Clinical Neurology and Neurosurgery 184 (2019) 105375

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Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Why do neurologists miss catatonia in neurology emergency? A case series T

and brief literature review
Sucharita Ananda, Vimal Kumar Paliwala, , Laxmi S Singha, Ravi Uniyalb
⁎

a
Department of Neurology, SGPGIMS, Raebareli road, Lucknow, UP, India
b
Department of Neurology, King George Medical University, Lucknow, UP, India

ARTICLE INFO ABSTRACT

Keywords: Catatonia is a well-described clinical syndrome characterized by features that range from mutism, negativism
Catatonia and stupor to agitation, mannerisms and stereotype. Causes of catatonia may range from organic brain disorders
Extrapyramidal disorder to psychiatric conditions. Despite a characteristic syndrome, catatonia is grossly under diagnosed. The reason for
Parkinsonism missed diagnosis of catatonia in neurology setting is not clear. Poor awareness is an unlikely cause because
Major depression
catatonia is taught among conditions with deregulated consciousness like vegetative state, locked-in state and
Schizophrenia
akinetic mutism. We determined the proportion of catatonia patients correctly identified by neurology residents
in neurology emergency. We also looked at the alternate diagnosis they received to identify catatonia mimics.
Twelve patients (age 22–55 years, 7 females) of catatonia were discharged from a single unit of neurology
department from 2007 to 2017. In the emergency department, neurology residents diagnosed none of the pa-
tients as catatonia. They offered diagnosis of extrapyramidal syndrome in 7, meningitis in 2, and conversion
reaction, acute psychosis/encephalopathy and non-convulsive status epilepticus in one each. Their final diag-
nosis at discharge was catatonia due to general medical condition in 6 (progressive supranuclear palsy in 2, post-
status epilepticus, uremic encephalopathy, glioblastoma multiforme and tuberculous meningitis in one each),
catatonia due to major depression in 4, schizophrenia and idiopathic catatonia in one each. Extrapyramidal
syndrome appeared as common mimic of catatonia. The literature reviewed also revealed the majority of organic
catatonia secondary to causes that are usually associated with extrapyramidal features. Therefore, we suggest
that neurologists should consider catatonia in patients presenting with extrapyramidal syndromes.

1. Introduction
Catatonia is a mysterious disorder that is characterized by at least
three of the following - negativism (not following or resisting com-
mands), bizarre posturing, catalepsy (maintaining the induced anti-
gravity postures), mutism, waxy flexibility (resisting passive move-
ment), grimacing, echolalia, echopraxia, stupor, mannerisms, agitation
and stereotype. Catatonia was first described and proposed as a sepa-
rate disorder by Karl Ludwig Kahlbaum in 1874 [1]. Emil Kraepelin and
later Eugen Bleuler associated catatonia with schizophrenia in the early
1900s [2,3]. Catatonia was a pure psychiatric condition till late 1900s.
However later, catatonia was also seen in patients suffering from af-
fective disorders and general medical conditions [3–5]. Therefore, re-
cent Diagnostic and Statistical Manual of Mental Disorders 5th edition
(DSM V) criteria classify catatonia as “catatonia secondary to general
medical condition”, “catatonia as a specifier for schizophrenia”, “cata-
tonia as a specifier for affective disorders” and “catatonia with cause
not specified” [1,6]. The causes of catatonia are a myriad ranging from
pure psychiatric illnesses to neurological diseases like encephalitis and
neurodegenerative conditions. Despite a characteristic clinical entity,
catatonia is under recognized in neurology clinics. This can be attrib-
uted to frequently changing diagnostic criteria of catatonia, low sensi-
tivity of diagnostic criteria, other neurological conditions sharing
clinical features with catatonia and poor awareness of this condition
[7].
We performed this retrospective study to understand the reason for
delayed/missed diagnosis of catatonia in neurology settings. We aimed
to determine the proportion of patients that were correctly diagnosed as
catatonia by neurology residents. We also aimed to compare the initial
diagnosis offered to these patients in the neurology emergency by
neurology duty residents to the final diagnosis they received at the time
of discharge from hospital in order to identify the important clinical
mimics of catatonia. We also reviewed the literature on patients with
catatonia secondary to neurological and medical conditions.

⁎
Corresponding author.
E-mail address: dr_vimalkpaliwal@rediffmail.com (V. Kumar Paliwal).

https://doi.org/10.1016/j.clineuro.2019.105375
Received 2 August 2018; Received in revised form 9 May 2019; Accepted 21 May 2019
Available online 22 May 2019
0303-8467/ © 2019 Elsevier B.V. All rights reserved.
S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375

2. Methods

Catatonia due to GMC (Glioblastoma multiforme

Catatonia due to GMC (TBM with tuberculoma?

Catatonia related to GMC (bi-fronatal gliosis,

Operated case of Schwannoma Catatonia not

We collected the details of the catatonia patients that were dis-
charged from a single unit of the department of Neurology from 2007 to

Major depressive disorder recurrent

Major depressive disorder recurrent

Major depressive disorder recurrent

Major depressive disorder recurrent

2017. The case files of the patients were evaluated for their presenting
clinical features, examination findings, initial diagnosis made by the

Catatonia due to schizophrenia

GMC – General medical condition, PSP – Progressive supranuclear palsy, SE – Status epilepticus, FTC – Follow through case, TBM – Tuberculous meningitis, VP shunt – Ventriculo-peritoneal shunt.
Catatonia due to GMC (PSP)

Catatonia due to GMC (PSP)

neurology residents, investigations, catatonia days, hospitalization days
and the final diagnosis at the time of discharge. Based on the presenting

Catatonia due to GMC

paradoxical reaction)
clinical features, all patients were subjected to the DSM V criteria for

otherwise specified
catatonia. Patients fulfilling the DSM V criteria for diagnosis of cata-
tonia were included in the study. The patients were also subjected to

epilepsy, SE)

frontal lobe)
the DSM IV criteria and Bush Francis Catatonia Rating Scale (BFCRS)

Etiology
[6,8,9]. Catatonia was classified as:

1 Malignant catatonia - characterized by presence of hyperthermia,

fever and features of neuroleptic malignant syndrome
2 Periodic type which can be either hyperkinetic or hypokinetic [10].

Acute renal failure,?

Antipsychotic drugs
“Bhang” (cannabis)
Precipitating cause

Status epilepticus
(domperidone)
3. Results

Prokinetics

prokinetics

Septicemia
addiction

None

None

None
Twelve patients fulfilled the DSM V criteria for the diagnosis of

–
catatonia. All twelve patients also fulfilled DSM IV criteria and BFCRS.

TBM relapse,? paradoxical reaction,? VP shunt failure

Seven patients were females. Age of the patients ranged from 22 to 55

Drug induced extrapyramidal syndrome? Recurrence

PSP, Operated carcinoma breast with suspicion of
years. Duration of catatonic symptoms was less than 5 days in 4 patients

Chronic meningitis?Chronic subdural hematoma

and 5 to 15 days in 7 patients and 1 month in 1 patient. The clinical
details of the patients are given in Table 1.

Extrapyramidal syndrome, hypertension

Drug induced extrapyramidal syndrome

The frequencies of different clinical features of catatonia in de-
Drug induced extrapyramidal disorder

Drug induced extrapyramidal disorder

creasing order were waxy flexibility, mutism, negativism, catalepsy,

Acute psychosis/encephalopathy
stereotypies, agitation and echolalia. None of our patient had stupor,
mannerisms, posturing, grimacing and echo-praxia.
Initial diagnosis that was offered to patients after their first clinical

of tumor/Metastasis
Conversion reaction
examination in the emergency department was extrapyramidal syn-

Non-convulsive SE
drome (seven patients). Two patients were diagnosed with meningitis,
Initial Diagnosis

brain metastasis
PSP, DM, sepsis
and one each was diagnosed as acute psychosis/encephalopathy, con-
version reaction and non-convulsive status epilepticus. The neurology
residents diagnosed none of the patient with catatonia or with any
primary psychiatric condition. The final diagnosis at the time of dis-
charge were catatonia due to general medical condition (GMC) in six
Duration

1 month

15 days

15 days
5 days

7 days

7 days

4 days
7 days
3 days

2 days

2 days
5 days
patients, catatonia due to major depressive disorder recurrent in four
patients, catatonia due to schizophrenia in one patient and catatonia
not otherwise specified in one patient.
Mutism, Negativism, waxy-flexibility, recent onset of headache, off and
Mutism, catalepsy, waxy-flexibility, mask like face, reduced blink rate,

Negativism, mutism, waxy-flexibility, with fever, dyspnea, chest rales

Seven patients who were offered a diagnosis of extrapyramidal

Fever, mutism, cataplexy, waxy-flexibility, negativism FTC of TBM
Mask-like face, negativism, mutism, stereotypies, waxy-flexibility,

syndrome in the neurology emergency by duty residents actually suf-

fered from catatonia secondary to major depressive disorder recurrent
Initial diagnosis, presenting clinical features and etiology of catatonia.

Agitation, waxy flexibility, stereotypies, mood fluctuations

Excessive talkativeness, echolalia, stereotypies, catalepsy

(four patients), progressive supra-nuclear palsy (PSP) (two patients)

Fever, mutism, cataplexy, negativism, waxy flexibility

and catatonia not otherwise specified (one patient). Six patients with
the final diagnosis of “catatonia due to general medical condition” had
Mutism, withdrawal, waxy flexibility, cataplexy
Mutism, Negativism, Catalepsy, waxy-flexibility
Mutism, negativism, catalepsy, waxy-flexibility

PSP in two patients, acute renal failure, epilepsy with bi-frontal gliosis,
on fever, trivial head trauma 2 months back
Mutism, waxy-flexibility, catalepsy, rigidity

glioblastoma multiforme (GBM) and tuberculous meningitis (TBM) in

hydrocephalus with VP shunt (6 months)

one patient each. None of our patient had malignant catatonia. Two
patients had hyperkinetic episodic catatonia whereas ten patients had
hypokinetic episodic catatonia. Prokinetic drugs precipitated catatonia
in two patients. Cannabis intake, status epilepticus and septicemia were
the probable precipitating causes of catatonia in one patient each.
(Table 1)
Clinical Features

Ten patients received lorazepam and two patients received dia-

zepam for the control of catatonia symptoms. Four patients received
gaze palsies

additional dopaminergic treatment (amantadine and levodopa in two

rigidity

each), four patients received anti-depressants for major depression and

two patients received anti-psychotic drugs. Six patients showed com-
plete recovery from catatonia whereas six patients showed partial re-
Age/sex

40Y/M

26Y/M

51Y/M

32 Y/F
22Y/F

29Y/F
50Y/F

50Y/F
26Y/F

55Y/F

30Y/F
45/M

covery with residual features in the form of waxy flexibility in all six
patients, additional negativism in two and mutism in one. Three of
Table 1

these patients with partial recovery had PSP, and one each had GBM,
S.No

10

11
12

TBM and epilepsy with acute renal failure.

1

4
5

6
7
8

2
S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375

4. Discussion medical comorbidity (Table 2) [11–32]. Common causes of catatonia

In this retrospective study, we tried to assess the yield of catatonia
as a diagnosis in the neurology emergency. We could also identify the
important mimic of catatonia. Though none of the patients were diag-
nosed as catatonia, seven patients were diagnosed as extrapyramidal
syndrome, which appears to be a close mimic of catatonia. Rest of the
five patients received a nearly correct etiological diagnosis.
Nevertheless, it is important to identify catatonia despite correctly
identifying its cause because catatonia is potentially reversible in the
majority by the use of long-acting benzodiazepines. By this study, we
tried to answer some questions. Is catatonia really under diagnosed? Is
it a rare disease? Does it require training in the psychiatry departments
to correctly diagnose catatonia? Which departments generally see these
patients? Why catatonia was misdiagnosed as extrapyramidal disorder?
Catatonia is under diagnosed especially in the general medicine and
neurology settings. In a Dutch study that included 139 acutely psy-
chotic patients, treating physicians could diagnose catatonia in only 2%
patients as compared to 18% patients that were diagnosed by the re-
search group. [7]
Catatonia is not a rare syndrome. In a meta analysis of all the pre-
valence studies on patients with catatonia published from 1935 to
2017, the mean prevalence of catatonia among medical and psychiatry
patients was 9.0%. We found only twelve patients that were diagnosed
as catatonia in one treating neurology unit in last one decade. This
suggests that catatonia is often missed in patients presenting to the
emergency departments.
We believe that diagnosis of catatonia does not require training in
the psychiatry settings but requires a high index of suspicion. The
above-mentioned Dutch study was performed in a psychiatry setting
but still, the yield of the diagnosis was low.
Which medical departments see these patients? To answer this
question, we reviewed all the studies that included patients with cata-
tonia suffering from any general medical conditions or primary psy-
chiatric illness with medical/neurological co-morbidities. We included
only those studies that clearly presented the break-up of the underlying
etiology of catatonia. By using the key words – catatonia, waxy-flex-
ibility, catalepsy, mutism, negativism in Pubmed Central and Google
scholar, we found 7 studies on catatonia due to medical conditions and
15 studies on catatonia due to primary psychiatric disease with a
among the patients suffering from medical conditions were en-
cephalitis, encephalopathy, drug induced, Tourette syndrome, epilepsy
and stroke. Smith et al found 75 of 92 patients suffering from medical
condition and having catatonia due to an underlying psychiatric con-
dition [14]. Similarly, 120 of 560 catatonia patients suffering from a
primary psychiatric condition (15 studies, Table 2) had catatonia sec-
ondary to a general medical condition. Most common causes of organic
catatonia in psychiatric patients were drug induced, encephalitis and
neurodegenerative disorders. The review of these studies shows that
catatonia is reported from medical departments as often as from psy-
chiatry departments. Therefore, we suggest that medical and neurology
fraternity needs to learn to identify catatonia not only because it can be
organic catatonia, but also due to the fact that an organic cause may
underlie catatonia in patients suffering from psychiatry condition.
In this study, the first impression of the neurology residents of these
patients was a valuable input to understand how physicians may per-
ceive the clinical features of catatonia. Catatonia was mostly confused
with the extrapyramidal disorder. However, if we look at the traditional
teachings in the neurology clinics, the differential diagnoses of cata-
tonia are vegetative state, locked-in state and akinetic-mute state. These
conditions share the pathophysiology of “deregulated consciousness”
with catatonia. However, these conditions do not share many clinical
features with catatonia except for mutism, negativism and on rare oc-
casions cataplexy. Mutism and negativism in these conditions are due to
paresis of voluntary muscles and cataplexy is secondary to profound
rigidity or spasticity depending upon the underlying etiology. Unlike
catatonia, all these conditions occur after a clinical event that produces
a significant and usually an irreversible brain injury.
On the other hand, extrapyramidal syndromes may have several
similarities with catatonia (Table 3). Extrapyramidal syndromes may
occur secondary to idiopathic Parkinson’s disease, Parkinson plus syn-
dromes, drug/toxin induced parkinsonism and advanced stage of de-
mentias. Two of our patients had advanced stage of PSP. Majority of the
causes of organic catatonia in the studies that were reviewed in Table 2
had conditions that presents with significant extrapyramidal features
like post-encephalitis sequelae, neurodegenerative disorders, late stage
of dementia and drug-induced extrapyramidal syndrome. Some experts
suggest that the presence of drug induced extrapyramidal syndrome is a
risk factor for the development of catatonia [9,33]. Movement disorder

Table 2
Classification of catatonia in studies with medical patients and psychiatric patients with comorbid medical and neurological conditions.
Variables Studies with medical/Neurological patients Psychiatric patients with medical comorbidity

Granata Kakooza Jaimes Smith Cavanna Carroll Barnes No. of studies=15

et al. [11] et al. [12] Albornoz et al. et al. [15] et al. [16] et al. [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]
[13] [14] [17]
N=16 N=8 N=10 N=95 N=48 N =261 N =25 N =560

Catatonia due to GMC 10 20 261 5 120

1.Neurodegenerative 2 4 8 – 16
2. Encephalopathy – 3 25 – 4
3. Tumors – 1 13 – 1
4. Encephalitis 16* – 6 40 3 29
5. Epilepsy – 3 25 – 8
6.Developmental – 3 – – 9
7.Stroke 1 – 31 – 5
8.Drug induced 1 45 42
9. Others 8** 6 – 48*** 74 2 6
Catatonia due to affective – 64 – 9 194
disorder
Catatonia due to – 11 – 1 246
schizophrenia
Catatonia not otherwise – – – 10
specified

* NMDAR encephalitis.
** Nodding head syndrome.
*** Tourette syndrome.

3
S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375

Table 3
Similarities and differences between catatonia and extrapyramidal disorders.
Feature Extrapyramidal disorder Catatonia

Bradykinesia Present Present

Rigidity Present Present
Tremors Present Absent
Staring looks Present Absent
Hypomimia Present Present
Gait abnormality Short-shuffling gait Refusal to walk
Psycho-motor withdrawal Present Present
Mutism Advanced stage of Parkinson plus syndromes and dementia Present
Negativism Absent Present
Gagenhalten (waxy-flexibility) Present Present
Catalepsy Absent Present
Agitation Present Present
Posturing & mannerisms Rare (in advanced dementia and Parkinson disease due to drug related motor complications) Present
Echolalia, echopraxia & stupor Present in advanced dementia and parkinsonism Present
Response to levodopa, amantadine Present Present
Response to lorazepam Absent Prompt response in majority

associated with catatonia can be hypokinetic or hyperkinetic type [34].
The hypokinetic type movements are mutism, rigidity, waxy- flexibility
and cataplexy. This was the most common type of catatonia in our
patients. The hyperkinetic type consists of features like hyperthermia,
extreme rigidity and is a fatal condition if not treated appropriately.
Four of our patients had history of intake of offending drugs prior to the
onset of catatonia. Catatonia also improves with levodopa and aman-
tadine that may further anchor the belief of a neurologist on the di-
agnosis of Parkinsonism in their patients. Therefore, we suggest that
patients presenting with extrapyramidal syndrome should also be
evaluated for catatonia.
Our study had several limitations. It was a retrospective study. Our
study had small number of patients which might be due to either missed
diagnosis or missed patients on the retrospective chart review due to
lack of the term “catatonia” on the discharge tickets. We described the
outcome of our patients at the time of discharge from the hospital.
Many more patients of catatonia are expected to show complete re-
covery over a longer follow up. A prospective study can be more ap-
propriate to discuss the outcome of catatonia.
5. Conclusion
Catatonia is a common clinical syndrome that presents both in the
psychiatry and neurology/medicine departments. Catatonia is under
diagnosed in the neurology/medicine departments. Catatonia patients
show many clinical features that may easily be confused with extra-
pyramidal disorders. Some neurodegenerative disorders like dementias
and Parkinson-plus syndromes may present with catatonia. A subset of
psychiatry patients with catatonia may also have an underlying organic
cause of catatonia. Due to improvement in catatonia with dopaminergic
drugs, neurologists may further tend to diagnose patients with catatonia
as Parkinsonism. Therefore, a high index of suspicion especially for
patients presenting with extrapyramidal disorder is required to diag-
nose catatonia.
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