Catatonic Schizophrenia: 5 Surprising Tips to Deal with It

Introduction

Catatonic Schizophrenia was considered to be a subtype of Schizophrenia and other psychotic disorders that is now obsolete. The change in recent diagnostic guidelines has catatonic schizophrenia removed as a disorder and instead considered catatonia as an additional feature when diagnosing schizophrenia. The disorder can be dangerous but is treatable.

Catatonic Schizophrenia

Catatonic Schizophrenia is a psychiatric disorder characterized by schizophrenic features with dominant symptoms of catatonia. This disorder has been removed from DSM-V and ICD-11 diagnostic guidelines, and instead, they are added as an additional feature or specifier in the diagnosis of schizophrenia. Catatonia is defined as marked psychomotor abnormalities and behavioural dysregulation. Catatonia can be classified as: (a) excitement/hyperkinetic (increased movement, agitated behaviour), (b) withdrawn/hypokinetic (decreased response, mutism, no emotions), (c) mixed type (combined of both). According to the studies, 10-25% of individuals diagnosed with schizophrenia do present with catatonic symptoms.[1] The research studies have found the aetiology of catatonic schizophrenia as multifactorial. Evidence shows there is dysfunction of GABAergic neurotransmitters. Also, dysregulation between the ventromedial prefrontal cortex (VMPFC) and dorsolateral prefrontal cortex (DLPFC) leads to catatonic symptoms. [2] Early diagnosis and prompt intervention are necessary to reduce long-term consequences and improve the overall well-being of the individual.

Symptoms of Catatonic Schizophrenia

The individual can present with overlapping symptoms of both schizophrenia and catatonia. The signs and symptoms are as follows: 

Symptoms of Schizophrenia are:

1. Delusions (persecutory, self-reference)
2. Hallucinations (auditory)
3. Disorganized thought and speech
4. Disorganized behaviour (aggression) 
5. Thought Alienation
6. Marked apathy
7. Blunting emotional response
8. Social withdrawal
9. Avolition (inability to engage in goal-directed behaviours)

Symptoms of Catatonia include:

1. Decrease reactivity to spontaneous movement or activity (Stupor)
2. Purposeless motor activity without external stimuli (excitement)
3. Maintaining inappropriate or bizarre postures (Posturing)
4. Motiveless resistance to all instructions or movements (negativism)
5. Maintaining a rigid posture against all efforts to move (rigidity)
6. Perseveration of words and phrases 
7. Maintenance of limbs and body in externally imposed position (waxy flexibility)
8. Mimicking another’s speech and movement (Echolalia, Echopraxia)
9. Repetitive, abnormally frequent, goal-directed movements (Stereotypy)
10. Odd caricature of normal actions (Mannerism)

How to Diagnose Catatonic Schizophrenia

Catatonic schizophrenia is now no longer considered a stand-alone diagnosis. The difficulty arises when symptoms of schizophrenia and catatonia overlap. Sometimes the Catatonic symptoms may occur with other physical as well as mental health conditions like mood disorders, autism, and neurological disorders. Therefore, detailed psychiatric history, mental state examination and neurological examination an essential components in diagnosing this disorder. It must exclude the other causes of catatonia and establish a diagnosis of schizophrenia, to label the disorder. If suspicious of other conditions, then imaging and routine blood tests can be done. The catatonic symptoms and degree of severity of symptoms can be evaluated using the Bush Francis Catatonia rating scale (BFCRF). According to ICD-10 diagnosis behaviour guidelines, to meet the criteria for Catatonic Schizophrenia the individual must satisfy the general criteria for the diagnosis of schizophrenia with one or catatonic behaviour (as described in symptoms) dominating the clinical picture.

Important Tips to Deal with Catatonic Schizophrenia?

It is important to evaluate and diagnose catatonic schizophrenia, here are a few tips for dealing with catatonic schizophrenia:

1. Family education – Providing psychoeducation about the disorder to the patient and the patient’s family is extremely necessary, to provide the details of the disorder including symptoms, treatment plan and prognosis.
2. Encourage treatment – it is essential to encourage the patient to visit their mental health professional for proper treatment and motivate them to be compliant with the treatment plan.
3. Collaborate with medical team – treat catatonic schizophrenia, requires a medical team including a psychiatrist, nursing services, and counsellors who can provide around-the-clock care for the patient.
4. Nursing care – patients present stupor become immobile which results in pressure ulcers or poor self-hygiene causing significant impact. Vigilant nursing care can shift the patient side-to-side, assist in self-care, can overall help the patient and their family.   

Treatment of Catatonic Schizophrenia

The key to the treatment of Catatonic Schizophrenia is early identification of catatonia in a patient suffering from schizophrenia and initiation of treatment. If an individual is already taking anti-psychotic medications, then it should be stopped immediately as it can contribute to catatonic symptoms s in a person with schizophrenia. Prompt and urgent medical attention is required when suspecting catatonia as it can be dangerous and affect the overall quality of life. For catatonia, the first line of treatment is benzodiazepines mainly lorazepam (given in the form of IV injectable or oral tablet). Individuals may take 3-7 days to respond to the treatment. People who do not respond to Benzodiazepine treatment or if there is a malignant form of catatonia are taken for Electroconvulsive therapy (ECT). ECTs are considered as treatment of choice for catatonic schizophrenia. Other medications including anti-NMDA agents like amantadine have shown some efficacy.[3] However, the overall prognosis of schizophrenic catatonia is poor.

Conclusion

Catatonic schizophrenia is a chronic and debilitating mental health disorder which requires an extensive treatment plan. Detailed evaluation and early diagnothe sis of this disorder is an essential component in treating this disorder though the overall prognosis of catatonic schizophrenia is poor. It is certain to provide proper management for the overall well-being of the individual.  

References

1. Ungvari GS, Goggins W, Leung SK, Gerevich J. Schizophrenia with prominent catatonic features (‘catatonic schizophrenia’). II. Factor analysis of the catatonic syndrome. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Mar 30;31(2):462-8.
2. Ellul P, Choucha W. Neurobiological Approach of Catatonia and Treatment Perspectives. Front Psychiatry. 2015;6:182.
3. Muneoka K, Shirayama Y, Kon K, Kawabe M, Goto M, Kimura S. Improvement of mutism in a catatonic schizophrenia case by add-on treatment with amantadine. Pharmacopsychiatry. 2010 Jun;43(4):151-2.