How to Recognize Catatonia in Major Depressive Disorder

Thus far, the Major Depressive Disorder (MDD) specifier lineup has included some unsavory characters. As if these haven't been difficult enough, there is also the possibility of MDD patients developing catatonia. Like psychosis, catatonia in psychiatry is most often associated with schizophrenia spectrum illnesses. If you specialize in mood disorders, however, you'll be sure to encounter the symptoms of catatonia in MDD and mania. In fact, it is considered more common in mood disorders than in Schizophrenia (e.g., Huang, et al., 2013; Takacs and Rihmer, 2013; Nath et al., 2021).

The presentation

When teaching about catatonia, it seems most of my students at first only associate catatonia with the statuesque state made popular by the catatonic character Chief Bromden in One Flew Over the Cuckoo's Nest. While the retarded (slowed) state of catatonia is marked by little to no psychomotor activity, catatonia can also present as a state of psychomotor excitation. As you'll see, while obvious psychomotor agitation/retardation are primary symptoms, stranger things do occur.

The man in the illustration is not unlike what we might witness in a catatonic patient: a grimaced face in a state of holding a strange position. I'll never forget the first catatonic patient I ever saw. Correctional officers told me an inmate I was familiar with became "stuck in position" in the early morning hours. Looking into his cell, I saw him sitting on the edge of his bunk, both raised feet off the floor despite the bunk being a mere 18 inches off the ground, and arms folded. He was mute, staring straight ahead, and expressionless.; his head occasionally turned at a glacial pace toward me, then forward again. When medical personnel arrived to examine the man, he did not budge for sternum rubs or foot tickling.

Not all cases are so obvious, though. Like any condition, catatonia exists on a spectrum, and subtler symptoms may be missed at first. Today, let's examine Mark's case (name disguised) involving the psychomotor-retarded state of Catatonia.

Mark, a 30-something Navy veteran with PTSD, was struggling through a major depressive episode. There were family woes, physical problems, and he couldn't finding meaningful work. Mark's depression ebbed and flowed over the year he was working with Dr. H. Family and medical complications improved, but Mark felt an huge existential chasm without purposeful work; a store clerk didn't cutt it. Try as he might, he just received a steady stream of notices he wasn't chosen for applied-for jobs.

As Mark's depression deepened, during one session with Dr. H, he 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. When he moved, it was almost mechanical, 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 Dr. H suspected Mark's desciption was catatonic features associated with MDD, he referred Mark for medical evaluation to rule-out other medical complications. 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 found him in the stockroom, expressionless and "stuck." When he tried to get Mark's attention by waving his hand, Mark began repeatedly to try to wave his own hand. He also appeared to have become incontinent. In the emergency room, medical staff found no evidence of a culpable physical problem or substance. He was treated with benzodiazepines and began to improve. Considering Dr. H's input on how depressed Mark has been, along with the emerging catatonic features, he was hospitalized for more acute care.

The DSM-5 criteria for catatonia are as follows:

Three or more of the following:

• Stupor (no psychomotor reactivity/inability to physically 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, or acknowledgment of, 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)
• Stereotypy (repetitious, meaningless motions)
• Agitation (internally generated/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, symptoms of retardation and agitation may be mixed and matched, and are sometimes known to even vacillate between primarily retarded and primarily agitated catatonic states(DSM-5). Nath et al. (2021) interestingly noted that a review of recent literature indicated retarded-type symptoms tend to be most prevalent in affective disorders. Further, Nath noted that his preliminary research suggests patients tend to experience an unwavering catatonic symptom collection during each affective episode they encounter.

Treatment implications

Identifying catatonic symptoms as soon as possible is important because:

• We don't want our patients to end up like Mark in the stockroom.
• They could injure themselves, for example 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 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 fleeting and 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 symptoms are ever-present.

Suspicion of catatonia, like the previous specifiers, warrants an immediate referral to psychiatry, or an emergency room if severe. Medical evaluation is warranted regardless of severity because many medical conditions, especially neurological diagnoses, are associated with catatonic states.

Benzodiazepines often work well (e.g., Takacs & Rihmer, 2013; Jhawer et al., 2019; Walther et al., 2019) to remit the episode, but that does not mean symptoms can't return. Hospitalization with electroconvulsive therapy (ECT) is not unusual for patients fitting the MDD with catatonic features specifier, and ECT tends to be very effective (e.g., Luchini et al., 2015; Walther et al., 2019). Thus, while catatonia is a severe symptom, it is correlated to favorable treatment outcomes.

Once stabilized, the job of a therapist is to not only help the depression continue to remit, but continue to evaluate for resurfacing. In the long run, prevention is the best option. If we know a patient is prone to catatonic features, it is 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. Nath (2021) noted that sometimes catatonia precedes the onset of the MDD episode. If this is true, coaching the patient and people close to them about identifying catatonia is also important to not only manage the catatonia, but to possibly prevent an MDD episode.

Astute clinical observations can spare a patient injured by MDD the disabling, additional insult of catatonia and the corollary dangers.

On Thursday, Oct. 21, 2021, we'll examine another contributor of agitation: mixed features, or the imposition of manic/hypomanic symptoms on some MDD episodes.