Catatonia DSM-5 Multiple Diagnostic Codes

Catatonia DSM-5 Multiple Diagnostic Codes

Catatonia

Catatonia is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who display apparent unresponsiveness to external stimuli, despite being awake. Catatonia affects a person’s mental functioning and behavior, often occurring in relation to other mental disorders or medical conditions.

Introduction

Catatonia sufferers do not respond to other people or stimuli in the normal way. Commonly characterized by stupor - in which a person cannot move or speak - catatonia may occur in the context of a psychiatric disorder like schizophrenia, with a general medical disorder like encephalitis, or in an unspecified form.

Episodes of catatonia associated with another mental or medical disorder are diagnosed when the individual exhibits at least three of the 12 associated psychomotor features, which - as well as unresponsiveness - can include agitation, mutism or echolalia - repetition of another person’s speech.

Catatonia may affect an individual for a few hours in isolation or may recur periodically over weeks, months or even years (Hervey et al 2013). The complex condition occurs in more than ten per cent of people with acute psychiatric illnesses and can cause serious medical complications (Rasmussen et al 2016).

Symptoms

Someone experiencing catatonia will display various signs and symptoms, the most common of which are as follows:

Mutism - the patient is verbally unresponsive

Immobility - an individual displays altered arousal and lack of reaction to stimuli

Negativism - bodily manipulations are resisted during examination

Posturing - the individual maintains bodily or facial postures for long periods of time

Stereotypy - patients display repetitive motor or verbal behavior

Echophenomena - individuals may repeat other people’s speech or movements

Other signs that a person is experiencing catatonia include a rigid posture, withdrawal and refusal to eat, as well as staring and excessively repeating random words (verbigeration).

Catatonia is sometimes divided into two subsets: retarded catatonia and excited catatonia. The former is characterized by slow movement and unresponsiveness; the latter is typified by restlessness or agitation, and sufferers may have a fast heartbeat and raised blood pressure.

Although catatonia is most commonly witnessed in its retarded form, excited catatonia - also known as malignant or lethal catatonia - is associated with serious risks of complication, including altered consciousness, hyperthermia and internal body process dysfunctions (Rasmussen et al 2016).

Diagnostic criteria for catatonia

A diagnosis may be made when a person exhibits three or more of the diagnostic criteria for each type of catatonia.

Catatonia associated with another mental disorder (catatonia specifier)

  • Stupor - no conscious mental activity is witnessed within the person’s environment.
  • Catalepsy - the individual maintains a fixed/frozen posture.
  • Waxy flexibility - slight, even resistance to bodily manipulation.
  • Mutism - little to no verbal response; cannot be explained by aphasia.
  • Negativism - opposition or unresponsiveness to external stimuli or instructions.
  • Posturing - spontaneous and active maintenance of a posture against gravity.
  • Mannerism - exaggerated or repetitive gestures or expressions.
  • Stereotypy - repetitive movements without obvious purpose.
  • Agitation - emotionally restless; not as a result of external stimuli.
  • Grimacing - displaying contorted facial expressions.
  • Echolalia - mimics another’s speech.
  • Echopraxia - mimics another’s movements.

Catatonic disorder due to another medical condition

In cases where catatonia is experienced as a result of another disorder, the above measures will again be used in the diagnosis, alongside several other criteria - namely:

B. There is evidence that the disturbance being experienced is a direct result of another medical condition.
C. The disturbance cannot be better explained by another mental disorder.
D. The disturbance does not occur only during episodes of delirium.
E. The disturbance causes distress or impairment in social, occupational or other key areas of functioning.

(American Psychiatric Association 2013)

Unspecified catatonia

If an individual is experiencing symptoms of catatonia that cause significant distress or impairment but that cannot be clearly attributed to another mental or medical condition, or there is not enough information to do so, they may be diagnosed with unspecified catatonia.

Some practitioners use rating scales to aid diagnosis, such as the Bush-Francis Catatonia Rating Scale (BFCRS). The BFCRS scale assesses individuals through 23 indicators on a continuum of zero to three to measure the presence and severity of catatonia (Bush G., Fink. M, Petrides G., et al. 1996).

Another helpful diagnostic aid is the Lorazepam Challenge Test. After examination, the patient is given an intravenous dose of the medication lorazepam and examined again five minutes later for a reduction in symptoms. The process may be repeated again; a significant reduction in catatonic symptoms is usually observed within ten minutes in favorable responses, confirming catatonia as the diagnosis (Sienaert, P. et al 2014).

Causes of catatonia

There is no single cause of catatonia, the disorder is usually associated with another mental or medical condition. Catatonia may occur in psychiatric disorders like schizophrenia, bipolar disorder and major depressive disorder, as well as among individuals who have experienced extreme trauma.

A variety of medical conditions may cause - or be associated with - catatonia, such as encephalitis or neurodegenerative disease. Infections, severe vitamin B12 deficiency, autism or exposure to toxins may also be associated with the condition(Psychology Today 2018).

Alternatively, catatonia can occur as a side effect of medication, the result of faulty neurotransmitter activity in the brain or have an altogether unknown cause.

Catatonia differential diagnosis and comorbidity

Catatonia can be difficult to diagnose as the condition’s features are characteristic of many other disorders. Physical conditions with similar features include convulsive status epilepticus, metabolic conditions like pellagra and diabetic ketoacidosis, neuroleptic malignant syndrome and a whole host of other neurological disorders (Wilcox & Reid Duffy 2015).

Symptoms of catatonia may be present in a range of mental disorders, too, including schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, substance/medication-induced psychotic disorder, bipolar and depressive disorders (American Psychiatric Association 2013).

Living with catatonia

Catatonia may come and go over periods of months or years, or may occur as an isolated episode. The condition causes significant distress to sufferers, impacting on areas of functioning such as work and relationships.

Someone experiencing the symptoms of catatonia will be unresponsive, may appear to be in a trance and adopt strange postures or expressions. An individual in a severe catatonic state may be at risk of self-injury, exhaustion, malnutrition and hyperpyrexia (American Psychiatric Association 2013).

Those with affective symptoms may experience long periods of remission from catatonia. Conversely, individuals diagnosed with schizophrenia many experience catatonia as a chronic condition, although symptoms may sometimes present in association with neuroleptic malignant syndrome (Wilcox &Reid Duffy 2018).

Although it is not possible to prevent catatonia because the cause cannot be accurately determined, it is suggested that taking excessive amounts of neuroleptic medications like thorazine should be avoided (Healthline 2018).

Once diagnosed, catatonia can be treated and patients usually respond positively and rapidly to treatment. Different types of treatment may be offered to bring the condition under control, usually taking the form of medication or electroconvulsive therapy.

Treatment for catatonia

Catatonia is a treatable condition, commonly managed with medication or brain stimulation therapy.

Medication

Benzodiazepine medication is often used to treat catatonia, particularly lorazepam, which is sold under the brand name Ativan among others. Acting on the brain and nerves, benzodiazepines have a calming effect and can be used to treat anxiety, symptoms of alcohol withdrawal and insomnia.

Anxiety is a common feature of catatonia in many cases; benzodiazepines work to reduce panic by enhancing the effects of the GABA chemical in the body and regulating nerve abnormalities in the brain.

In patients who cannot actively swallow medication, benzodiazepines can be conveniently administered by placing a tablet under the tongue, or by intramuscular injection. In many cases, signs of recovery may start to show in a matter of hours.

It is recommended that individuals experiencing catatonia continue to take benzodiazepines until any underlying condition is being treated - this is to prevent a relapse into a catatonic state. In some situations, it may be necessary for patients to take the medication indefinitely to keep the condition under control (Rasmussen et al 2016).

Other medications that may be used to treat catatonia include:

  • Bromocriptine
  • Amobarbitol
  • Reserpine
  • Tricyclic antidepressants
  • Zolpidem

(Healthline 2018)

Alternative treatments

Electroconvulsive therapy (ECT) is also used to treat catatonia. Individuals who do not respond to benzodiazepines after a number of days generally respond to ECT, which should be used as a secondary treatment option as consent from patients in a catatonic state may be difficult to obtain.

In some cases, however, ECT may be preferable in the earlier stages of treatment - particularly if an individual is suffering from malignant catatonia. This excited form of the condition has a high mortality rate if treatment is not administered rapidly and effectively (Rasmussen et al 2016).

ECT is administered painlessly in a supervised medical setting once the patient is sedated. A machine delivers as electric shock to the brain, causing it to go into seizure for a minute or so. This, in turn, changes the flow of neurotransmitters in the brain and can improve the symptoms of catatonia (Healthline 2018).

In some cases, patients may be treated with anesthetic pain medications or, in co-existing conditions such as vitamin deficiency, supplementary nutrients may be given (Psychology Today 2018).

Catatonia can be severe and potentially life-threatening, however, with rapid and effective treatment, catatonia can be controlled and the prognosis for recovery is good - especially among individuals experiencing catatonia with mood disorders (Sienaert, P. et al 2014).


Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

References

Hervey, W., Stewart, J., Catalano, G. (2013) Psychopharmacology for the Clinician. Psychiatry Neurosci DOI: 10.1503/jpn.120249.

Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016) Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World Journal of Psychiatry, 6(4), 391–398. http://doi.org/10.5498/wjp.v6.i4.391.

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bush G., Fink. M, Petrides G., et al. (1996) Catatonia I. Rating scale and standardized examination, Acta Psychiatr Scand 93:129-136.

Sienaert, P., Dhossche, D. M., Vancampfort, D., De Hert, M., & Gazdag, G. (2014) A Clinical Review of the Treatment of Catatonia. Frontiers in Psychiatry, 5, 181. http://doi.org/10.3389/fpsyt.2014.00181.

Psychology Today (2018) Catatonia. https://www.psychologytoday.com/gb/conditions/catatonia Date Accessed: 20/09/2018.

Wilcox, J. A., & Reid Duffy, P. (2015) The Syndrome of Catatonia. Behavioral Sciences, 5(4), 576–588. http://doi.org/10.3390/bs5040576.

Healthline Media (2018) What Causes Catatonia? https://www.healthline.com/symptom/catatonia Date accessed: 20/09/2018.


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