Catatonic Schizophrenia

What Is Catatonic Schizophrenia? What Causes Catatonic Schizophrenia?

Catatonic schizophrenia is a type (or subtype) of schizophrenia that includes extremes of behavior. At one end of the extreme the patient cannot speak, move or respond - there is a dramatic reduction in activity where virtually all movement stops, as in a catatonic stupor.

At the other end of the extreme they are overexcited or hyperactive, sometimes mimicking sounds (echolalia) or movements (echopraxia) around them - often referred to as catatonic excitement.

Patients may also present other disturbances of movement - seemingly purposeless actions are performed repetitively (stereotypic behavior), sometimes to the exclusion of involvement in any creative or productive activity.

Sometimes an individual with catatonic schizophrenia may deliberately assume bizarre body positions, or manifest unusual limb movements or facial contortions, sometimes resulting in the misdiagnosis with tardive dyskinesia.

A patient with catatonic schizophrenia may stay immobile for long periods, in positions we may think are extremely uncomfortable; they may resist attempts to reposition them. The individual may resist any attempt to change how he/she appears.

Catatonic schizophrenia is much rarer today than it used to be, because treatments have improved. Experts say that to be in a state of catatonia is more likely to affect individuals with other types of mental illnesses, rather than schizophrenia.

With treatments available today, patients with catatonic schizophrenia are much better able to manage their symptoms, making the likelihood of leading a happier and healthier life much greater.

According to Medilexicon's medical dictionary:

Catatonic schizophrenia is Schizophrenia characterized by marked disturbance, which may involve stupor, negativism, rigidity, excitement, or posturing; sometimes there is rapid alternation between the extremes of excitement and stupor. Associated features include stereotypic behavior, mannerisms, and waxy flexibility; mutism is particularly common.

What are the Signs and Symptoms of Catatonic Schizophrenia?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

• Physically immobile - the patient cannot speak or move. They may stare and hold their body in a fixed position. They appear to be unaware of their surroundings (catatonic stupor).
• Waxy flexibility - this is part of physical immobility. If the patient's arm, for example, is moved by someone else into a certain position, it remains in that position for possibly hours.
• Excessive mobility - the patient moves excitedly with what appears to have no specific or useful purpose. This may include pacing around energetically, walking in circles, making loud and unusual utterances.
• Uncooperative - the patient may resist any attempt to move them. They may say absolutely nothing (not speak) and not respond to instructions.
• Strange movements - the patient's posture may be unusual or inappropriate. There may be bizarre mannerisms and grimacing.
• Unusual behavior - the patient may repeat words, follow a ritual/routine with obsession. He/she may be obsessed with lining things up in a specific way.
• Echolalia (mimicking utterances) and/or Echopraxia (mimicking movements) - the patient may repeat something someone else has just said. There may be repetition of a movement or gesture made by another person.

Apart from the above, which are examples of catatonic schizophrenia symptoms, the patients may also have the following signs and symptoms of schizophrenia:

• Delusions - The patient has false beliefs of persecution, guilt of grandeur. He/she may feel things are being controlled from outside. It is not uncommon for people with schizophrenia to describe plots against them. They may think they have extraordinary powers and gifts. Some patients with schizophrenia may hide in order to protect themselves from an imagined persecution.
• Hallucinations - hearing voices is much more common than seeing, feeling, tasting, or smelling things which are not there, but seem very real to the patient.
• Thought disorder - the person may jump from one subject to another for no logical reason. The speaker may be hard to follow. The patient's speech might be muddled and incoherent. In some cases the patient may believe that somebody is messing with his/her mind.
• Lack of motivation (avolition) - the patient loses his/her drive. Everyday automatic actions, such as washing and cooking are abandoned. It is important that those close to the patient understand that this loss of drive is due to the illness, and has nothing to do with slothfulness.
• Poor expression of emotions - responses to happy or sad occasions may be lacking, or inappropriate.
• Social withdrawal - when a patient with schizophrenia withdraws socially it is often because he/she believes somebody is going to harm them. Other reasons could be a fear of interacting with other humans because of poor social skills.
• Unaware of illness - as the hallucinations and delusions seem so real for the patients, many of them may not believe they are ill. They may refuse to take medications which could help them enormously for fear of side-effects, for example.
• Cognitive difficulties - the patient's ability to concentrate, remember things, plan ahead, and to organize himself/herself are affected. Communication becomes more difficult.
  
  There may also be incoherent speech, poor personal hygiene, angry outburst, and uncoordinated movements (clumsiness).

Without proper treatment a catatonic episode can persist for days and even weeks.

Patients with catatonic schizophrenia symptoms are not usually able to get medical help on their own. When their symptoms appear to have subsided, it is common for them to believe they are fine and do not need treatment. Seeking medical help is frequently initiated by a family member or good friend.

What are the Risk Factors for Catatonic Schizophrenia?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

The risk factors for catatonic schizophrenia are fundamentally the same as those for most schizophrenia sub-types, including:

• Genetics - children with a family history of schizophrenia have a higher risk of developing it themselves. If there is no history of schizophrenia in your family your chances of developing it (any type, child-onset or adult-onset schizophrenia) are less than 1%. However, that risk rises to 10% if one of your parents was/is a sufferer.
  
  A gene that is probably the most studied "schizophrenia gene" plays a surprising role in the brain: It controls the birth of new neurons in addition to their integration into existing brain circuitry, according to an article published by Cell.
  
  A Swedish study found that schizophrenia and bipolar disorder have the same genetic causes.
• Viral infection - if the fetus (unborn baby in the womb) is exposed to a viral infection, there is a bigger risk of developing schizophrenia.
• Fetal malnutrition - if the fetus suffers from malnutrition during the mother's pregnancy there is a higher risk of developing schizophrenia.
• Stress during early life - experts say that severe stress early on in life may be a contributory factor towards the development of schizophrenia. Stressful experiences often precede the emergence of schizophrenia. Before any acute symptoms are apparent, people with schizophrenia habitually become bad-tempered, anxious, and unfocussed. This can trigger relationship problems. These factors are often blamed for the onset of the disease, when really it was the other way round - the disease caused the crisis. Therefore, it is extremely difficult to know whether schizophrenia caused certain stresses or occurred as a result of them.
• Childhood abuse or trauma
• Age of parents when baby is born - older parents have a higher risk of having children who subsequently develop schizophrenia, compared to younger parents.
• Drugs - the use of drugs that affect the mind or mental processes during adolescence may sometimes raise the risk of developing schizophrenia.

What are the Causes of Catatonic Schizophrenia?

Nobody is sure what the causes of catatonic schizophrenia and all other schizophrenia sub-types are. Research indicates that most forms of schizophrenia are caused by brain dysfunction; we just don't know why that brain dysfunction occurs. Most likely, it is caused by a combination of genetics and environmental triggers.

What are environmental triggers? Imagine your body is full of buttons, and some of those buttons result in schizophrenia if somebody comes and presses them enough times and in the right sequences. The buttons would be your genetic susceptibility, while the person pressing them would be the environmental factors.

Experts believe that an imbalance of dopamine, a neurotransmitter, is involved in the onset of schizophrenia. They also believe that this imbalance is most likely caused by your genes making you susceptible to the illness. Some researchers say the levels of other neurotransmitters, such as serotonin, may also be involved.

Changes in key brain functions, such as perception, emotion and behavior lead experts to conclude that the brain is the biological site of schizophrenia.

Schizophrenia could be caused by faulty signaling in the brain, according to research published in the journal Molecular Psychiatry.

How is Catatonic Schizophrenia diagnosed?

A physician who suspects a patient may have catatonic schizophrenia will recommend a series of medical and psychological tests and exams in order to help with the diagnosis. Diagnostic tests and exams may include:

• Physical exam - the patient's height, weight, heart rate, blood pressure, temperature are checked. The doctor will listen to the heart and lungs, and check the abdomen.
• CBC (complete blood count) - to check for alcohol and drugs, as well as thyroid function.
• MRI (magnetic resonance imaging) or CT (computed tomography) scan - the aim here is to look for brain lesions or any abnormalities in the brain structure.
• EEG (electroencephalogram) - to check for brain function.
• Psychological evaluation - the psychiatrist will ask the patient (if possible) about their thoughts, feelings and behavior patterns. They will discuss symptoms, when they started, how severe they are, and how they affect the patient's life. The doctor will also try to find out how often and when episodes had occurred.
  
  The doctor will most probably try to find out whether the patient had any thoughts about self-harm or harming other people.
  
  The doctor, usually a psychiatrist will try to talk to friends and family. If the patient is unresponsive or if their behavior is inappropriate, the doctor will check for catatonic signs.

Diagnostic Criteria for Catatonic Schizophrenia

For diagnosis of catatonic schizophrenia to be officially confirmed, the patient must beat specific DSM symptom criteria. DSM stands for the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. This manual is used by health care professionals to diagnose mental conditions - insurance companies also use this manual when deciding on reimbursing the patient's medical expenses.

The diagnostic criteria for catatonic schizophrenia include:

• Inability to move
• Inability to speak
• Staying still for a long time (in the same position)
• Overly excited (or excessive) seemingly non-purposeful behavior
• Resistance to being; being uncooperative (resisting instructions)
• Grimacing, unusual postures, odd movements
• Echolalia and Echopraxia - mimicking what other people say and mimicking other people's movements

A Proper Diagnosis May Take Time

Sometimes a long time may pass before a diagnosis of catatonic schizophrenia is confirmed. Other conditions/illnesses, mania, seizure disorder, substance abuse or severe depression have to be considered - these conditions have many overlapping signs and symptoms.

What are the Treatment Options for Catatonic Schizophrenia?

Catatonic schizophrenia is a condition that lasts throughout life - it is a chronic condition. Patients with catatonic schizophrenia require treatment on a permanent basis; even when symptoms seem to have disappeared - a period when patients tend to feel they are fine and require no more help. Treatment is basically the same for all forms of schizophrenia; there are variations depending on the severity and types of symptoms, the health of the patient, his/her age, as well as some other factors.

A whole team of health care professionals will be involved in treating a person with catatonic schizophrenia. Schizophrenia can affect many areas of the patient's life - therefore the team will have a wide range of experts, including:

• A case worker
• A GP (general practitioner, primary care physician, family doctor)
• A pediatrician
• A pharmacist
• A psychiatric nurse
• A psychiatrist
• A psychotherapist
• A social worker
• Members of the patient's family

Treatment options for catatonic schizophrenia generally include drugs (medications), ECT (electroconvulsive therapy), psychotherapy, hospitalization and vocational skills training.

Medication:

• Benzodiazepines - this is a class of drugs that act as tranquilizers. They are regularly used to treat anxiety; hence they are also called anti-anxiety medications. Benzodiazepines are usually the medication of choice for catatonic schizophrenia. The drug is fast acting and may be administered intravenously (injected into a vein, perhaps the only way if the patient is in a state of catatonia). Benzodiazepines help relieve catatonic symptoms rapidly. There is a risk of dependency if used for a long time. To relieve catatonic symptoms the patient may have to take this medication for several days or weeks.
• Barbiturates - drugs that act as CNS (central nervous system) depressants - their effects may range from mild sedation to total anesthesia. Put simply - they are sedatives and have a similar effect as benzodiazepines. Barbiturates can rapidly relieve the symptoms of catatonia. If used for a long time there is a risk of dependency. This drug is not routinely used for catatonic schizophrenia treatment.
• Antidepressants and mood-stabilizing drugs - people with catatonic schizophrenia often have other mental health problems/illnesses, such as depression, aggression or hostility.
• Antipsychotic medications - these are generally used for schizophrenia. As antipsychotics may worsen catatonic symptoms, they are not usually used for patients with catatonic schizophrenia.

ECT (electroconvulsive therapy) - this is a procedure in which an electric current is sent through the brain to produce controlled seizures (convulsion). It is sometimes used on patients with depression who either have not responded or cannot take antidepressants. It is also sometimes used for patients with very severe depression, or those at high risk of suicide. Experts believe that ECT triggers a massive neurochemical release in the brain, caused by the controlled seizure. ECT is sometimes used for catatonic patients who have not responded to medications or other treatments. Side effects may include short-term memory loss (usually resolves rapidly). It is important that the doctor explain clearly the pros and cons of ECT to the patient and/or guardian or family member.

Hospitalization - this may be necessary during severe episodes. Patients are safer in a hospital setting; they are more likely to get proper nutrition, sleep and hygiene, as well as the right treatment. Sometimes partial hospitalization is possible.

Psychotherapy - for patients with catatonic schizophrenia, medications are the main part of treatment; however, psychotherapy is also an important part. If symptoms are extremely severe, psychotherapy may not be appropriate.

Psychotherapy consists of a series of techniques for treating mental health, emotional and some psychiatric disorders. Psychotherapy helps the patient understand what helps them feel positive or anxious, as well as accepting their strong and weak points. If people can identify their feelings and ways of thinking they become better at coping with difficult situations.

Social and vocational skills training - this may help the patient live independently; a vital part of recovery for the patient. The therapist can help the patient learn good hygiene, prepare nutritional meals, and have better communication. There may be help in finding work, housing and joining self-help groups.

Compliance (adherence) - compliance or adherence in medicine means following the therapy regime (the treatment plan). Unfortunately, lack of compliance is a major problem for patients with schizophrenia. Patients can go off their medication for long periods during their lives, at huge personal costs to themselves and often to those around them as well.

Experts say that a significant percentage of patients go off their medication within the first twelve months of treatment. In order to address this, successful schizophrenia treatment needs to consist of a life-long regimen of both drug and psychosocial, support therapies.

What are the Possible Complications of Catatonic Schizophrenia?

Untreated catatonic schizophrenia may develop into serious and severe problems of a health, financial, behavioral and legal nature - these problems may affect every part of the patient's life. Complications may include:

• Depression --> Suicidal thoughts --> Suicidal behavior - a significant number of patients with schizophrenia have periods of depression. Depression symptoms should not be ignored, as there is a risk that it may worsen and lead to suicidal thoughts and behaviors if left untreated. The National Health Service (NHS), UK says that "Research has found that 30% of people with schizophrenia will attempt suicide at least once, and 1 in 10 people with schizophrenia will commit suicide." (this refers to schizophrenia in general, and not specifically to catatonic schizophrenia).
• Malnutrition
• Hygiene problems
• Substance abuse - which may include alcohol, prescription medications and illegal drugs
• Inability to find or maintain employment, resulting in poverty and homelessness. The patient may feel reluctant to re-enter the job market because of fears of being unable to cope with responsibilities. Experts say that individuals who manage to continue working tend to have a better quality of life compared to those who don't - therefore, it is recommended that the patient try to return to work.
• Prison
• Serious family conflicts
• Inability to study or attend school and other educational institutions
• Being a victim of crime
• Being a perpetrator of crime
• Smoking-related diseases