In this episode, I interview Heidi Combs, MD, associate professor of psychiatry at Harborview Medical Center and the course director for the University of Washington’s MS3 clerkship. We discuss the importance of recognizing catatonia in hospitalized patients on medical services, as well as her physical exam for catatonia and approach to treatment. This episode is directed to internists and internists in training, and is likely appropriate for anyone from MS3s to practicing clinicians.
The Importance of Recognizing Catatonia
Estimates of the incidence of catatonia varies, but we are likely grossly under-identifying it by misidentifying it as delirium or pharmacologic over-sedation. It has been estimated to affect up to 4% of patients in medical ICUs and likely affects many hospitalized patients on medical services as well.
Catatonia can develop in the setting of psychiatric disease (bipolar disorder is actually more commonly associated with catatonia than schizophrenia is), medical conditions (the list is long but includes infections, electrolyte disorders, autoimmune conditions and endocrinopathies), or medications (benzodiazepine downtitration or withdrawal, and the addition of antipsychotic agents). It can also develop in patients without any identified risk factors.
The Catatonia Exam
The 23-item Bush Francis Catatonia Rating Scale is used to grade catatonia severity (each item is scored 0-3), and the 14-item Bush Francis Catatonia Screening Instrument is used to screen for catatonia: 3 items is considered a positive screen, and even with 2 items, catatonia should be strongly considered.
First, observe the patient and speak with the patient. Do they have negative motor symptoms: Immobility/stupor or staring? Do they have positive motor symptoms, such as excitement, grimacing, mannerisms, or stereotypy?
Then speak with the patient. Do they copy what you say (echolalia) or make repetitive statements of their own (verbigeration)? Is there a complete or relative paucity of verbal production or long speech latency? This would classify as mutism.
Examine the patient for rigidity by moving their arm around at the elbow and wrist joints. if they push harder the harder that you push in any direction, this is called negativism, a.k.a gegenhalten. Instead of placing their hand down gently, let go with the arm above the bed, to see if it remains in place (waxy flexibility).
Ask the patient to put their hands out in front of them with the palms down (like checking for pronator draft, but pronated instead of supinated). Instruct the patient NOT to let you move their hand up any further. Then apply gentle upward pressure to the palms. Do they let you easily raise their arms? This is the anglepoise lamp sign, also known as passive obedience or mitgehen.
Tell the patient “do not shake my hand. I do not want you to shake it.” Then extend your hand for a handshake. If they shake your hand, or vacillate between extending their arm and bringing it back for an extended period, this is ambitendency.
Without giving instructions, abduct your arm and dramatically shake your head, like a monkey. If the patient copies you, this is echopraxia.
Reach into your pocket, and tell them “Please stick out your tongue so that I can put a pin in it.” If the patient then sticks out their tongue, this is abnormal and is considered automatic obedience.
Two or three positive findings suggests a clinical diagnosis of catatonia, which is reason enough to start a benzodiazepine trial in order to treat obvious cases and help confirm the diagnosis in questionable cases, if the patient has a positive response to treatment. A negative response does not rule out catatonia, since roughly 30% of patients may not improve with benzodiazepines alone, so zolpidem or memantine could also be tried.
You can perform a benzodiazepine trail by giving 1mg of ativan IV, and re-examining the patient roughly 30 minutes later. Many patients require higher doses to achieve a clinical response. You could go to ativan 1mg PO TID after the initial trial, then try 2mg PO TID, 3mg PO TID, 4mg PO TID, up to 6mg PO TID, uptitrating every two doses, and stopping when the patient seems fully treated or sedated.
Have you ever given your patients Ambien (zolpidem) in the morning? Patients with catatonia will actually become more interactive with zolpidem (e.g. 5mg). This is an alternative agent that can be tried if the response to benzodiazepines is incomplete.
For emergent cases, or those not responsive to benzodiazepines, consider ECT.
Carroll, B. T., et al. “Treating persistent catatonia when benzodiazepines fail.”Current Psychiatry 4 (2005): 56-64.
Saddawi-Konefka, D., Berg, S. M., Nejad, S. H., & Bittner, E. A. (2014). Catatonia in the ICU: An Important and Underdiagnosed Cause of Altered Mental Status. A Case Series and Review of the Literature*. Critical care medicine, 42(3), e234-e241.