How long does catatonia last
the person's body may be frozen, but their minds are not – new study
Occasionally, as a doctor, I am asked to see a patient in the emergency department who is completely mute. They sit motionless, staring around the room. I lift up their arm and it stays in that position. Someone takes a blood test and they don’t even wince. They haven’t eaten or drunk anything for a day or two.
Questions start running through your mind. What’s wrong with them? Would they respond to someone else? Do they have a brain injury? Are they putting it on? And – hardest of all – how am I to know what’s going on if they can’t tell me?
I’m a psychiatrist and a researcher specialising in a rare condition known as catatonia, a severe form of mental illness where people have problems with movement and speech. Catatonia can last anywhere from a few hours to weeks, months or even years. Some people have reoccuring episodes. I’ve spoken to doctors, nurses, academics, patients and carers about this condition. One question comes up more than any other: what are people with catatonia thinking? Are they even thinking?
When a person can hardly move or speak, it’s easy to assume that they aren’t conscious either. Research in recent years has shown that this isn’t the case. In fact, if anything, it’s the opposite. People with catatonia often express intense anxiety and say they feel overwhelmed with feelings. It’s not that people with catatonia have no thoughts - it might be that they have too many.
But what are these thoughts? What could the mind possibly do that would make you freeze? In a new study, my colleagues and I have tried to shed some light on this.
Hundreds of patients
By looking at the case notes of hundreds of patients who had experienced catatonia, we found that a few had spoken about what had happened, either at the time or later on. Many weren’t aware of or didn’t remember what was happening.
Some described experiencing overwhelming fear. Some were aware of the pain of staying rigid for so long, but, nonetheless, seemed unable to move. What we found most interesting, though, were those people who had – on one level – a rational explanation for the catatonia. One patient’s notes read:
I met him kneeling on the floor with his forehead on the floor. He said he had adopted the position to save his life and kept asking to be seen by a neck doctor … He kept talking about his head falling off his neck.
If you actually believed that your head was at imminent risk of falling off, maybe it wouldn’t be such a bad idea to hold it in place on the floor.
For others, it was voices (hallucinations) that were instructing them to do certain things. One person was being told that his head would explode if he moved - a fairly compelling reason to stay still. Another thought God was telling him not to eat or drink.A woman with catatonia ‘posturing’. Internet Archive Book Images/Wikimedia
One theory for catatonia is that it is similar to the “death feint” that some animals show. When faced with a predator of overwhelming size or strength, some prey animals will freeze and presumably the predator may not notice them.
One patient in the study vividly described seeing a snake (which also spoke to her). We can’t say from one example that her body was adopting a primitive defence to a predator, but it’s certainly a possibility.
Catatonia remains a mysterious condition, stuck halfway between neurology and psychiatry. At least by understanding what people may be experiencing, we can provide reassurance and empathy.
Causes, Symptoms, Treatment, and More
What is catatonia?
Catatonia is a psychomotor disorder, meaning it involves the connection between mental function and movement. Catatonia affects a person’s ability to move in a normal way.
People with catatonia can experience a variety of symptoms. The most common symptom is stupor, which means that the person can’t move, speak, or respond to stimuli. However, some people with catatonia may exhibit excessive movement and agitated behavior.
Catatonia can last anywhere from a few hours to weeks, months, or years. It can reoccur frequently for weeks to years after the initial episode.
If catatonia is a symptom of an identifiable cause, it’s called extrinsic. If no cause can be determined, it’s considered intrinsic.
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) no longer categorizes catatonia into types. However, many mental health professionals may still classify catatonia into three types: akinetic, excited, and malignant.
Akinetic catatonia is the most common catatonia form. It causes slow movement. A person with akinetic catatonia may stare into space and often doesn’t speak. These common symptoms can be seen in people with akinetic catatonia.
People with excited catatonia appear “sped up,” restless, and agitated. They sometimes engage in self-harming behavior. This form is also known as hyperkinetic catatonia.
People with malignant catatonia may experience delirium. They often have a fever. They may also have a fast heartbeat and high blood pressure.
According to the DSM-5, several conditions may cause catatonia. They include:
- neurodevelopmental disorders (disorders affecting the development of the nervous system)
- psychotic disorders
- bipolar disorders
- depressive disorders
- other medical conditions, such as cerebral folate deficiency, rare autoimmune disorders, and rare paraneoplastic disorders (which are related to cancerous tumors)
Catatonia is a rare side effect of some medications used to treat mental illnesses. If you suspect that a medication is causing catatonia, seek immediate medical attention. This is considered a medical emergency.
Withdrawal from some medications, such as clozapine (Clozaril), can cause catatonia.
Imaging studies have suggested that some people with chronic catatonia may have brain abnormalities.
Some experts believe that having an excess or lack of neurotransmitters causes catatonia. Neurotransmitters are brain chemicals that carry messages from one neuron to the next.
One theory is that a sudden reduction in dopamine, a neurotransmitter, causes catatonia. Another theory is that a reduction in gamma-aminobutyric acid (GABA), another neurotransmitter, leads to the condition.
Women have a higher risk of developing catatonia. The risk increases with age.
Although catatonia has historically been associated with schizophrenia, psychiatrists now classify catatonia as its own disorder, which occurs in the context of other disorders.
An estimated 10 percent of acutely ill psychiatric inpatients experience catatonia. Twenty percent of catatonic inpatients have schizophrenia diagnoses, while 45 percent have mood disorder diagnoses.
Women with postpartum depression (PPD) may experience catatonia.
Other risk factors are cocaine use, low salt concentration in the blood, and the use of medications such as ciprofloxacin (Cipro).
Catatonia has many symptoms, the most common of which include:
- stupor, where a person can’t move, can’t speak, and appears to be staring off into space
- posturing or “waxy flexibility,” where a person stays in the same position for an extended period
- malnourishment and dehydration from lack of eating or drinking
- echolalia, where a person responds to conversation by only repeating what they’ve heard
These common symptoms can be seen in people with retarded catatonia.
Other catatonia symptoms include:
- catalepsy, which is a type of muscular rigidity
- negativism, which is a lack of response or opposition to external stimulation
- echopraxia, which is the mimicking of another person’s movements
Symptoms specific to excited catatonia include excessive, unusual movements. These include:
- purposeless movements
Malignant catatonia causes the most severe symptoms. They include:
Vital signs such as blood pressure, breathing rate, and heart rate can fluctuate. These symptoms require immediate treatment.
Similarity to other conditions
Catatonia symptoms mirror those of other conditions, including:
- acute psychosis
- encephalitis, or inflammation in the brain tissue
- neuroleptic malignant syndrome (NMS), a rare and serious reaction to antipsychotic medications
- nonconvulsive status epilepticus, a type of severe seizure
Doctors must rule out these conditions before they can diagnose catatonia. A person must show at least two chief catatonia symptoms for 24 hours before a doctor can diagnose catatonia.
No definitive test for catatonia exists. To diagnose catatonia, a physical exam and testing must first rule out other conditions.
The Bush-Francis Catatonia Rating Scale (BFCRS) is a test often used to diagnose catatonia. This scale has 23 items scored from 0 to 3. A “0” rating means the symptom is absent. A “3” rating means the symptom is present.
Blood tests can help to rule out electrolyte imbalances. These can cause changes in mental function. A pulmonary embolism, or blood clot in the lungs, can lead to catatonia symptoms.
A fibrin D-dimer blood test can also be useful. Recent studies indicate that catatonia is associated with elevated D-dimer levels. However, many conditions (such as pulmonary embolism) may affect D-dimer levels.
CT or MRI scans allow doctors to view the brain. This helps to rule out a brain tumor or swelling.
Medications or electroconvulsive therapy (ECT) may be used to treat catatonia.
Medications are usually the first approach to treating catatonia. Types of drugs that may be prescribed include benzodiazepines, muscle relaxants, and in some cases, tricyclic antidepressants. Benzodiazepines are usually the first medications prescribed.
Benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), and diazepam (Valium). These medications increase GABA in the brain, which supports the theory that reduced GABA leads to catatonia. People with high rankings on the BFCRS usually respond well to benzodiazepine treatments.
Other specific medications that may be prescribed, based on an individual’s case, include:
- amobarbital, a barbiturate
- bromocriptine (Cycloset, Parlodel)
- carbamazepine (Carbatrol, Epitol, Tegretol)
- lithium carbonate
- thyroid hormone
- zolpidem (Ambien)
After 5 days, if there’s no response to the medication or if symptoms worsen, a doctor may recommend other treatments.
Electroconvulsive therapy (ECT)
Electroconvulsive therapy (ECT) is an effective treatment for catatonia. This therapy is performed in a hospital under medical supervision. It’s a painless procedure.
Once a person is sedated, a special machine delivers an electric shock to the brain. This induces a seizure in the brain for a period of around a minute.
The seizure is believed to cause changes in the amounts of neurotransmitters in the brain. This can improve catatonia symptoms.
According to a 2018 literature review, ECT and benzodiazepines are the only treatments that have been clinically proven to treat catatonia.
People typically respond quickly to catatonia treatments. If a person doesn’t respond to prescribed medications, a doctor may prescribe alternative medications until symptoms subside.
People who undergo ECT have a high relapse rate for catatonia. Symptoms usually appear again within a year.
Because the exact cause of catatonia is often unknown, prevention isn’t possible. However, people with catatonia should avoid taking excess neuroleptic medications, such as chlorpromazine. Medication misuse may aggravate catatonia symptoms.
Psychiatrist's opinion: "Classic catatonic syndrome" (December 27, 2007)
December 27, 2007, 00:00
The phenomenon of "Zoya's standing" is commented on by a psychiatrist-psychotherapist of the State Scientific Center for Social and Forensic Psychiatry. VP Serbsky Svetlana Kondrashova:
Apparently, we are talking about a classic catatonic syndrome. This phenomenon is very common in the later stages of endogenous disease - schizophrenia. Catatonic stupor is indeed characterized by severe rigidity (hardening) of the muscles - up to such a state when it is impossible for a person to give an injection. Even 20 years ago, the wards with the most severe patients in psychiatric hospitals sometimes resembled wax museums, but today it is almost impossible to detect catatonic syndrome in its pure form in any normal psychiatric clinic. Over the past 12 years, psychopharmacotherapy has taken a huge step forward. Modern drugs allow you to stabilize the disease at an earlier stage, without bringing it to a catatonic stupor. nine0003
Stone Zoe is said to have let out heart-rending cries.
This behavior is also very typical for catatonia. The only thing that makes me doubt in this story is the period of 128 days. Catatonic stupor can last for days, in rare cases it reaches 7-8 days, but no more. However, it is easy to see that almost all more or less reliably confirmed facts from the story about "Zoya standing" fall on the first week from New Year to Christmas. The further description is more and more reminiscent of a typical folk myth-building. nine0003
Some believe that among religious people there is a higher percentage of crazy people, and some believe that the opposite is true - religion brings mental health to a person's life. What does the statistics say about this?
There are no special statistics on this topic, but, based on my own professional experience, I can say that both are partially right. If a person adheres to religious dogmas, without falling into fanaticism and not being carried away by superstitions, then such faith really heals, because it gives a person a sense of security. On the other hand, a huge number of not quite adequate people are looking for recovery in the church. I noticed a long time ago that mentally vulnerable people in some incomprehensible way find those places where they can be helped. For example, there are no signs at our institution. Nevertheless, we have long ceased to be surprised that our potential patients are drawn here like a magnet. They just come to this fence, stand and look at it. nine0003
From the point of view of an atheist, the monk's reasoning about the resurrection of Christ is the same nonsense of a madman as the fear of little green men. Is there a fundamental difference here from the point of view of psychiatry?
Certainly. The monk is not obsessed with the reality in which he lives. He fully owns information about it and understands its logic. The monk is able to think rationally and critically. The madman differs from him in that his reality does not belong to him. He doesn't know how to navigate it. And if something out of the ordinary happens to a monk, he will say: “Thank God for everything!” - and a madman will crawl under a chair. nine0003
What is catatonia and why is it dangerous
November 7, 2020 Likbez Health
If a person falls into a stupor, speaks badly and adopts a strange posture, he urgently needs the help of a doctor.
What is catatonia
Catatonia, or catatonic syndrome, is a condition in which a person becomes immune to external stimuli and loses the ability to move and speak normally.
Until the beginning of the 20th century, it was thought that this only happened in schizophrenia. But then scientists found that more than 50% of cases of catatonia appear in bipolar disorder, about 10-15% are schizophrenia, and 21% are not associated with mental illness at all. nine0003
Catatonia is similar to mental disorders and other illnesses and is therefore difficult to recognize. For example, with it, as with a stroke, a person may respond with incomprehensible phrases or stop talking altogether. Urgent help is needed in both cases, but it will be different.
Catatonia may develop rapidly or gradually over several days. In the first case, the symptoms are usually strong and obvious; jumps in pressure or temperature are added to motor and speech disorders. This can lead, for example, to a stroke. In the second option, the symptoms are hardly noticeable, and this is the most dangerous: complications may appear in 3-4 days or the person will die. nine0003
Imagine a grandmother with dementia. She often sits on the edge of the bed and looks out the window. But suddenly she spends the whole day like this. Then the grandmother stops talking, reacting to others, but continues to sit. Then she refuses food, water.
The body is exhausted, and 2-3 days after the onset of the first symptoms, blood clots form in the legs from a long immobile posture. At some point, they come off and clog the vessel. The person is dying. But he would have been saved if the dangerous symptoms had been noticed on the first day. nine0003
Why catatonia occurs
Catatonia was first described in detail in 1874, but its causes have not yet been established. Scientists have several theories that roughly explain what changes in the body lead to the onset of catatonic symptoms.
Some researchers believe that the problem lies in the disruption of the transmission of nerve impulses in those areas of the brain that are responsible for muscle contractions. Others associate catatonia with a change in the balance of neurotransmitters - substances that are produced by brain neurons and are involved in the transmission of signals from cell to cell and many biochemical processes. Still others blame the excess or lack of certain hormones of the hypothalamus and pituitary gland, the production of antibodies to brain proteins. nine0003
Such disturbances in the functioning of the body appear in many diseases:
- psychiatric, such as bipolar disorder, schizophrenia, autism, depression, anorexia nervosa;
- endocrine: Cushing's syndrome, hyperthyroidism, Sheehan's syndrome and others;
- neurological, eg epilepsy, multiple sclerosis, Parkinson's disease, brain tumors, dementia;
- metabolic - this is when substances accumulate in the body that have a bad effect on the brain: this happens with Wilson's disease - Konovalov, an increase and decrease in the concentration of sodium in the blood, kidney failure and other diseases; nine0050
- autoimmune, eg systemic lupus erythematosus, antiphospholipid syndrome;
- caused by psychoactive substances: alcohol, antipsychotics, sedatives, drugs;
- infectious: HIV, typhoid fever, tuberculosis, meningoencephalitis, herpes and others;
- vascular, for example thrombosis of the arteries and veins of the brain, stroke, cerebral hemorrhage.
What are the symptoms of catatonia
There are many signs of catatonia. The DSM-5, used by psychiatrists around the world, identifies 12 main ones. But doctors add other symptoms to them:
- Remaining immobile (stupor).
- Long-term maintenance of a posture that has been given to the body (catalepsy). If a person is planted or placed, he will not move.
- Prolonged silence (mutism). The person does not respond, even if you address him by name. On the contrary, he is likely to turn away.
- Changing the position of the limbs, like a plasticine figurine (wax flexibility). Some patients obey easily and can follow any command, like robots. nine0050
- Passive and strong resistance to any attempt to change the position of the arms and legs (negativism). Sometimes it is physically impossible to bend or straighten the limbs.
- Maintaining an uncomfortable posture (posing). For example, a person can arch on the bed without touching the pillow with his head, as if hanging in the air.
- Pretentiousness of movements (mannership). A catatonic person may gesticulate strangely and inappropriately.
- Repetitive monotonous movement (stereotype). Recall how in horror movies the possessed are constantly swaying, tapping their fingers, or moving their mouths terribly. Most likely, they have an attack of catatonia. nine0050
- Excessive excitement without external stimuli. A person can rush around the room, show aggression, rush at others.
- Involuntary movements of lips, eyebrows. Grimaces that are not built to amuse others.
- Repetition of other people's words (echolalia). Moreover, speech often becomes incoherent, monotonous, words and phrases are spoken continuously, sometimes for a very long time.
- Copying other people's movements (echopraxia).
In addition, there may be symptoms associated with disruption of the autonomic nervous system. With catatonia, the temperature rises, thirst increases, saliva flows, blood pressure rises and the pulse quickens. Often patients refuse water and food. nine0003
When a doctor makes a diagnosis, he looks for a combination of several symptoms. But medical attention is needed even with the appearance of one symptom. Otherwise, you can miss not only catatonia, but also a stroke, the debut of schizophrenia, a complication of meningitis or another disease.
How catatonia is treated
If a person cannot move, does not respond to being addressed, an ambulance should be called. If the symptoms are mild, it is important to go to the therapist as soon as possible.
Based on the words of relatives or by analyzing the medical record, the doctor will determine whether there are mental illnesses, alcohol dependence or other pathologies that can cause catatonia. And if necessary, send to a psychiatrist. nine0003
He will prescribe medication or electroconvulsive therapy as soon as possible.
If there is no danger to the patient's life, examination will help to find the causes of catatonia:
- complete blood count;
- biochemical examination;
- blood electrolyte test;
- liver function tests;
- CT or MRI of the brain.
An electroencephalogram will be done if there is a suspicion of a brain tumor or seizures. nine0003
What medications are prescribed
The psychiatrist uses strong prescription medications to treat catatonia. Taking them on your own is dangerous.
First of all, drugs from the group of second-generation anxiolytics based on benzodiazepine are given. They reduce muscle spasm, soothe, help remove the symptoms of catatonia. Benzodiazepines are effective in 66-100% of patients.
If these drugs do not help, the treatment regimen is changed. Sometimes alternative drugs with sedative, anticonvulsant and muscle relaxant effects give the best effect. For example, lithium preparations will not allow a recurrence of an attack of catatonia. nine0003
Medicines from the group of neuroleptics are rarely prescribed: it is impossible to guess how the patient's body will react. On the one hand, drugs can remove muscle spasm. But at the same time, they can cause neuroleptic malignant syndrome. This is a condition when the temperature and pressure rise and the symptoms of catatonia intensify.
When electroconvulsive therapy is used
Electroconvulsive therapy is a treatment method in which an electric current is passed through the brain. It suppresses the foci that emit the wrong impulses and helps relieve muscle spasm and cramps. nine0003
Electroconvulsive therapy is used if benzodiazepines have failed or if the patient is at risk of death.
Catatonic attacks sometimes stop completely after electroconvulsive therapy. But there is a risk of side effects: headache, amnesia, confusion.
How successful catatonia is being treated
The sooner catatonia is treated, the better for the patient. Prompt help helps avoid complications and save lives.
But not everyone recovers. According to statistics, 12-40% of patients are successfully cured. Poor prognosis in children and adolescents with schizophrenia, as well as in the elderly. They may need ongoing psychiatric care. nine0003
If a person has been suffering from kidney failure, alcoholism, Parkinson's disease or other pathology for a long time, then the disturbances in the brain function are already chronic. Therefore, at any time, the catatonic syndrome can recur. In order not to be late with help, you need to remember the dangerous symptoms and follow the doctor's recommendations.
How not to get catatonic
Scientists have not yet learned how to prevent catatonia, like other mental illnesses or brain tumors. But, given the causes of the syndrome, we can advise the following:
- Reduce alcohol consumption and treat addiction symptoms.
- Never use drugs.
- Do not ignore symptoms of depression.
- Do not take hypnotics, sedatives, neuroleptics without a prescription from a specialist.
- Seek medical attention if headaches, dizziness, flies in the eyes.
- Treat kidney and liver diseases in time.