What is catatonic schizophrenia?

Catatonic schizophrenia is one of the five subtypes of schizophrenia, along with paranoid, disorganized, residual, and undifferentiated [1]. However, in the most recent publication of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [2], these five subtypes have been removed due to concerns relating to the validity and stability of these diagnoses [3].

Now, catatonia is either classified as a diagnosable condition of its own or as a symptom of another psychiatric or medical condition. In either case, it is classified with the same symptoms and criteria listed [2][3]. As such, the diagnosis of catatonic schizophrenia is no longer used. However, catatonia may still be a presenting symptom of a schizophrenia diagnosis, along with the criteria of the other previous subtypes.

Catatonia

Catatonia is a symptom that can be present in a variety of conditions, including schizophrenia, psychosis, bipolar disorder, autism, encephalitis, meningitis, multiple sclerosis [4]. Catatonia can also present as a result of a medication or drug toxicity, such as neuroleptic malignant syndrome, which can be caused by antipsychotic medication [5].

Catatonia involves abnormal motor functioning, categorized as akinetic catatonia, involving a lack of movement, or hyperkinetic catatonia, involving excited or impulsive movement.

A third category, malignant catatonia, can occur alongside either akinetic or hyperkinetic catatonia, and involves responses in the entire body that can potentially be fatal, such as hyperthermia, sweating, and increased breathing and heart rate [6].

Symptoms of catatonic schizophrenia

Symptoms of schizophrenia include positive symptoms, such as hallucinations and delusions, negative symptoms, such as blunted emotions and social withdrawal; cognitive impairments, such as disordered or disorganized thoughts or speech; and abnormal psychomotor functioning, such as catatonia [2].

Symptoms of catatonia include:

  • Immobility is the most seen symptom of catatonia, involving an inability to move, sometimes for hours or even days, appearing frozen in place.
  • Mutism is also a common symptom and involves an inability to speak without reaction to external stimuli or prompting.
  • Posturing is when a person holds a position in place for some time against gravity, such as an arm or leg in the air.
  • Negativism occurs when refusing or not responding to all given instructions and stimuli.
  • Grimacing is the abnormal or contorted facial movements and expressions.
  • Waxy flexibility describes some resistance to attempts to move positioning.
  • Echolalia is repeating or mimicking others’ words.
  • Echopraxia is repeating or mimicking others’ movements.
  • Stereotypies are repetitive movements that are not goal orientated.
  • Psychomotor agitation is increased activity with no external prompt or reason. This may be unpredictable and occur just prior to, or interrupting, immobility.
  • Verbigeration is repetition of seemingly meaningless or unrelated words or phrases, also known as 'word salad’.
  • Rigidity is stiff and rigid movements or remaining in place after being moved by someone else.

Symptoms of malignant catatonia include hyperthermia, sweating, and increased breathing and heart rate. This may occur alongside a lack or excess of movement and could be fatal.

Furthermore, many of these symptoms, particularly immobility or stupor, result in decreased food and fluid intake, which can cause dehydration and malnutrition if left unmanaged for some time.

Diagnosing catatonic schizophrenia

A healthcare provider will conduct an examination to diagnose a mental health condition, including gaining information about the persistence and severity of symptoms, family medical history, and any other prior diagnoses.

Schizophrenia is diagnosed if the patient has experienced delusions, hallucinations, disordered thoughts or speech, disordered or abnormal movements, or negative symptoms, including social withdrawal, lack of motivation, and blunted emotions. These symptoms will be rated in severity from 0 to 4, a new requirement of the updated diagnostic criteria [2][3].

As previously mentioned, catatonic schizophrenia is no longer a specific diagnosis in the DSM-5 [1][2]. However, catatonia as a specifier of schizophrenia can be diagnosed if at least three of the listed symptoms of catatonia are present.

As catatonia can be present in many other psychiatric conditions, it is important for doctors to rule out any other conditions in which catatonia can be present, such as bipolar disorder or schizoaffective disorder, by determining if there have been long periods of major depression or mood disturbances [2][7].

Similarly, doctors will need to rule out causes related to substance use or medication toxicity, as well as any medical conditions, so they will conduct a thorough medical examination.

What causes catatonic schizophrenia?

It is unclear what causes catatonic schizophrenia, but several factors may impact it.

Brain structure and function

Research suggests that catatonia specific to schizophrenia could be caused by a decrease in gray matter in the brain, which can cause impairments in cognition, memory, and information processing [8][9]. In addition, there may also be differences in the function of certain chemicals or neurotransmitters in the brain [10].

Also, there is evidence that parts of the brain associated with fear and emotion are impaired in those with catatonia, prompting suggestions that immobility or negative symptoms of schizophrenia are a response to conscious or subconscious anxiety or a ‘fight or flight’ reaction [8].

Genetics

Schizophrenia and catatonic schizophrenia are more common in people with a parent or close relative with the condition than in those without [11][14]. However, a family history of schizophrenia does not mean that the condition will develop in offspring [12].

Social and environmental influences

Schizophrenia may be triggered by various social or environmental factors, such as stress, childhood trauma and abuse, social isolation, socioeconomic class, and complications during pregnancy and childbirth. These factors have been found, alone or in combination with others, to increase the risk of psychosis and schizophrenia [13].

Gender

Some research suggests that schizophrenia is more common or severe in males but that catatonic schizophrenia is equal in males and females [14].

Alcohol and drugs

Substance use, in particular the use of cannabis, has been found to increase the risk of psychosis. This risk is higher in those who use cannabis from a younger age, in large doses, and with a high frequency and regularity [13][15].

Similarly, some research suggests that cocaine, amphetamines, and alcohol can contribute to an increased risk of psychosis [13].

What is the difference between catatonic schizophrenia and paranoid schizophrenia?

The DSM-IV [1], in which the subtypes of schizophrenia were last categorized, specifies that catatonia is not present in paranoid schizophrenia. Similarly, for a diagnosis of paranoid schizophrenia, disorganized speech and behavior and flat affect are also not present.

These symptoms are likely to be seen in catatonic schizophrenia, forming a large part of the diagnostic criteria.

Paranoid schizophrenia is mainly categorized by a preoccupation with delusions and/or hallucinations, particularly those that are persecutory in nature.

How common is catatonic schizophrenia?

Research suggests that of all people with a diagnosis of schizophrenia, catatonia occurs in only 7-8% [14]. Another study indicates that of all people with a diagnosis of catatonia, only 20% have a diagnosis of schizophrenia. At the same time, other mental and physical health conditions make up a much larger proportion of this group [16].

These findings indicate that a catatonic type of schizophrenia is very rare and that there are more often other causes for catatonia than schizophrenia. Hence, a careful and thorough diagnostic procedure is crucial to provide proper treatment.

Treatment for catatonic schizophrenia

Medication

Benzodiazepines are recommended as first-line treatment for catatonia and are incredibly useful in treating the condition. Benzodiazepines often completely alleviate many symptoms, such as immobility and negativism [5][8]. However, this success has been found to occur more often in catatonia that is not specific to schizophrenia, so alternative treatments may be required [16].

This differing success of benzodiazepine treatment may be due to a difference in the underlying cause of the catatonic symptoms, the differing nature and severity of schizophrenia amongst individuals, or other individual differences [16].

Antipsychotics are often used in the treatment of schizophrenia and can help to alleviate the symptoms of the condition, especially hallucinations and delusions. However, antipsychotics can cause or contribute to catatonic symptoms, so it is advised that these medications are stopped while catatonia is treated [5][16].

If other treatments are unsuccessful, or once catatonia has been successfully treated, antipsychotics can be started or reintroduced but require careful monitoring due to the risk of serious side effects such as neuroleptic malignant syndrome [5].

Electroconvulsive Therapy (ECT)

If benzodiazepines have not alleviated the symptoms of catatonia, it is recommended that a course of ECT be started, especially in the case of malignant catatonia [5].

ECT successfully manages catatonia [10], although there are issues around gaining consent, as catatonic patients often cannot consent to treatment, so surrogate consent must be acquired [16].

Physical health

Catatonia can cause issues around physical health, particularly dehydration and malnutrition, which can be fatal if left untreated. As such, intravenous fluids may be required until catatonic symptoms are alleviated. Once the patient is no longer catatonic, they will be able to eat and drink again, and physical health intervention will no longer be required.

Resources:

  1. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric Association.
  2. American Psychiatric Association. (2013, text revision 2022). Schizophrenia Spectrum and Other Psychotic Disorders. In The Diagnostic and Statistical Manual of Mental Disorders(5th ed., text rev.).APA. Retrieved from https://doi.org/10.1176/appi.books.9780890425787.x02_Schizophrenia_Spectrum
  3. Highlights of Changes from DSM-IV-TR to DSM-5.(2013). Psychiatry. Retrieved from https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
  4. Rogers, J.P., Pollak, T.A., Blackman, G., & David, A.S. (2019). Catatonia and the Immune System: A Review. The Lancet, 6(7), 620–630. Retrieved from https://doi.org/10.1016/S2215-0366(19)30190-7
  5. Rasmussen, S.A., Mazurek, M.F., & Rosebush, P.I. (2016). Catatonia: Our Current Understanding of its Diagnosis, Treatment and Pathophysiology. World Journal of Psychiatry, 6(4), 391–398. Retrieved from https://doi.org/10.5498/wjp.v6.i4.391
  6. Farkas, J. (2022). Catatonia. The Internet Book of Critical Care. Retrieved from https://emcrit.org/ibcc/catatonia/
  7. Walther, S., & Strik, W. (2016). Catatonia. CNS Spectrums, 21(4), 341–348. Retrieved from https://doi.org/10.1017/S1092852916000274
  8. Ellul, P., & Choucha, W. (2015). Neurobiological Approach of Catatonia and Treatment Perspectives. Frontiers in Psychiatry, 6, 182. Retrieved from https://doi.org/10.3389/fpsyt.2015.00182
  9. Akre, K. (2022). Catatonia. Encyclopedia Britannica.Retrieved from https://www.britannica.com/science/catatonia
  10. Jain, A., & Mitra, P. (2022). Catatonic Schizophrenia. In: StatPearls[Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK563222/
  11. Schizophrenia Working Group of the Psychiatric Genomics Consortium. (2014). Biological Insights from 108 Schizophrenia-Associated Genetic Loci. Nature, 511, 421-427. Retrieved from https://doi.org/10.1038/nature13595
  12. Gejman, P.V., Sanders, A.R., & Duan, J. (2010). The Role of Genetics in the Etiology of Schizophrenia. The Psychiatric Clinics of North America, 33(1), 35–66. Retrieved from https://doi.org/10.1016/j.psc.2009.12.003
  13. Stilo, S.A., & Murray, R.M. (2019). Non-Genetic Factors in Schizophrenia. Current Psychiatry Reports, 21(100). Retrieved from https://doi.org/10.1007/s11920-019-1091-3
  14. Kleinhaus, K., Harlap, S., Perrin, M.C., Manor, O., Weiser, M., Harkavy-Friedman, J.M., Lichtenberg, P., & Malaspina, D. (2012). Catatonic Schizophrenia: A Cohort Prospective Study. Schizophrenia Bulletin, 38(2), 331–337. Retrieved from https://doi.org/10.1093/schbul/sbq087
  15. Marconi, A., Di Forti, M., Lewis, C.M., Murray, R.M., & Vassos, E. (2016). Meta-Analysis of the Association Between the Level of Cannabis Use and Risk of Psychosis. Schizophrenia Bulletin, 42(5), 1262–1269. Retrieved from https://doi.org/10.1093/schbul/sbw003
  16. Rosebush, P.I., & Mazurek, M.F. (2010). Catatonia and its Treatment. Schizophrenia Bulletin, 36(2), 239–242. Retrieved from https://doi.org/10.1093/schbul/sbp141