonia.

Catatonia is a motor dysregulation syndrome in which patients lose the ability to move normally despite having the full physical capacity to do so. It is a syndrome, a cluster of symptoms, and in itself is not a diagnosis. The syndrome was first described by the German psychiatrist, Karl Kahlbaum, in 1874 in his monograph, Die Katatonie oder das Spannungsirresein (Kahlbaum, 1874). Kahlbaum reported twenty-six cases of what he called tension insanity, of various etiologies. Its recognition in the following years rose dramatically in psychiatric populations, with prevalence estimates between 6% and 38% (Fink & Taylor, 2003). Its identification rose to such extents that Emil Kraepelin’s notion of dementia praecox considered catatonia to be a hallmark of the disorder. Others, such as Kleist, Wernicke, and Leonhard, noted catatonic features in patients with affective disorders (Shorter, 1997). As a syndrome, there are a number of cardinal features which have been described (Fink & Taylor, 2003). Mutism refers to verbal unresponsiveness; alternatively, echolalia (repetition of the sounds and words produced by others) may also occur. Patients may also imitate physical gestures (echopraxia). Negativism refers to the process of actively resisting any efforts to be moved or failure to obey requests or commands; this process is involuntary. Conversely, patients may demonstrate automatic obedience, the inability to resist following commands. Other patients demonstrate waxy flexibility (cerea flexibilitas), allowing their limbs to be molded at the examiner’s will. Patients may exhibit catalepsy, maintaining abnormal and peculiar postures for an extended period of time; prior to the advent of adequate treatment, some patients would maintain these postures for days or months. Patients may also demonstrate stereotypies (purposeless, repetitive motor behavior) and mannerisms (odd, purposeful or exaggerated movements). A wide variety of causes of catatonia have been reported (Takaoka & Takata, 2003). Psychiatric conditions, including schizophrenia, bipolar disorder, post-traumatic stress disorder, eating disorders, and depressive disorders have been associated with catatonia. Medical causes such as autoimmune disorders, paraneoplastic syndromes, and metabolic disturbances have also been identified. Catatonia also occurs in a variety of neurological conditions including encephalitis, stroke, and seizure disorders. Catatonia has been associated with ecstasy, phencyclidine, inhalant, steroid, and neuroleptic use, as well as the abrupt withdrawal of benzodiazepines. A number of subtypes of catatonia have been described (Fink & Taylor, 2003). Kahlbaum’s instrumental role in delineating the entity led to a specific form of retarded catatonia (with rigidity, inhibition of movement, abnormal posturing, mutism, and failure to respond to painful stimuli) to be called Kahlbaum’s syndrome. In contrast, excited catatonia (delirious mania, Bell’s mania) involves restless movements, talkativeness, agitation, frenzy, disorientation, and confusion. Periodic catatonia, most frequently associated with bipolar disorder, involves fluctuations between stupour and excitement. Malignant catatonia (lethal, pernicious) is characterized by rigidity and an altered level of consciousness with hyperthermia and autonomic instability; this condition is potentially life threatening. Neuroleptic malignant syndrome and serotonin syndrome are considered forms of malignant catatonia. Literature regarding catatonia in children and adolescents is sparse. Features particular to child and adolescent presentations have been described which include: (1) increased slowness affecting motor and verbal responsiveness, (2) difficulty initiating and completing actions, (3) increased reliance on cueing by others, (4) increased passivity and lack of motivation, (5) reversal of circadian rhythms, (6) Parkinsonian features, (7) excitement and agitation, and (8) increased repetitive and ritualistic behavior (Wing & Shah, 2000). A number of rating scales have been developed to assist with its identification, including the Bush-Francis Catatonia Screening Instrument (BFCSI), the Bush-Francis Catatonia Rating Scale (BFCRS), and the Modified Roger’s Rating Scale (MRRS). The lorazepam challenge may also assist in evaluation. It involves the administration of 1–2mg of intravenous lorazepam. A positive test results in the rapid relief of catatonic symptoms, albeit usually transiently (Fink & Taylor, 2003). There is a high response rate, cited as typically between 75%–100% (Hawkins et al., 1995). Admission to neurology or a medical intensive care unit is warranted for cases of catatonia associated with neuroleptic malignant syndrome, encephalitis, and non-convulsant status epilepticus. Atypical antipsychotics are preferred over typical agents due to the risk of precipitating or worsening a potential malignant state. If initially useful, regular doses of lorazepam (starting at 3mg per day) should be used to prevent relapse into catatonia. Parenteral nutrition and intravenous fluids should be considered for those with poor intake. Vitals should be monitored regularly for autonomic instability. If the above measures are unsuccessful, electroconvulsive therapy has been identified as the definitive treatment (Fink & Taylor, 2009).

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