Catatonia miasms

Clinic

• Catatonia is an entity that is characterized by abnormal movements, immobility, abnormal behaviors and withdrawal.

• Although catatonia has historically been related to schizophrenia, it is most often seen in mood disorders.
• Catatonia may be observed in other mental, neurological and medical conditions.
• There is growing evidence of the effectiveness of the NMDA receptor antagonists in catatonia.

Signs / Symptoms

• Immobility, Mutism, Staring
• Negativism: Withdrawal / Refusal to eat
• Posturing rigidity
• Waxy flexibility/ Catalepsy
• Stereotypy (Purposeless, repetitive movements)
• Echolalia / Echopraxia
• Verbigeration (Repeat meaningless phrases).
• They are aware of their surroundings as some patients can recall in detail their catatonic state and their actions.

Suggestion

Stereotypy is mentioned as a symptom of Catatonia. Both are Purposeless, repetitive Movements / Vocalizations/ Immobility. Obviously the patient has no difficulty in movement system and the core of disorder is located in his free-will. It is distinguished from Rigidity / Dystonia. E.g. in Parkinson disease who have a lot of dystonia, he know what he want to do but he cannot. On the other side a Catatonic schizophrenia, the patient do not know what is is doing. So I suggest psychosis, Altered pattern of thinking for Catatonia and disagree with Rigidity.

The Question is whether Psychosis equals to Hallucination + Delusion or Unsightliness would be a necessary component?

1. Negativism: JE
2. Stereotypy: RBS

Types

Here is a good classification for Catatonia (Hyperkinetic vs Hypokinethic)

As I discuss in chapter of Basal ganglia Encephalitis, this form of categorization is very basic. I could suggest NMDR encephalitis as the Master of Nero-cognitive Hyperkinetics and on the other side Parkinsonism, as the Master of Hypokinietic disorders. Although Both JE and WEE cover both side of this spectrum, But JE is more obviously good for Hyperkinetics and WEE for Hypokinietic.

Withdrawn /Akinetic Negativism Catatonia

• Mutism
• Rigidity: Patients may sit or stand in the same position for hours, may hold odd positions, and may resist movement of their extremities.

• Miasm: JE

Excited Catatonia

• Odd mannerisms/gestures
• Performing purposeless or inappropriate actions
• Excessive motor activity restlessness/ Agitation, Combativeness, Hyperactive
• Stereotypy: Speech and actions may be repetitive or mimic another person
• Impulsivity
• Delusions and hallucinations

Entities

• Rigidity
• Stereotypy
• Agitation / Excitability
• Hyperactive
• Delusions / Hallucinations

Miasm

RBS

Malignant Catatonia

Malignant catatonia is a life-threatening condition that may progress rapidly within a few days

• Autonomic dysfunction: Fever, muscle injury, Hypertension, Tachycardia, Tachypnea, Diaphoresis (sweating) and delirium.
• Waxy flexibility and holds a position against gravity when passively moved into that position, then it is likely catatonia.
• Catalepsy (Waxy flexibility + Rigidity)
• Stupor
• Negativism: Mutism
• Rigidity, posturing
• Certain lab findings: Leukocytosis, Elevated creatine kinase, Low serum iron.
• Signs and symptoms of malignant catatonia overlap significantly with neuroleptic malignant syndrome (NMS)

Entities

• Rigidity
• Autonomic dysfunction (Hypertension, Tachycardia, Tachypnea, Diaphoresis (sweating), and delirium.
• Leukocytosis
• Consciousness altered

Miasm

RBS

Periodic catatonia

• It is an inconsistently defined entity. It is a distinct form of "non-system schizophrenia"
• it is characterized by recurrent acute phases with hyperkinetic and akinetic features and often psychotic symptoms, and the build-up of a residual state in between these acute phases, which is characterized by low-level catatonic features and apathy (Aychic akinesia) of varying severity.
• The condition has a strong hereditary component.
• According to modern classifications, this may be diagnosed as a form of bipolar disorder, schizoaffective disorder or schizophrenia.
• Independently, the term periodic catatonia is sometimes used in modern literature to describe a syndrome of recurrent phases of acute catatonia (excited or inhibited type) with full remission between episodes, which resembles the description of "motility psychosis

Entity

System / systematic catatonias

• These are chronic-progressive conditions characterized by specific disturbances of volition and psychomotricity, leading to a dramatic decline of executive and adaptive functioning and ability to communicate. They are considered forms of schizophrenia but distinct from other schizophrenic conditions.
• Affective flattening and apparent loss of interests are common but may be related to reduced emotional expression rather than lack of emotion.
• Heredity is low. Of the 21 different forms (6 "simple" and 15 "combined" forms) that have been described, most overlap only partially - if at all - with current definitions of either catatonia or schizophrenia, and thus are difficult to classify according to modern diagnostic manuals.

Early childhood catatonia

• s are also a diagnosis exclusive to the Wernicke-Kleist-Leonhard school, and refers to system catatonias that manifest in young children. Clinically, these conditions resemble severe regressive forms of autism.

Chronic catatonia-like breakdown or Autistic catatonia

• It refers to a functional decline seen in some patients with pre-existing ASD and/or intellectual disability which usually runs a chronic-progressive course and encompasses attenuated catatonic symptoms as well as mood and anxiety symptoms that increasingly interfere with adaptive functioning.
• Onset is typically insidious and often mistaken for background autistic symptoms.
• Slowing of voluntary movement,
• Reduced speech
• Aboulia (Apathy)
• Increased prompt dependency
• Obsessive-compulsive symptoms are frequently seen
• Negativism
• (Auto-)aggressive behaviors
• Ill-defined hallucinations
• It seems to be related to chronic stress as a result of life transitions, loss of external time structuring, sensory sensitivities and/or traumatic experiences, co-morbid mental disorders, or other unknown causes. Since clinical catatonia can not always be diagnosed, this condition has also been renamed to the more general term "late regression".
• Self-injurious behaviors in autism

Related diseases

Catatonia is almost always secondary to another underlying illness, often a psychiatric disorder.

• Mood disorders such as a bipolar disorder and depression are the most common etiologies to progress to catatonia.
• Other psychiatric associations include schizophrenia and other primary psychotic disorders. It also is related to ASD.
• Catatonia is also seen in many medical disorders, including infections (such as encephalitis), autoimmune disorders, meningitis, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia).

Catatonia and ASD

• Neurodevelopmental disorders are associated with a higher risk of paediatric catatonia, including ASD, Tourette’s Syndrome, Down’s Syndrome, childhood disintegrative disorders and Prader-Willi Syndrome
• An incidence rate of catatonia of 4%-17% has been found in adolescents and adults with ASD, based on a review of 6 studies (n=811) in 200613.

Catatonia & JE

Catatonia is a syndrome of specific motor abnormalities, closely associated with disorders of mood, thought, and cognition. The principal symptoms of catatonia are mutism, immobility, negativism, posturing, stereotypy, and echo phenomena. Catatonia occurs in various psychiatric illnesses as well as medical disorders like infections of the central nervous system such as encephalitis, autoimmune disorders, cerebrovascular events, systemic metabolic disturbances, and toxic drug states. Catatonia may often mislead the clinician and the patient may be misdiagnosed as primarily suffering from a psychiatric disorder and be treated accordingly. Encephalitis may present with various psychiatric symptoms including catatonic features as its sequel that may sometimes be misunderstood as a primary psychiatric disorder. We highlight a case of a young female in her postpartum period, who presented with initial aggressive behavior and sleep deprivation followed by features of catatonia accompanied with fever. She initially responded well to benzodiazepines; however, her subsequent response was poor. When she was subjected to neuroimaging, it revealed signal intensity alteration in the bilateral basal ganglia and temporal regions suggestive of encephalitis; cerebrospinal fluid (CSF) viral markers examination revealed immunoglobulin M (IgM) positivity for Japanese encephalitis (JE). This case report highlights the diagnostic dilemma and management issues of a case of JE with catatonic symptoms