Understanding Catatonic Depression

Catatonia is a syndrome; depression is a mood disorder

Medically reviewed by Melissa Bronstein, LICSW

Catatonic depression describes a syndrome in which catatonia (a span of disturbed activity) exists at the same time as major depressive disorder (MDD). People with this condition can have symptoms of both ailments.

Catatonic depression can cause many types of symptoms. These can range from decreased movement to odd actions. It can also involve low mood and other symptoms of MDD.

When found early, this syndrome is highly treatable with a good outlook. Without treatment, it can lead to severe problems. These can occur when a person stops eating or moving.

This article explains what catatonic depression means, its symptoms, and how it is found. It also describes treatments and what the future can involve for those with it.

What Does Catatonic Depression Mean?

Catatonic depression is also called major depressive disorder with catatonic features. This describes the co-existence of catatonia with major depressive disorder.

Once thought to exist as a symptom of schizophrenia, research shows that catatonia, or catatonic behavior, can occur alone or at the same time as several mental and physical conditions like MDD. It is a syndrome in which a broad range of symptoms affect your movement and actions, interfering with everyday life. Catatonia affects about 10% of people with psychiatric conditions.

Major depressive disorder is the most commonly diagnosed form of depression. It is characterized by symptoms that include persistent low mood, withdrawal or isolation, lack of pleasure or interest in once enjoyable activities, and thoughts of suicide or death.

Having catatonic depression means that you can experience symptoms of catatonia and major depressive disorder at the same time. An episode of catatonic depression can last for weeks, months, or even years.

Learn More: What Is Catatonic Behavior in Schizophrenia?

Characteristic Symptoms

Research indicates that immobility and mutism (minimal or absent speech) are the two most common symptoms of catatonia, each occurring in over 90% of people with this condition.

However, symptoms of catatonic depression can vary by individual. Behavior can be decreased, increased, or abnormal. According to the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5), it requires the presence of three of the following 12 clinical signs:

• Stupor: This combination of reduced responsiveness due to a lack of movement and speech occurs despite the affected person being conscious.

• Catalepsy: With catalepsy, there is a lack of response to external stimuli. A person's limbs remain in the position in which they are placed.

• Waxy flexibility: This involves light resistance to repositioning that decreases shortly after the movement begins, compared to wax that bends as it warms. Waxy flexibility often occurs with catalepsy.

• Mutism: More than being withdrawn, mutism involves being unable or unwilling to speak despite comprehending speech.

• Negativism: This behavior involves an automatic and motiveless resistance to suggestions or instructions.

• Posturing: Posturing involves spontaneously holding a specific uncomfortable or abnormal position for an extended period. This occurs without prompting or positioning from another person.

• Mannerisms: Mannerisms involve an unusual, exaggerated, or peculiar way of performing a normal action like movement or speech.

• Stereotypies: These behaviors include repetitive, non-goal-directed movements and speech that may interfere with normal functioning.

• Psychomotor agitation: Psychomotor agitation involves increased movement, restlessness, and irritability, often with a heightened responsiveness to internal and external stimuli.

• Grimacing: Grimacing describes the act of maintaining odd facial expressions such as wincing or a furrowed brow.
  

• Echolalia: This behavior involves automatically copying another person's speech for no apparent purpose.

• Echopraxia: Echopraxia involves automatically copying another person's movements or behaviors for no reason.

Akinetic Characteristics of Catatonic Depression

The most common type of catatonia is called akinetic catatonia. It involves extreme resistance to movement.

Akinetic characteristics of this type of catatonia include persistent staring. The affected person may appear non-responsive, though they remain alert and aware of their surroundings. Their response to external stimuli and voice communication is typically decreased.

Causes of Catatonic Episodes

The causes of catatonic episodes are not fully understood. Researchers have proposed that catatonic episodes may be linked to the following:

• Reduced activity of gamma-aminobutyric acid (GABA) (a neurotransmitter in the brain)

• Dysfunction of dopamine (a brain chemical involved in medical conditions like Parkinson’s disease)

• Dysfunction of glutamate (an amino acid that acts as a neurotransmitter in your brain)

• Abnormalities in the thalamus and frontal lobes of the brain

• Intense fear or anxiety
  

Risk Factors

Having one or more of the following risk factors can make you more likely to have a catatonic episode:

• Psychiatric disorders like major depressive disorder, autism, schizophrenia, or bipolar disorder

• General medical conditions such as strokes, autoimmune disorders, neurodegenerative diseases

• Viral, fungal, and bacterial infections such as meningitis and encephalitis

• Brain injuries

• Drug and alcohol use

• Withdrawal of certain medications, such as benzodiazepines or clozapine, before the end of a treatment course

• A first-degree relative affected by catatonic symptoms

Hospitalization for Severe Symptoms

The onset of catatonic depression can lead to serious medical complications if treatment is not started in the early phases. Immobility and refusal to eat and/or drink can increase the risk of the following complications that may require hospitalization:

• Deep vein thrombosis

• Pulmonary embolism

• Malnutrition

• Dehydration

• Pneumonia

• Pressure sores

• Muscle contractures (tightening of muscles, tendons, or joints causing a deformity)

• Infection

• Worsening of underlying conditions
  

Diagnostic Catatonic Depression Assessment

Getting a prompt and accurate diagnostic catatonic depression assessment is essential if you have symptoms of this condition. Misdiagnosis of catatonic depression can lead to improper medication. It can also result in potentially life-threatening outcomes.

A diagnostic catatonic depression assessment includes a thorough physical and psychiatric evaluation for identifying catatonic symptoms in people with major depressive disorder. While there is no laboratory test for catatonic depression, these tests can help identify causes or complications related to your symptoms.

Depending on your symptoms, this assessment can involve the following:

• Complete medical history including history of symptoms and current medications taken from you or someone caring for you if you are unable to provide these details

• Observation of your symptoms

• Comprehensive physical examination, including vital signs

• Laboratory tests to assess that include complete blood count (CBC), blood urea nitrogen, creatinine, muscle and liver enzymes, thyroid hormones, electrolytes, blood glucose, and urinalysis

• Comprehensive neurological examination including pupil dilation, eye movements, reaction to pain, and reaction to light or sound

• Testing for other neurological conditions involving electroencephalogram (EEG) and/or magnetic resonance imaging (MRI)

Also, a consideration of differential diagnosis for the following conditions:

• Extrapyramidal side-effects: Side effects linked with antipsychotic drugs

• malignant syndromeNeuroleptic: A life-threatening reaction to antipsychotic treatment

• Nonconvulsive status epilepticus: A prolonged seizure that presents as an altered mental state

• Abulia or akinetic mutism: Disorders of diminished motivation that involve lack of initiation to speak or move

• Locked-in syndrome: A rare disorder of the nervous system that involves paralysis except for eye movement

• Vegetative state: A lack of awareness of self or surroundings, often related to a severe cerebral injury

• Stiff person syndrome: An autoimmune disorder that involves lower body stiffness and spasms
  

Catatonic Depression Treatment Plan

A catatonic depression treatment plan combines therapies for catatonia and depression. However, since catatonia increases your risk of serious complications, treatment of catatonia typically takes priority.

A catatonic depression treatment plan can include the therapies below to address catatonic behavior.

Medication

Regardless of the underlying condition, benzodiazepines are the first-choice treatment for catatonia. They work by improving the effects of the GABA neurotransmitter.

The benzodiazepine Ativan (lorazepam) is generally the first-choice drug. It is the most frequently used and has an 80% remission rate in adults and 65% in children. Treatment can often be seen within the first 10 minutes after administering the medication.

There are no treatment standards on how long benzodiazepines should be continued. They are typically stopped when the underlying illness has resolved. When these drugs are given for long periods, the dosage is generally tapered off during withdrawal.

ECT

Electroconvulsive therapy (ECT) uses the benefits of inducing a seizure in your brain to "reset" it. Treatment involves brief electrical brain stimulations under anesthesia. It is often reserved as a second-line treatment for catatonia if benzodiazepines don't work.

While ECT has a response rate of 80% to 100%, achieving the desired result can take several sessions. Some researchers suggest that ECT should be the treatment of choice for catatonia because of its effectiveness.

Repetitive Transcranial Magnetic Stimulation (rTMS)

Repetitive Transcranial Magnetic Stimulation (rTMS) is an emerging treatment for catatonic depression. rTMS uses a magnet placed on your forehead that releases pulses to your brain.

It provides stimulation to your brain, similar to ECT. However, rTMS does not require anesthesia or produce the cognitive side effects that occur with ECT. Treatment requires daily appointments for several weeks.

Why Do People Have Relapsing Catatonic Depression Episodes?

It is not known why relapsing catatonic depression occurs. In some people, catatonic symptoms will emerge each time lorazepam is tapered off, causing a relapse into a catatonic state. This requires that benzodiazepines be extended for long-term maintenance treatment.

Recovery, Well-Being, and Ongoing Treatment

With early treatment, the prognosis for catatonic depression is good. About 80% of people with catatonia have symptoms that improve with as little as one dose of lorazepam. However, most people will require more than one dose to fully treat their condition. Timing varies by individual.

Even if your catatonia symptoms resolve, you may still need other treatments to address the underlying cause.

Major depressive disorder is typically treated with medication, psychotherapy, or both. Research indicates that a combination of antidepressants and psychotherapy treatment is the most effective approach.

In addition to medication and psychotherapy, the following lifestyle habits may help you manage life with major depressive disorder:

• Focus on self-care by controlling stress, getting enough sleep, maintaining a healthy lifestyle, and avoiding drugs and alcohol.

• Set small, achievable goals that are realistic to achieve so you can maintain confidence and motivation.

• Know the warning signs of depression triggers. Contact your mental health professional if you recognize these symptoms so you can discuss ways to improve your situation.

• Educate friends and family about MDD and ways they can support you and alert you to warning signs.

• Seek support from family members or a support group to help you maintain relationships in times of crisis.

• Follow your treatment plan even if you start to feel better. Don't make changes or discontinue medication without consulting your mental health professional.
  

Getting Help for Catatonic Depression

If you or someone you know are having symptoms of catatonic depression, call 911 or go to your nearest emergency room for immediate care.

If you or someone you know are having thoughts of suicide or another type of mental health crisis, call, text, or chat 988 to reach the 988 Suicide and Crisis Lifeline.

Summary

Catatonic depression is a type of depression that involves distorted speech, movement, and actions. It is a syndrome in which catatonia exists at the same time as MDD.

While catatonia is often assumed to be reduced movement, it can also involve extreme or odd motor symptoms.

This syndrome is also called major depressive disorder with catatonia. This describes the fact that catatonic behavior is linked to depression.

Catatonic depression can prevent you from eating, drinking, or moving. With early treatment, the outlook is good for most people. Without treatment, you increase your risk of severe health issues that can threaten your well-being.

Read the original article on Verywell Health.