Catatonic Depression

In 1843, French neurologist and psychiatrist Jules Baillarger described a syndrome in which patients appeared in "a state of stupor, with fixed gaze, a facial expression of frozen astonishment, muteness, and indifference." The condition later became known as catatonia.

Originally catatonia was believed to be a type of schizophrenia, but more recent studies found that more than one quarter of patients with mania and 20 percent of individuals with depression experience symptoms of catatonia. Today, catatonia is considered a neuropsychiatric syndrome associated with several other conditions including post-traumatic stress disorder, bipolar disorder, and depression. Catatonic depression is no longer recognized as a separate disorder by the American Psychiatric Association.

Fortunately, catatonic depression is also easily treatable.

Symptoms of Catatonic Depression

In depression, catatonia is most often associated with bipolar I disorder. In bipolar I, a patient experiences periods of mania broken by severe depressive episodes. It may also be found in other mood disorders including bipolar II and major depressive disorder (MDD).

In addition to other symptoms of depression, catatonic patients may experience:

  • extreme negativism
  • hypokinesis: immobility or being unable to move
  • selective mutism: the patient is unable to speak due to extreme anxiety
  • unusual movements
  • posturing: imitating another person's speech (echolalia) or movements (echopraxia)
  • mania: immobility alternating with agitation           
  • intense emotional pain triggered by normal physical movements
  • refusal to eat or drink (often found in older patients)

Severely depressed individuals with catatonia may have difficulty completing normal tasks. For instance, the simple act of sitting up in bed up may take hours.

Catatonia in severely depressed people often manifests in similar physical symptoms as those with catatonic schizophrenia.

An individual with catatonic depression may need to be monitored by a clinician or caregiver to make sure she doesn't harm herself or others.

Causes of Catatonia

Experts believe mood disorders are caused at least in part by irregular production of neurotransmitters, chemicals in the brain that allow cells to communicate with each other. The two neurotransmitters most often associated with depression are serotonin and norepinephrine.

Antidepressants such as selective serotonin re-uptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) work by acting on those specific receptors.

Catatonia, on the other hand, is believed to be caused by irregularities in the dopamine, gamma-aminobutyric acid (GABA), and glutamate neurotransmitter systems. Because catatonia is always accompanied by an underlying neurological, psychiatric, or physical illness, its diagnosis must focus on the root cause in order to successfully treat the catatonic symptoms.

Treatments

Benzodiazepines and electroconvulsive therapy (ECT) are the main treatments for catatonic symptoms in depression. Increasingly, N-methyl-D-aspartic acid (NMDA) antagonists, certain atypical antipsychotics, and repetitive transcranial magnetic stimulation (rTMS) are being used to treat catatonia as well.

Benzodiazepine

Benzodiazepines is a psychoactive drug that enhances the effect of the neurotransmitter gamma-aminobutyric acid (GABA), and is effective in quickly relieving catatonic symptoms in most patients, including anxiety, muscles spasms, agitation, and insomnia.

The benzodiazepine lorazepam has been the most common treatment, resolving catatonic symptoms in 70 percent of patients.

Electroconvulsive Therapy

Electroconvulsive therapy is by far the most effective treatment for catatonia, resolving symptoms in 85 percent of cases. Although ECT is now considered a safe and effective treatment for a range of mood disorders and mental illnesses, there is still a stigma surrounding ?"electroshock therapy" and it currently lags behind benzodiazepine as the primary treatment for catatonic symptoms. However, a combination of lorazepam and ECT may be the best treatment for catatonia.

NMDA
There is growing evidence showing N-Methyl-D-aspartate (NMDA)—an amino acid derivative which mimics the behavior of the glutamate neurotransmitter—can be used to effectively to treat catatonia as well, although more studies are needed to adequately address its effectiveness and side effects.

rTMS
Other treatments that have shown promise are repetitive Transcranial Magnetic Stimulation (rTMS) and certain atypical antipsychotics—particularly those that block D2 receptors—may be effective as well but, as with NMDA, more research is necessary.