An Overview of Catatonic Depression

Catatonic depression is when catatonia occurs concurrently with depression. Catatonia is a state in which a person experiences marked disturbances in motor activity. Although generally thought of as reduced engagement and activity, it may also manifest as excessive or peculiar motor symptoms.

Catatonia can be a part of another mental disorder or medical condition or it may fall into the category of "unspecified." Unspecified catatonia includes all cases in which there is no major psychotic, affective, or medical disorder that can be diagnosed.

Catatonia itself is not uncommon, affecting about 10% of people with psychiatric conditions in Western countries. However, it is rare for people with major depressive disorder to have it. When catatonia occurs with depression, it is generally within the context of bipolar disorder.

In fact, people with symptoms of catatonia are most frequently diagnosed with bipolar disorder followed by schizophrenia, which is the second most common psychiatric condition associated with catatonia.

Catatonia is a syndrome that includes many different signs and symptoms, some of which are fairly broad in nature. Possible manifestations can include:

• Stupor: Perhaps the most prominent sign is stupor. Stupor is characterized by a lack of mobility and speech.
• Posturing: Persons with catatonia are able to remain in the same posture for quite considerable periods of time.
• Waxy flexibility: The clinician who is examining someone with catatonia is able to position the individual in very uncomfortable poses which the individual will continue to maintain for a long period of time.
• Negativism: Attempts to move one of the catatonic person's body parts are met with resistance equal to the amount of strength that is being applied.
• Automatic obedience: People with catatonia automatically obey all instructions given by the examiner.
• Ambitendency: The person with catatonia alternates between cooperating with the examiner's instructions and resisting them.
• Psychological pillow: The catatonic individual lies down with their head a few inches above the bed, almost as if there is an invisible pillow resting under his head. This position can be maintained for an extended amount of time.
• Forced grasping: The individual repeatedly and forcibly grasps the examiner's hand when it is offered.
• Obstruction: The catatonic individual stops suddenly in the middle of a movement without any apparent reason for doing so.
• Echopraxia: This involves mimicking the actions of the person speaking.
• Aversion: A person with catatonia turns away when spoken to.
• Mannerisms: This symptom involves performing repeated, purposeful movements (e.g., saluting).
• Stereotypies: People with catatonia sometimes engage in repeated, non-purposeful movements (e.g., rocking).
• Motor perseveration: People with catatonia may also continue to make a particular movement even after it has lost its original relevance.
• Excitement: Another symptom of catatonia involves engaging in excessive and purposeless activity that is not driven by outside stimuli.
• Speech abnormalities: Speech may exhibit certain irregularities, such as repetition of what other people say or monotonous speech.

While it is unknown exactly what causes catatonia, a number of theories have been put forth, including the following:

• Deficiency in gamma-aminobutyric acid (GABA)
• Dysregulation in glutamate
• Dysregulation in dopamine
• Abnormalities of metabolism in the thalamus and frontal lobes

One evolutionary theory suggests that catatonia may be due to an exaggerated primal fear response. It is possible, these scientists suggest, that our prehistoric ancestors, who had to frequently deal with predators, evolved the ability to remain very still for long periods of time in order to avoid detection by dangerous animals. Catatonia, they say, might be this ancient defense mechanism being triggered into action by strong feelings of fear.

Diagnosing catatonic depression begins with conducting a health assessment of the person's symptoms. Doctors typically ask about when the symptoms first appeared. They will also want to know about anything that seems to make these symptoms improve or worsen.

To diagnose catatonic depression, a physician or psychiatrist may often talk to family members or loved ones about the person's symptoms. A person who has catatonic depression may not be able to answer questions.

Doctors must also rule out other conditions that may lead to similar symptoms.

Benzodiazepines and electroconvulsive therapy (ECT) are the two main treatments for catatonia, although certain other treatments, such as some atypical antipsychotics, may also be utilized.

Benzodiazepines are the first-line choice for treating catatonia. They work by increasing the effects of the neurotransmitter GABA. This type of medication is also able to quickly provide relief for symptoms such as anxiety, sleeplessness, agitation, and muscle spasms. About 70% of people with catatonia do well with a benzodiazepine called Ativan (lorazepam).

Benzodiazepines are generally tried first, but ECT may be the first choice for malignant catatonia. ECT is performed under general anesthesia so that the individual does not experience any pain during the procedure.

Research suggests that benzodiazepines are an effective first-line treatment for catatonia and that ECT may be used as a second-line treatment if benzodiazepines are ineffective, but researchers suggest that ECT should be considered as a first choice intervention in instances of severe catatonia. The two therapies—prescription medication and ECT—may also be combined.

Some other treatments that may also be used include N-methyl-D-aspartate (NMDA) and repetitive transcranial magnetic stimulation (rTMS). Research suggests that N-methyl-D-aspartate (NMDA), an amino acid derivative and NMDA receptor agonist that mimics the actions of glutamate, shows some effectiveness for relieving catatonic symptoms. RTMS is a noninvasive procedure in which magnetic pulses are directed toward certain areas of the brain. These magnetic currents are thought to stimulate brain cells in a way that may reduce depression and anxiety.

Such treatments are promising, but further research is needed to determine their effectiveness in treating catatonic depression.

While catatonia can be serious and life-threatening, the prognosis is good with appropriate treatment. While there is a lack of large-scale clinical studies examining current treatment approaches, the available research supports the effectiveness of both benzodiazepines and electroconvulsive therapy (ECT).

Prompt recognition and treatment at the beginning of the catatonic state are essential for the best outcomes.