Catatonic syndrome (psychiatry): treatment, symptoms

This concept in medical practice implies a set of symptoms manifested by psychomotor disorders. This pathology was first described in 1874 by Kahlbaum, who considered this disease as a separate nosological unit. Almost immediately it was recognized that catatonia is a symptom of schizophrenia. At the moment, experts do not adhere to such a clear position, highlighting several options for the causes of the pathology.

The disease can occur at any age. Including children. The peak of cases is in the age group of 17-30 years. The list of main symptoms includes:

• impulsive behavior;
• stupor;
• excitation.

Psychiatrists treat pathology. The combination of electroconvulsive and drug therapy makes it possible to successfully defeat the disease or transfer it to a stage of stable remission.

Catatonic syndrome: schizophrenia

The catatonic form is one of the manifestations of schizophrenia. It occurs in approximately 2.5% of all diagnosed cases of confirmation of this complex psychological illness. Many doctors believe that catatonic syndrome is unique to schizophrenia. In other situations, we can only talk about catatonic disorders.

The pathology is characterized by active and passive negativism, in which the patient resists when trying to change his posture. Patients suffering from active negativism refuse to carry out tasks received from the doctor. For example, when asked to sit down, the patient may defiantly remain standing and turn his back. In the passive form, the patient resists due to muscle tension.

Stupor causes, methods of diagnosis and treatment

There are more than 10 types of torpor - the differences lie in the primary source of the lesion and the course of the symptom. Depending on the type of pathology, an effective course of treatment or medication schedule is also selected. Any form of stupor has common symptoms - muscle tension, clouding of consciousness, immobility, increased body tone, silence, weakening of natural reflexes.

Catatonic stupor

Catatonic disorder usually occurs due to severe fear, danger, an emotionally elevated state of affect, autism, postpartum or post-traumatic depression, or an overdose of antipsychotics. Manifests itself in three stages:

• Pathetic - a slight limitation of mental and motor abilities without clouding of reason.
• Impulsive - an acute sudden manifestation of symptoms with a risk of threat to others and the patient himself.
• Silent - numbness of the body with disordered thinking and an aggressive attitude.

Emotional stupor

Appears after a severe psycho-emotional shock, witnessed grief or a shocking event. The medical name for the symptom is a state of passion. The patient can cause physical harm not only to others but also to himself, and therefore needs constant monitoring.

Mental block

Characteristic of people with a fine mental organization, vulnerable and sensitive individuals. The emotional level of such patients is higher than that of the average person. Most often these are creative people, teenagers during puberty, women during pregnancy or menopause. The symptom manifests itself in the form of apathy, prolonged melancholy, and creative crisis.

Jet Stupor

A psychogenic form of the disorder, which can occur either as an independent mental disorder or as a result of prolonged reactive psychosis. Characteristic signs are absolute mutism and immobility. The patient is silent, does not move, does not react to any stimuli.

Apathetic stupor

Other terms are asthenia or waking coma. A patient with damage to motor and mental functions is in complete apathy, most often in a lying position. The patient is not interested in anything, ignores hunger, thirst, and natural needs.

Manic stupor

The exact opposite of numbness - the patient is in heightened arousal, which manifests itself in all reflexes and abilities:

• good mood, laughter, fun even with severe grief;
• rapid acceleration of the ability to speak and think;
• sudden chaotic movements of all parts of the body;
• increased feelings of hunger, thirst, pain, desires.

Other types of stupor

• Catapleptic - numbness with waxy flexibility without complete immobility.
• Hebephrenic - complete lack of response to external factors, speech and sensations;
• Hysterical - apathy with loud crying, screaming, hysterics, unreasonable laughter.
• Depressed - numbness due to emotional shock, the patient refuses food and water, and may harm himself.
• With muscle numbness - position in a tense position of the embryo without any reflexes.
• Negativistic - the patient is immobilized, but retains reflexes, and when trying to “stir up” he resists.

Symptoms of catatonic syndrome

The presence of pathology can be determined by the symptoms of catatonic syndrome. It is necessary to contact for consultation at the first manifestations of the diagnosis. Timely initiation of treatment speeds up recovery.

The list of the most common symptoms includes:

• persistent repetition of facial expressions and movements surrounding stereotypy;
• counteracting attitude negativism;

• echo symptoms, in which the patient involuntarily repeats phrases and words;
• isolation;
• mutism, characterized by the patient’s inability to speak with full health of the speech apparatus;
• a strange body position with the head elevated, called “air cushion syndrome”;
• the grasping reflex, which manifests itself in the unreasonable grasping of surrounding objects;
• the presence of pathological flexibility;
• excessive facial expressions, grimaces;
• hypertrophied wide eyes.

The number of symptoms accompanying catatonic disorders is varied. Only a doctor can make an accurate determination. Some of them are particularly common. For example, the proboscis symptom noted in catatonic syndrome.

Proboscis symptom (In catatonic syndrome)

The position of the lips, in which, due to muscle contraction, they are constantly extended forward and form a “tube,” is a natural stage in the development of the facial muscles and facial expressions of a child in the first year of life. When pathology appears in an adult, it indicates the possible onset of catatonia.

Often proboscis syndrome is not accompanied by other manifestations of stupor or increased excitability. To eliminate the pathology, you need to contact a psychiatrist.

Symptoms of catatonic stupor

For reference. The main manifestations of catatonic stupor include lethargy, silence, and increased muscle tone.

Catatonic stupor can occur in three ways:

• cataleptic variant of stupor;
• negativistic;
• stupor with development of numbness.

The cataleptic variant is manifested mainly by waxy flexibility - the patient does not make his own movements, but at the same time his body can be given any position in which he will remain for a long time (no matter how uncomfortable this position is).

There is also a variant called the “Dupré psychic pillow symptom” - the patient’s head is raised, as if he were lying on an invisible pillow (if the patient is sitting, he can keep his hands raised above his knees, as if they were lying on a pillow).

With waxy flexibility, the patient can freeze in any uncomfortable position, since an attack of cataleptic stupor can develop spontaneously during any work.

Pavlov's symptom is also often observed - the patient reacts only to quiet speech, loud speech is ignored by him. In addition, patients with this syndrome often “come to life” at night (begin to move slowly in the dark and silence) and fall into a stupor in the morning.

Such patients may spontaneously disinhibit in complete silence. With the negativistic variant, there is involuntary resistance to any attempts to change the patient’s posture.

For reference. The highest degree of inhibition is considered to be the variant of stupor with numbness. Such patients remain frozen in the fetal position for a long time, not reacting to external influences. Air cushion symptoms may also occur.

Specific symptoms

Some patients with catatonic stupor may experience the proboscis sign (involuntary stretching of the lips in a tube) and the staircase sign, which is manifested by a lack of fluidity of movement (intermittent, jerking movements).

The staircase sign usually occurs when the patient moves with waxy flexibility (when the doctor lowers or raises his arm).

Also, in patients with catatonic stupor, Bumke's symptom is observed (there is no reaction of the pupils to painful stimuli).

Sometimes Kleist's symptom (last word syndrome) is determined - patients with mutism begin to answer the question only when the person asking it turns around and leaves.

Segla's symptom is manifested by attempts to answer a question (the patient tries to move his lips).

Less common symptoms:

• Wagner-Jauregg - patients with mutism answer the question after pressing on their eyeballs;
• Saarma - patients with mutism answer only questions addressed to other people;
• Osipova - when reading aloud, such patients name punctuation marks along with the text.

Treatment of catatonic syndrome

Treatment of this pathology can only be carried out in a specialized psychiatric hospital. After a thorough examination, an individual course of therapy is developed for each patient. Medications play a major role in this:

• mood stabilizers;
• benzodiazepines;
• antiglutamantics;
• muscle relaxants;
• neuroleptics.

Additionally, electroconvulsive therapy is prescribed. In the case of malignant forms of pathology, such therapy is prescribed primarily to relieve the acute stage. The therapy involves passing electrical impulses through the brain tissue. The procedure is performed only in a hospital under the supervision of a doctor. If necessary, call an ambulance. After completion of the course, drug therapy continues.

Types of catatonic syndrome

Manifestations of pathology differ depending on the type. Only a doctor can make an accurate diagnosis.

Affective syndromes

They are accompanied by frequent changes in behavior from a high level of disinhibition to states of catatonic sleep and complete refusal to interact with the outside world.

Delusional syndromes

Obsessive movements are accompanied by delirium. Delusional states can also occur with passive negativism. This further aggravates the patient’s retreat into his inner world and refusal to communicate.

Hallucinatory syndromes

Patients in both the active and passive stages may experience hallucinations. In a state of stupor and lack of reaction to the outside world, this further worsens the patient’s condition. With active negativity of the patient, they can become socially dangerous.

Oneiric catatonic syndrome

It begins immediately with the acute phase, characterized by a noticeable increase in psychomotor agitation. In this state, the patient can be dangerous to others, and manic thoughts may arise. Moreover, in this state the patient seems to be in a waking dream. In perception, real and fictitious circumstances alternate.

Regressive catatonic syndrome

This variant of pathology turns an adult into a child in terms of behavioral style. Moreover, often in an infant. The sounds produced may resemble meowing.

Lucid catatonic syndrome

Characterized by the absence of delirium, stupor, or hallucinations. An increased level of excitement manifests itself, movements become abrupt and fussy. Stupor with numbness and negativistic stupor will occur.

Treatment of catatonic stupor

Initial treatment is aimed at relieving symptoms. Benzodiazepines are the first line of treatment and high doses are often required. A test dose of intramuscular lorazepam often results in noticeable improvement within half an hour. In France, zolpidem has also been used in diagnosis, and response may occur within the same time period. Ultimately, the root cause needs to be treated. Electroconvulsive therapy (ECT) is an effective treatment for catatonia, but it has been noted that additional high-quality randomized controlled trials are needed to evaluate the effectiveness, tolerability, and protocols of ECT for catatonia.

Antipsychotics should be used with caution because they may worsen catatonia and are a cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate cessation of the antipsychotic. Excessive glutamate activity is thought to be associated with catatonia; when first-line treatment options fail, NMDA antagonists such as amantadine or memantine are used. Amantadine may have increased tolerance with long-term use and may cause psychosis due to its additive effects on the dopamine system. Memantine has a more targeted pharmacological profile to the glutamate system, reduces the incidence of psychosis and may therefore be preferable for people who cannot tolerate amantadine. Topiramate is another treatment option for refractory catatonia; it produces its therapeutic effects by causing glutamate antagonism through modulation of AMPA receptors. Treatment modalities include pharmacotherapy and electroconvulsive treatment (ECT). Prompt treatment in the early stages of catatonic states is critical to achieve long-term relief of symptoms. Treatable conditions must be identified immediately. In particular, neuroleptic malignant syndrome (NMS), encephalitis, including anti-NMDA receptor encephalitis, nonconvulsive status epilepticus, and acute psychosis must be diagnosed and treated. Although BZPs are extremely safe medications when used in the short term, when There are several issues to consider in the treatment of BZD. These include (1) the risk of hypoventilation in obese patients or patients with obstructive sleep apnea, (2) falling in elderly patients or patients with balance problems once they begin to move after resolution of their catatonia, and (3) the potential for and small, for previously immobile patients to develop into a more agitated form of catatonia. Once the catatonic state is successfully treated and patients become more active, physical and psychiatric examinations and additional investigations may be performed as needed. Surgery usually eliminates the need for interventions such as intravenous hydration and catheterization because patients begin eating and drinking almost immediately. Psychiatric diagnoses are now classified on a syndromic basis. Catatonia syndrome, however, remains in diagnostic uncertainty, recognized predominantly as a subtype of schizophrenia. However, catatonia is present in approximately 10% of acute psychiatric patients, only a small number of whom have schizophrenia. Among patients with comorbid mood disorders, which constitute the largest subgroup of patients with catatonic illness, catatonic symptoms usually resolve abruptly and completely with benzodiazepine therapy.