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Catatonic Schizophrenia: Symptoms, Causes, Treatment

Catatonic schizophrenia is one of 5 main subtypes of schizophrenia that is characterized by behavior at extreme opposite ends of the spectrum. At one end of the spectrum, the person may be unable to speak, move, or respond – they are stuck in a “catatonic stupor.” On the other end of the spectrum, the person may become hyperactive, repeat various words/sounds, and may engage in bizarre bodily movements. In other words, the person may be stuck in a state of “excitement” or a state of “stupor” – polar opposites. In neither the catatonic stage nor the excitement stage do the behaviors make logical sense.

Before catatonic schizophrenia is specifically diagnosed, the individual usually is diagnosed with standard symptoms of schizophrenia. It eventually becomes apparent that they meet a more specific “catatonic” diagnosis upon further evaluation of symptoms. In regards to all subtypes of the illness this is regarded as being pretty rare. Some experts suggest that to be in a “catatonic state” is usually the result of another comorbid mental illness; in addition to schizophrenia.

Catatonic Schizophrenia Symptoms

A general diagnosis of schizophrenia must be fulfilled before a catatonic subtype can be diagnosed. It should also be noted that individuals may experience temporary and/or isolated catatonic symptoms with any subtype of schizophrenia. In order to diagnose catatonic schizophrenia, the catatonic symptoms must be a dominant.

  • Bizarre movements: The person may engage in “odd” or bizarre movements for absolutely no reason. They may sit inappropriately, make crazy facial expressions, engage in “grimacing,” or repeat certain movements. Some people with catatonic schizophrenia arrange objects exactly the same way and obsessively follow a bizarre routine.
  • Command automatism: The person with schizophrenia automatically complies with any instructions that are given to him or her. In other words if you tell the individual to do something, they will immediately comply without question.
  • Echolalia: This involves mimicking speech that the person hears someone else say. They may continuously repeat a word or phrase said by someone else for no apparent reason. They are essentially “echoing” what someone else says.
  • Echopraxia: This involves mimicking a gesture or movement that someone else does. They may continuously repeat the gesture or movement that they see someone else do.
  • Excessive mobility: On the other end of the spectrum, people also can experience excessive amounts of movement. They may flail arms, pace back and forth, make loud noises, and engage in a variety of nonsensical movements. These movements typically have no purpose and the individual lacks rationale behind them.
  • Excitement: This is characterized by motor activity that is not influenced by an external stimulus. It will appear as if the person is moving with no apparent cause or purpose. The amount of movement or excitement varies depending on the person.
  • Extreme resistance: The person may not respond to any verbal instructions and/or commands. They may resist all attempts to be moved from their current position and may not speak at all. This is essentially the polar opposite of command automatism.
  • Negativism: This consists of resisting all attempts or instructions to move the person. A person with catatonic schizophrenia may resist if you attempt to move their positioning. There is no apparent motivation behind this resistance. In some cases the person will actually move in the opposite direction of what they were instructed.
  • Perseveration of words or phrases: The individual will repeat particular words that are contextually inappropriate. They may also repeat various phrases that do not make any logical sense in the midst of conversation.
  • Physical immobility: People may be unable to move their body and/or speak. They are frozen in a rigid position or stuck in what’s characterized as a “catatonic stupor.” At times the person may appear to be frozen or completely void of any physical movement. They may stay stuck in a certain position for hours.
  • Posturing: The person maintains odd or bizarre postures. These postures may appear uncomfortable and are completely voluntary on behalf of the person with this illness. In other words, the postures are self-initiated and held – sometimes for hours.
  • Rigidity: The individual may maintain an extremely rigid, strong, or tense posture against any efforts to move them. In other words, if you attempt to move their body, you may feel an overwhelming stiffness or tension as a result of their rigidity.
  • Stereotypies: The person may repeat actions without purpose or reason. This is a common symptom. A stereotypy may be something as simple as body rocking or swaying.
  • Stupor: This is characterized by a major decrease in reaction to environmental stimuli as well as in spontaneous movements. In some cases the stupor may be severe enough to be classified as “mutism.” The individual lacks cognitive function and consciousness which makes them appear almost unresponsive. While in a state of stupor, the person’s eyes may be open and follow various objects in their immediate surroundings.
  • Waxy flexibility: In some cases, people with catatonic schizophrenia exhibit what’s referred to as “waxy flexibility.” This means that if you were to position their body in odd positions, they will simply maintain the positions and hold them for an extended period of time. In other words, this is like molding or bending a wax figure. They will hold their limbs and body and maintain whatever position another person positions them in.

Catatonic Schizophrenia Causes

Researchers do not know what causes schizophrenia let alone the catatonic subtype. Catatonia is thought to be caused by dysfunction in the GABA and glutamate systems.  Researchers have been able to note brain changes as well as hypothesize how neurotransmitters may also play a role.

  • Abnormal metabolism: The metabolism throughout the thalamus and prefrontal lobe becomes abnormal.
  • Dopamine blockages: Researchers note that blockages of dopamine activity in the brain can lead to catatonic symptoms.
  • Fear response: Some hypothesize that catatonia is a result of an evolutionary fear response. Once this fear response becomes activated, it leads to a catatonic or completely still state.
  • GABA deficits: This is an inhibitory neurotransmitter that helps people regulate excitability throughout the nervous system. It is thought that a deficiency in GABA can lead to catatonic symptoms because there is no modulation of the basal ganglia.
  • Glutamate excess: An excess in glutamate activity is thought to be involved in catatonic symptoms. Most of the time it is noted that the glutamate transmission becomes “hyperactive.”
  • Psychomotor problems: There are clear problems with psychomotor activity among individuals with catatonia.

Source: http://apt.rcpsych.org/content/13/1/51.full.pdf

Catatonic Schizophrenia Treatment Options

Although antipsychotics are often utilized in the treatment of schizophrenia, they may end up worsening the catatonia. They also can lead to the development of neuroleptic malignant syndrome – a very dangerous condition that has similar symptoms to catatonia. In cases of neuroleptic malignant syndrome, antipsychotics need to be immediately discontinued.

  1. Benzodiazepines: When a person is stuck in a state of catatonia, it has been found that the benzodiazepine class of drugs works best at treating symptoms. This is considered the first line of treatment and typically the administration 1 to 2 mg of lorazepam (Ativan) results in marked improvement in catatonic symptoms.
  2. Electroconvulsive Therapy (ECT): This has been established as being an effective treatment option for catatonic symptoms. Usually if the benzodiazepines are not able to take care of the symptoms, this is a second option that may be utilized.
  3. NMDA antagonists: These are considered third-line treatment options (following trials of benzodiazepines and ECT). These consist of medications such as Amantadine or Memantine – medications used for neurodegenerative disorders. The tricky thing with these medications is that the person may develop a tolerance with extended usage and could experience psychosis as a result of the way the medication affects the dopamine system. A third medication that is sometimes considered is Topiramate which works by modulating the AMPA receptors as a glutamate antagonist.

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