Catatonia

Catatonia is a relatively rare clinical finding in the pediatric setting. It may occur as part of the presentation of a primary psychiatric illness, including mood and psychotic disorders, or secondary to physical illness or medication effects (Schieveld 2006). Slooter et al. (2005) cited an incidence of 0.16 case per million in the pediatric population. Commonly cited causes of secondary catatonia are listed in Table 30-7.

The core features of catatonia include mutism, stupor, motoric immobility, negativism, excitement, catalepsy, and posturing. DSM-IV-TR (American Psychiatric Association 2000) also includes echola-

Table 30-7. Causes of secondary catatonia

Neurological causes

Angioma

Basilar artery thrombosis

Bilateral infarction of the anterior cingulate gyrus Bilateral infarction of the temporal lobes Cerebral anoxia Closed head injury

Encephalitis or other central nervous system infection

Glioma

HIV encephalopathy Normal-pressure hydrocephalus Seizure disorders

Surgery involving the hypothalamus Other medical causes

Addison's disease Bacterial sepsis Cushing's disease Hyperthyroidism Malaria

Postoperative states Systemic lupus erythematosus Typhoid fever Uremia Viral hepatitis Vitamin deficiencies Medications and toxins Antipsychotic agents Corticosteroids Cyclobenzaprine

3,4-Methylenedioxymethamphetamine (MDMA)

Phencyclidine (PCP)

Sedative-hypnotic withdrawal

Tetraethyl lead poisoning

Source. Reprinted from Masand PS, Christopher EJ, Clary GL, et al.: "Mania, Catatonia, and Psychosis," in The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson JL. Washington, DC, American Psychiatric Publishing, 2005, p 240. Copyright 2005, American Psychiatric Publishing, Inc. Used with permission.

lia and echopraxia as potential symptoms. The term malignant catatonia is sometimes used for patients who have associated signs of hyperthermia or autonomic instability (Takaoka and Takata 2003). Historically, the term lethal catatonia has been used to describe cases of prolonged psychomotor excitement, with disturbances in autonomic function and, in its final stage, a confusional state that may resemble delirium or NMS (Castilo et al. 1989). The differential diagnosis for catatonia includes Parkinson's disease, stroke, malignant hyperthermia, and selective mutism. Hyperkinetic movement disorders, such as Tourette's syndrome and cerebral palsy, and hypokinetic movement disorders, such as Huntington's disease and Wilson's disease, should also be considered (Masand et al. 2005).

Patients with catatonia are at risk of a number of potentially serious medical complications that stem primarily from the patients' immobility and inability to communicate their symptoms. These include cardiovascular deconditioning and dysfunction with associated deep venous thrombosis, aspiration pneumonitis, decubiti, contractures, and malnutrition. The latter may necessitate nasogastric feeding or surgical gastrostomy.

First-line management of catatonia includes treatment of any identifiable underlying etiological factors and maintenance of nutrition and homeostasis. Benzodiazepines, including lorazepam, have been found to be beneficial, in particular for the motor and speech symptoms (Masand et al. 2005). Other pharmacological agents include carbamazepine and bromocriptine (Takaoka and Takata 2003). There are isolated case reports of the use of atypical neuro-leptic medications (e.g., risperidone) to treat halo-peridol-induced catalepsy (Delbello et al. 2000). However, electroconvulsive therapy is cited as the single most efficacious treatment, including for pe-diatric patients (American Psychiatric Association 2001; Takaoka and Takata 2003). In severe cases, dantrolene has been administered with electrocon-vulsive therapy to control the signs of hyperthermia and muscular rigidity (Nolen and Zwaan 1990).

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