Catatonia 

Catatonia used to be defined as a disorder of its own but this is no longer the case in DSM V. It is instead a feature of multiple psychiatric and non-psychiatric disorders. It can commonly be seen in mood disorders such as depression and bipolar disorders but also in schizophrenia. 

Catatonia is defined as having 3 or more of the following set of symptoms in each subtype:

• Types
  • Retarded catatonia 
    • Stupor 
    • Catalepsy (waxy flexibility) 
      • Can place patients in any position and they get stuck in this new position for hours to days 
      • 
    • Mutism 
    • Negativism 
  • Excited catatonia 
    • More activity, saying, doing 
    • Stereotypy 
      • Repetitive behaviour 
    • Agitation or grimace 
    • Echolalia
      • Patient copying what you say  
    • Echopraxia 
      • Patient copying what you do 
• Diagnosis 
  • Clinical 
  • Administer lorazepam (short acting IV benzos) 
    • If the patient is back to normal = diagnosis confirmed 
• Treatment 
  • IV lorazepam 
  • Malnutrition because they stop eating 
    • Trend albumin and consider enteral nutrition 
  • Administer low molecular weight heparin or pneumatic compression devices
    • Due to reduced movement 
  • Check for elevated CK and decreased kidney function
    • Risk of rhabdomyolysis if they haven't moved around 
    • 

Malignant catatonia 

Malignant catatonia is a subtype of catatonia. The symptoms are exactly the same as catatonia from other causes. 

• Symptoms 
  • Rigidity
    • Lead pipe rigidity with contracted muscles and shaking 
    • Elevated CK due to extended muscle contraction and the lack of movement 
  • Autonomic dysfunction 
    • Elevated heart rate
    • Elevated blood pressure
    • Elevated fever (>40C)
      • Rule out infectious causes 
• Causes 
  • Psychiatric disease present 
  • Not caused by medications 
• Treatment 
  • Same as retarded or excited catatonia 
  • IV lorazepam

Neuroleptic malignant syndrome 

Caused by dopamine antagonists - antipsychotics. 

• Symptoms 
  • Rigidity
    • Lead pipe rigidity with contracted muscles and shaking 
    • Elevated CK due to extended muscle contraction and the lack of movement 
  • Autonomic dysfunction 
    • Elevated heart rate
    • Elevated blood pressure
    • Elevated fever (>40C)
      • Rule out infectious causes 
  • Hyporeflexia 
  • Decreased or normal bowel sounds
• Causes 
  • Psychiatric disease often present 
  • Patient on antipsychotics 
    • 
• Diagnosis 
  • Patient on antipsychotics and has the symptoms above 
• Treatment 
  • Stop the antipsychotics
  • Use dantrolene to prevent rhabdomyolysis 

Serotonin syndrome 

Caused by serotonergic agents - serotonin excess. 

• Symptoms 
  • Not rigidity
    • Hypertonicity or hyperreflexia instead of rigidity 
    • Elevated CK due to extended muscle contraction and the lack of movement 
  • Autonomic dysfunction 
    • Elevated heart rate
    • Hyperactive bowel/diarrhea 
    • Elevated blood pressure
    • Elevated fever (>40C)
      • Rule out infectious causes 
  • Hyperreflexia 
  • Dilated pupils 
• Causes 
  • Psychiatric disease present - usually mood or anxiety 
  • Patient on SSRIs or MAO inhibitors 
• Diagnosis 
  • Patient on SSRIs/MAOI's and has the symptoms above 
• Treatment 
  • Stop the SSRIs or MAOI's

Malignant hyperthermia 

This will occurs in the OR under anesthesia.

• Symptoms 
  • Rigidity
    • Lead pipe rigidity with contracted muscles and shaking 
    • Elevated CK due to extended muscle contraction and the lack of movement 
  • Autonomic dysfunction 
    • Elevated heart rate
    • Elevated blood pressure
    • Elevated fever 
      • Rule out infectious causes 
• Causes 
  • Not a psychiatric cause 
  • Certain anesthetics (Succinylcholine or halothane gas common trigger)
  • 
• Diagnosis 
  • Ask for family history of reaction to anesthesia before the procedure 
• Treatment
  • Ice baths
  • Dantrolene = postsynaptic muscle relaxant