Catatonia – Prevention – Causes – Symptoms – Treatment

Definition
Catatonia is a condition marked by changes in muscle tone or activity associated with a large number of serious mental and physical illnesses. There are two distinct sets of symptoms that are characteristic of this condition. In catatonic stupor the individualexperiences a deficit of motor (movement) activity that can render him/her motionless. Catatonic excitement, or excessive movement, is associated with violent behavior directed toward oneself or others. Features of catatonia may also be seen in Neuroleptic Malignant Syndrome (NMS) which is an uncommon (but potentially lethal) reaction to some medications used to treat major mental illnesses.NMS is considered a medical emergency since 25% of untreated cases result in death. Catatonia can also be present in individuals suffering from a number of other physical and emotional conditions such as drug intoxication, depression, and schizophrenia. It is most commonly associated with mood disorders.

Description
In catatonic stupor, motor activity may be reduced to zero. Individuals avoid bathing and grooming, make little or no eye contact with others, may be mute and rigid, and initiate no social behaviors. In catatonic excitement the individual is extremely hyperactive although the activity seems to have no purpose. Violence toward him/herself or others may also be seen.

NMS is observed as a dangerous side effect associated with certain neuroleptic (antipsychotic) drugs such as haloperidol (Haldol). It comes on suddenly and is characterized by stiffening of the muscles, fever, confusion and heavy sweating.
Catatonia can also be categorized as intrinsic or extrinsic. If the condition has an identifiable cause, it is designated as extrinsic. If no cause can be determined following physical examination, laboratory testing, and history taking, the illness is considered to be intrinsic.

Causes
CATATONIC SCHIZOPHRENIA.
The cause of schizophrenia remains unknown. During the past decade, however, research has pointed to abnormalities in structure or function of certain areas of the brain , including the limbic system, the frontal cortex, and the basal ganglia. These three regions are interconnected, so that dysfunction in one area may be related to structural problems in another. Brain imaging of living people and studies of the brains of deceased persons point to the limbic system as the potential site of pathology in at least some, if not most, schizophrenic patients.

DEPRESSION WITH CATATONIC FEATURES.
Mood disorders are believed to be at least partially caused by irregularities in production of neurotransmitters within the brain. Neurotransmitters are chemicals that conduct impulses along a nerve from one nerve cell to another. Two of the most important neurotransmitters associated with depression are norepinephrine and serotonin. In animal studies, virtually all effective antidepressant medications affect the receptors for these neurotransmitters. Dopamine is another neurotransmitter that plays a role in the development of depressive disorders.

CATATONIC DISORDER DUE TO A GENERAL MEDICAL CONDITION. 
Numerous medical conditions can cause psychiatric symptoms. Some of the more common are infectious, metabolic, and neurological conditions. Catatonic symptoms have been linked to earlier infection with encephalitis and to Parkinson's disease. Although the appearance of patients with post-encephalitis catatonia may be similar to that of catatonic schizophrenic patients, the majority of post-encephalitic patients are not psychotic. Oliver Sacks vividly describes catatonic disorder due to encephalitis and Parkinson's disease in his 1973 book  Awakenings  .

Symptoms
CATATONIC SCHIZOPHRENIA.
Catatonic schizophrenia is a form of thought disorder with prominent motor symptoms and abnormalities. These symptoms include:

 * Catalepsy, or motionlessness maintained over a long period of time.
* Catatonic excitement, marked by agitation and seemingly pointless movement.
* Catatonic stupor, with markedly slowed motor activity, often to the point of immobility and seeming unawareness of the environment.
 * Catatonic rigidity, in which the person assumes a rigid position and holds it against all efforts to move him or her.
* Catatonic posturing, in which the person assumes a bizarre or inappropriate posture and maintains it over a long period of time.
* Waxy flexibility, in which the limb or other body part of a catatonic person can be moved into another position that is then maintained. The body part feels to an observer as if it were made of wax.
* Akinesia, or absence of physical movement.

Diagnosis
Catatonic symptoms are quite noticeable. Important diagnostic distinctions, however, must be made to determine their cause. Catatonic schizophrenia is diagnosed when the patient's other symptoms include thought disorder, inappropriate affect, and a history of peculiar behavior and dysfunctional relationships. Catatonic symptoms associated with a mood disorder are diagnosed when there is a prior history of mood disorder, or after careful psychiatric evaluation. Medical tests are necessary to determine the cause of catatonic symptoms caused by infectious diseases, metabolic abnormalities, or neurological conditions. The patient should be asked about recent use of both prescribed and illicit drugs in order to determine whether the symptoms are drug-related.

Treatment
Treatment for catatonic symptoms depends on the underlying cause. Catatonic schizophrenia is treated by a variety of pharmacological and psychotherapeutic methods. Hospitalization may be necessary to protect the patient's safety. Supportive psychotherapy and family education can help persons with schizophrenia and their families adjust to problems created by the illness. Such other supportive services as sheltered workshops and special education may also be necessary.

Treatment of catatonic symptoms due to mood disorder involves therapy directed at the underlying mood disorder. Manic episodes are treated with such mood stabilizers as lithium and valproic acid (Depakote). Depressive episodes are treated with antidepressant medications or, if necessary, electroconvulsive treatment (ECT).

Catatonic symptoms caused by a medical disorder require correct diagnosis of the underlying medical condition, followed by appropriate treatment. Levodopa and amantadine (Symmetrel) have shown some effectiveness in reducing catatonic symptoms due to post-encephalitic Parkinson'sdisease. Hospitalization and careful supervision of persons with catatonic symptoms may be necessary to insure that they do not hurt themselves or others.

Medication
Medication is the pillar of catatonic schizophrenia treatment. Benzodiazepines are the most common medicines for the treatment of catatonic schizophrenia. Also called anti-anxiety medications, these are basically sedatives. This medication may be injected in a vein, they act fast and reduce the catatonic symptoms.

Barbiturates is another option, but not as common as Benzodiazepines. They are also sedatives and could form a habit for the person consuming them for long period of time. This medicine too help in reducing the symptoms of catatonic schizophrenia.

If an individual suffers from depression along with catatonic schizophrenia, then, anti-depressants is an alternative. Mood stabilizing medication can also be used for controlling hostility and aggression.

Prognosis
Catatonic schizophrenia is usually a debilitating lifelong illness. Symptoms typically emerge in adolescence. Social and environmental stressors, such as leaving home for college or military service, use of an illicit drug, or the death of a close friend or relative may trigger the initial symptoms of schizophrenia. The classic pattern is one of worsened symptoms alternating with remissions rather than cure, although about 20% of patients eventually resume their previous level of functioning. Following the initial episode, most patients suffer a relapse within five years of the diagnosis. The course of the disorder varies, with women having a somewhat better prognosis, but persons with schizophrenia remain vulnerable to stress for their lifetime.

Catatonia associated with mood disorders is somewhat more treatable, although it may also recur from time to time throughout the patients life.

Catatonic symptoms caused by medical conditions can be treated and sometimes cured. Infections are the most completely curable. Metabolic and neurological conditions may be treatable, but various degrees of impairment may remain throughout the patient's life.

Prevention
There are no specific preventive measures for most causes of catatonia. Infectious disease can sometimes be prevented. Catatonic symptoms caused by medications or drugs of abuse can be reversed by suspending use of the drug.

Resources
BOOKS
Frisch, Noreen Cavan, and Lawrence E. Frisch. Psychiatric
Mental Health Nursing. Albany, NY: Delmar
Publishers, 1998.
Donald G. Barstow, RN

BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.
Kaplan, Harold I., MD and Benjamin J. Sadock, MD. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th edition. Baltimore, MD: Lippincott Williams and Wilkins, 1998.
Sacks, Oliver. Awakenings. New York: HarperPerennial, 1990.

http://www.minddisorders.com
http://www.buzzle.com-Medha Godbole