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3. Psychosis > Catatonia > Flashcards

Catatonia Flashcards

1
Q

in what types of disorders can catatonia develop

A

neurodevelopmental

psychotic

bipolar

depressive

other medical conditions

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2
Q

list some medical conditions in which catatonia can develop

A

cerebral folate deficiency

rare autoimmune + paraneoplastic disorders

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3
Q

how does the DSM categorize catatonia

A
  1. catatonia assoc. with another mental disorder (i.e bipolar, psychosis)
  2. catatonic disorder due to another medical condition
  3. unspecified catatonia
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4
Q

how many psychomotor features are listed in the criteria for catatonia

A

12

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5
Q

how many features must someone have out of the possible 12 in order to consider catatonia as a diagnosis

A

3 or more

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6
Q

what is the essential feature of catatonia

A

a marked PSYCHOMOTOR DISTURBANCE that may involve:

decreased motor activity

decreased engagement during interview or physical exam

or excessive and peculiar motor activity

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7
Q

why can the clinical presentation of catatonia be confusing?

A

because it can range from marked unresponsiveness to marked agitation

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8
Q

what is a severe example of motoric immobility assoc. with catatonia

A

stupor

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9
Q

what are examples of moderate motoric immobility associated with catatonia

A

waxy flexibility

catalepsy

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10
Q

what is an example of severely decreased engagement associated with catatonia

A

mutism

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11
Q

what is an example of moderately decreased engagement associated with catatonia

A

negativism

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12
Q

list the 12 symptoms of catatonia

A

stupor

catalepsy

waxy flexibility

mutism

negativism

posturing

mannerism

stereotypy

agitation, not influenced by external stimuli

grimacing

echolalia

echopraxia

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13
Q

what is stupor

A

no psychomotor activity, not actively relating to environment

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14
Q

what is catalepsy

A

passive induction of a posture held against gravity

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15
Q

what is waxy flexibility

A

slight, even resistance to positioning by examiner

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16
Q

what is mutism

A

no, or very little, verbal response (exclude if has known aphasia)

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17
Q

what is negativism

A

opposition or no response to instructions or external stimuli

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18
Q

what is posturing

A

spontaneous and active maintenance of a posture against gravity

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19
Q

what is mannerism

A

odd, circumstantial caricature of normal actions

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20
Q

what is stereotypy

A

repetitive, abnormally frequent, non goal directed movements

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21
Q

what is echolalia

A

mimicking anothers speech

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22
Q

what is echopraxia

A

mimicking anothers action

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23
Q

how many criteria are there for catatonia associated with another mental condition

A

just one–criterion A–which is the 3/12 symptoms needed

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24
Q

in what % of inpatients with schizophrenia is catatonia diagnosed

A

up to 35%

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25
Q

cases of catatonia associated with another mental disorder are most commonly associated with what mental disorders

A

depressive and bipolar

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26
Q

can catatonia be due to a medication

A

yes

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27
Q

what serious condition should be considered when assessing the etiology of catatonia

A

neuroleptic malignant syndrome

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28
Q

how many criteria are there for catatonia associated with another medical condition

A

5

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29
Q

criterion A for catatonia associated with another medical condition

A

3/12 of the symptoms

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30
Q

criterion B for catatonia associated with another medical condition

A

there is evidence from the history, physical examination, or lab findings that the disturbance is the direct pathophysiological consequence of another medical condition

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31
Q

criterion C for catatonia associated with another medical condition

A

disturbance not better explained by another mental disorder

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32
Q

criterion D for catatonia associated with another medical condition

A

disturbance does not occur only in the course of a delirium

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33
Q

criterion E for catatonia associated with another medical condition

A

disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

34
Q

what two types of medical disorders can, in particular, cause catatonia

A

neurological and metabolic

35
Q

examples of metabolic disorders that can cause catatonia

A

hypercalcemia

hepatic encephalopathy

homocystinuria

diabetic ketoacidosis

36
Q

examples of neurological disorders that can cause catatonia

A

neoplasms

head trauma

cerebrovascular disease

encephalitis

37
Q

can catatonia be life threatening

A

yes, in malignant form

38
Q

what characterizes malignant form of catatonia

A

fever and autonomic disturbances

39
Q

who first identified catatonia as a syndrome

A

Karl Ludwig Kahlbaum

german psychiatrist

1874

40
Q

in what populations is catatonia underrecognized

A

pediatric and autism pops

41
Q

what is the estimate prevalence of catatonia in CL populations

A

2-9%

42
Q

what is the estimated prevalence of catatonia in inpatients with psychosis?

mood disorders?

A

7-17% –> psychosis

15-31%–> mood disorders

43
Q

what are the risks stemming from hypoactive catatonia

A

can have impaired swallowing, dehydration, malnourishment from lack of eating

risk of aspiration, DVTs, PEs, contractures, pressure ulcers

44
Q

what % of those with autism spectrum disorders can experience catatonia

A

up to 10%

45
Q

risk factors for catatonia

A

prior episodes of catatonia

current or past EPS

mood disorders with psychomotor changes

autism spectru disorder

psychotropic medications (antipsychotics, antidepressants)

substances (cocaine, alcohol/benzo withdrawal)

withdrawal of long term anticholinergic use

electrolyte disturbance

dehydration

weight loss

meds that lower seizure threshold

46
Q

what electrolyte disturbances are a risk factor for developing catatonia

A

hyponatremia

hypomagnesemia

low serum iron

47
Q

what is a mnemonic to remember the core features of catatonia

A

WRENCHES

waxy flexibility
rigidity
echopraxia
negativism
catalepsy
high level of motor activity
echolalia
stupor, stereotypy
48
Q

what is a way, other than WRENCHES, to remember the features of catatonia

A

divide into categories of increased, decreased and abnormal motor activity

decreased behaviours--> 
stupor
negativism
mutism
posturing
catalepsy
abnormal behaviours--> 
stereotypy
mannerism
waxy flexibility
echolalia
echopraxia

increased behaviours–>
agitation
grimacing

49
Q

what scale measures the non DSM criteria of catatonia

A

Bush-Francis scale

includes:
verbigeration
withdrawal
mitgehen
gegenhalten
grasp reflex
automatic obedience
ambitendency
autonomic abnormality
combativeness
50
Q

what three subtypes of catatonia have been identified

A

stuporous

excited

malignant

51
Q

name an iatrogenic variant of malignant catatonia

A

NMS

52
Q

why do you have to treat malignant catatonia rapidly

A

it is life threatening

53
Q

how do you treat malignant catatonia

A

ECT

54
Q

what causes NMS

A

excessive dopamine blockade from dopamine antagonists or withdrawal of an agonist or GABA-A agnoist

55
Q

what is the dysfunctional neurotransmitter model of catatonia

A

?combo of:

  • reduced GABA activity in the frontal cortex
  • increased NMDA glutamatergic activity in the posterior parietal cortex
  • dampened dopaminergic action in the basal ganglia
56
Q

what is the neural network and circuits model of catatonia

A

suggests that disruption in the mesoencephalofrontal system (brainstem–> basal ganglia–> limbic system and cerebral cortex) causes it

57
Q

what is locked in syndrome

A

caused by PONTINE lesions can can be distinguished from catatonia because patients will usually try to communicate with their eyes on locked in syndrome

58
Q

what is stiff person syndrome

A

Stiff person syndrome is an autoimmune disorder that presents during severe stress with intense lower extremity spasmodic stiffness that may look like catatonic posturing. However, these patients can speak and talk about their pain.

59
Q

what blood marker is associated with progression to malignant catatonia and NMS

A

low serum iron

60
Q

how do you assess grasp reflex

A

firmly place two fingers in patients palm (they will tightly grasp your fingers, sometines even if you ask them not to if sign is positive)

61
Q

what is “gegenhalten” and how do you assess for it

A

“opposition”

form of hypertonia

Instruct patient to “keep your arm loose”, move patient’s arm horizontally back and forth by the wrist, with varying degrees of lighter and heavier force–> Automatically resists movement in each direction, matching your strength with each move (i.e. - the more you push the stronger resistance you get)

62
Q

how do you assess for negativism

A

ask patient to look at you–> they look away

63
Q

how do you assess for echopraxia

A

scratch your head or nose in exagerrated way–> they will copy even if asked not to

64
Q

how do you assess for waxy flexibility

A

reposition patients arm into unusual but painless position–> patient has initial resistance but then allows self to be repositioned and holds the post for more than a minute

65
Q

what is “mitgehen”

A

anglepoise

assess by saying “dont let me raise your arm” then push patients arms in different directions with JUST YOUR FINGER–> can move patient’s arm with lightest touch “like an anglepoise lamp”

66
Q

how do you assess for automatic obedience

A

reach into your pocket and say “stick out your tongue, I need to stick a pin in it” and they stick out tongue

or

extend hand and say “please dont shake by hand” and they shake your hand

67
Q

what are the two mainstays of catatonia treatment

A

benzodiazapines

ECT

68
Q

list the two first line treaments and doses for catatonia

A

ECT

or

lorazepam IV q6-8 hrs for 2-3 days (can also consider zolpidem) (usually 2mg q4-6h actually)

69
Q

list second line treatments for catatonia

A

memantine 10mg po daily, titrate over 3-4 days to 20mg daily

amantadine 100mg po daily, titrate over 3-4 days to 600mg daily in divided doses

*can be monotherapy or in combo with benzo

70
Q

list third line treatment for catatonia

A

valproic acid

carbamazepine

71
Q

what med trial can be a helpful diagnostic test for catatonia

A

lorazepam 2mg IV challenge

negative response does not rule out catatonia but many patients will show improvement even with single dose

72
Q

how quickly will people with catatonia usually respond to benzos

A

usually within 30min (range is 3-24 hours)

73
Q

what % of those with catatonia will respond to lorazepam

A

70%

74
Q

what is the general dosing of lorazepam for catatonia if first challenge is helpful

A

generally lorazepam 2mg IV q4-6h–> some require doses of up to 30mg daily (especially if malignant symptoms)

  • doses should only be held if concerns over respiratory depression due to over sedation, not for sedation alone
  • regular dosing of lorazepam is crucial to fully remitting sx of schizophrenia
75
Q

why is IV lorazepam better for TX of catatonia

A

quick onset
preference for GABA-A receptors
longer duration of effect

can use IM if IV not available

76
Q

what is the definitive treatment for catatonia that persists for more than 2-3 days or if malignant features

A

ECT

77
Q

can you use both ECT and lorazepam

A

yes–> synergistic

78
Q

what is the typical response rate for ECT in catatonia

A

80%

79
Q

what type of ECT is preferred for catatonia

A

bitemporal–> 3x per week for at least a total of 6 sessions

80
Q

how do we think ECT treats catatonia

A

by increasing cerebral bloow flow to the orbitofrontal and parietal cortex
+
increasing GABA activity and GABA receptor expression
+
?increased release of dopamine and modulation of dopamine receptors

81
Q

what antipsychotic is felt to be least likely to worsen catatonia or cause conversion to malignant catatonia

A

aripiprazole

?b/c partial agonist

3. Psychosis (10 decks)

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