Thus far the MDD specifier lineup has included some unsavory characters. As if they weren’t troubling enough, there is the possibility of our MDD patients developing Catatonia! Like Psychotic Features, Catatonia seems most often associated with Schizophrenia spectrum illnesses. If you specialize in mood disorders, you’ll be sure to encounter the symptoms of Catatonia in MDD and Mania, too. In fact, it is considered more common in mood disorders than in Schizophrenia (Huang, et al., 2013). Another misconception I have encountered is that Catatonia is simply the Stoic state made popular by the catatonic character of Chief Bromden in One Flew Over the Cuckoo’s Nest. While the retarded (slowed) state of Catatonia, marked by stupor, or a state of no psychomotor activity, is well-known, Catatonia can also present as a syndrome of psychomotor excitation.
The man in the blog illustration is not unlike what we can witness in a catatonic patient: a grimaced face in a state of holding a strange position. I will never forget the first catatonic patient I witnessed. Correctional officers told me an inmate I was familiar with became “stuck in position” over the early morning hours. Looking into his cell, I saw a man sitting on the edge of his bed, both raised feet off the floor despite the bunk being a mere 18 inches off the ground, and arms folded. He was mute, expressionless and when medical arrived to examine him, he did not budge to sternum rubs or foot tickling.
Not all cases are so obvious. Like any condition, Catatonia exists on a spectrum, and subtler states may be missed. Today, let’s examine Mark’s case involving the psychomotor-retarded state of Catatonia.
Mark, a 30-something Navy veteran with PTSD, was struggling through a Major Depressive episode for the past year. There were family woes, physical problems, and he was simply not finding work that gave his life meaning. Mark’s symptoms ebbed and flowed over the year he was working with Dr. H. Family and medical complications improved, but he felt a huge gap in his life meaning without purposeful work; a store clerk just wasn’t cutting it. Try as he might, Mark’s job applications were never fruitful. Every other week he’d receive notice he wasn’t chosen for this or that job. As his depression deepened, during one session with Dr. H Mark reported that he’s had instances of being “blanked out” and couldn’t respond to his wife or son except for a couple of mumbling words. If he moved it was with strange mannerisms, and his wife said he made some “funny faces, like he was pained.” These periods were fleeting, but he was worried. What if it happened on the job or while driving? Though he suspected the Catatonic Features were associated with MDD, Dr. H referred Mark for medical evaluation to make sure something else wasn’t responsible. A few days before his neurological examination, Mark’s wife called Dr. H and said Mark went to the hospital from work. She explained that his boss, Tom, found him in the stockroom, expressionless and “stuck.” When Tom tried to get Mark’s attention by waving his hand, Mark began repeatedly waving his hand. He also appeared to have wet himself. In the emergency room, medical staff found no evidence of a physical problem or substance causing the condition. He was treated with benzodiazepines and began to improve. Considering Dr. H’s input on how depressed he has been, along with the emerging Catatonic Features, Mark was hospitalized for more acute care.
The DSM-5 criteria for Catatonia are as follows:
3 or more of the following:
- Stupor (no psychomotor reactivity/inability to respond to the environment)
- Catalepsy (a state wherein the person can be “molded” into a position by someone else and hold there)
- Waxy flexibility (resistance to posturing by others)
- Mutism (little or no speech)
- Negativism (no response to external stimuli)
- Posturing (spontaneously maintain a position against gravity, like the inmate I evaluated)
- Mannerism (strange presentations of normal actions, like odd patterns of blinking, or head shaking)
- Sterotypy (repetitious, meaningless motions)
- Agitation (not influenced by the environment)
- Grimacing (making pained or odd facial expressions)
- Echolalia (mimicking what others say)
- Echopraxia (mimicking others’ motions)
As you can see, some symptoms can be of an agitated and animated presentation. Collections of such symptoms are more rare, and tend to present in manic patients. While not the norm, sometimes a vacillation between retarded and agitated catatonic symptoms occurs in MDD sufferers.
Can you identify Mark’s Catatonic Features? Feel free to share in Comments!
Identifying Catatonia symptoms is important because:
- We don’t want our patients to end up like Mark.
- They could injure themselves falling over or not being able to respond to something dangerous in their environment.
- It is possible, if of the agitated sort, the patient could inadvertently hurt someone else.
- Catatonic episodes can last days, weeks or months if not treated. If the patient is to get stuck in such a state, and they live alone, they could starve, dehydrate, develop blood clots from lack of motion, etc.
Identifying symptoms can be difficult, as they may be much more subtle than our example above, and often go missed (Jhawer et al., 2019). Perhaps the patient’s mutism is mistaken for someone who is so depressed they just don’t feel like talking. Maybe their grimacing/pained expressions are viewed as reflections of their mood. Agitation can easily be mistaken for anxiety. Noting anything slightly resembling Catatonia, a clinician will do well, if possible, to interview the patient’s loved ones or friends as to if other Catatonic Features are ever present.
Suspicion of Catatonic Features, like the previous specifiers, warrants an immediate referral to psychiatry, or emergency room if severe. Medical evaluation is also warranted regardless of severity because many medical conditions, especially neurological diagnoses, are associated with catatonic states. Benzodiazepines often work well (Jhawer et. al, 2019) to remit the episode, but that does not mean symptoms can’t return. Hospitalization with electroconvulsive therapy (ECT) is not unheard of for patients fitting the MDD with Catatonic Features specifier.
Once stabilized, the job a therapist is to not only help the depression continue to remit, but continue to evaluate for any return. In the long run, prevention is the best option. If we know a patient is prone to Catatonic Features, it of utmost importance to have a plan in place to immediately return to treatment if they or friends/loved ones recognize the onset of a depressive episode. Keeping the depression at bay likely would help keep the catatonia from re-emerging.
Astute clinical observations can spare a patient injured by MDD the disabling, additional insult of Catatonia and the corollary dangers.
Tomorrow, The New Therapist covers another specifier often marked by psychomotor disturbance: Mixed Features.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013
Huang YC, Lin CC, Hung YY, Huang TL. Rapid relief of catatonia in mood disorder by lorazepam and diazepam. Biomedical Journal. 2013;36(1):35-39. doi:10.4103/2319-4170.107162
Jhawer, H.; Sidhu, M.; Patel, R.S. Missed Diagnosis of major depressive disorder with catatonia features. Brain Sci. 2019, 9, 31
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. https://doi.org/10.5498/wjp.v6.i4.391