Catatonia
Description:
Catatonic syndrome (catatonia) (other - Greek - to pull, strain) - a psychopathological syndrome (group of syndromes) which main clinical manifestation are motive frustration. For the first time the catatonia is described by Kalbaum (1874) as an independent mental disease, afterwards is carried by Krepelin to schizophrenia.
The Lyutsidny catatonia accompanied with productive psychopathological frustration in the form of nonsense, hallucinations of mental avtomatizm is observed, probably, only at schizophrenia. The catatonia and a catatonia accompanied with stupefaction "Is empty", meet at brain tumors, first of all at tumors of its basal departments, at traumatic psychoses, is preferential in the remote period of a craniocereberal injury, at acute epileptic psychoses, at infectious and intoksikatsionny psychoses, at a general paralysis.
The catatonic syndrome arises both at children, and at adults. At the last - it is preferential up to 50 years. At later age catatonic frustration represent a rarity. At children catatonic frustration are shown by motive stereotypes (often rhythmical) - "manezhny" run, the uniform movements by extremities, a trunk or in the form of grimacing, walking on tiptoe, etc.
Often the echolalia, a mutism and verbigeration, the stereotypic impulsive movements and actions meet. Catatonic frustration at children can take the form of regressive behavior - the child of 5-6 years sniffs and licks the objects surrounding it. Наиб льш й the catatonic syndrome reaches intensity (first of all at schizophrenia) at the beginning of a disease at the age of 16-17-30 years. Especially this intensity concerns struporous frustration. After 40 years for the first time the arising expressed catatonic frustration represent a rarity. At women at the age of 40-55 years for the first time the appearing catatonic frustration some time very much remind hysterical - the expressional speech and a mimicry, theatrical behavior, a hysterical lump, etc.
Catatonia symptoms:
The structure of a catatonic syndrome allocates catatonic excitement and a catatonic stupor.
Catatonic excitement
Allocate two forms of catatonic excitement:
1. Pathetic catatonic excitement is characterized by the gradual development moderated by motive and speech excitement. In the speech there is a lot of pathos, the echolalia can be noted. The mood increased, but has character not of a hyperthymia, and exaltation, causeless laughter is periodically noted. At increase of symptomatology lines of a hebephrenia - gebefreno-catatonic excitement appear. Impulsive actions are possible. Disorders of consciousness do not arise.
2. Impulsive catatonic excitement develops sharply, actions prompt, often cruel and destructive, have socially dangerous character. The speech consists of separate phrases or words, the echolalia, an ekhopraksiya, perseverations are characteristic. At extreme expressiveness of this type of catatonic initiation of the movement chaotic, can gain choreiform character, patients are inclined to self-damages, are silent.
Catatonic stupor
The catatonic stupor is characterized by motive block, silence, a muscular hypertension. Patients can be in the held-down state within several weeks and even months. All types of activity, including instinctive are broken. Distinguish three types of a catatonic stupor:
1. The stupor with wax flexibility (a cataleptic stupor) is characterized by hardening of the patient for a long time in the pose accepted by it or given it, even very inconvenient. Without reacting to the loud speech, can respond to the silent shyopotny speech, rastormazhivatsya spontaneously in the conditions of night silence, becoming available to contact.
2. The Negativistichesky stupor is characterized, along with motive block, constant counteraction of the patient to any attempts to change his pose.
3. The stupor with catalepsy is characterized by the greatest expressiveness of motive block and a muscular hypertension. Patients accept and long keep an embriopoza, the airbag symptom can be observed.
Sindromokinez
Mutual transitions of one type of a stupor to another, pathetic excitement in impulsive though it is observed rather seldom are possible. Mutual transitions of catatonic excitement to a stupor and vice versa are possible: pathetic excitement can be replaced by a cataleptic stupor, impulsive - negativistichesky or a stupor with catalepsy, as well as the stupor can suddenly be interrupted by the corresponding type of excitement.
At a cataleptic stupor hallucinations, crazy frustration, sometimes signs of disturbance of consciousness as oneiroid - a so-called oneiric catatonia from which after an exit the most part of productive symptomatology amnezirutsya can be observed. The Negativistichesky stupor and a stupor with catalepsy are presented so-called lyutsidny (transparent, pure) a catatonia at which there are no productive symptoms, there is no stupefaction, patients are oriented, realize and remember surrounding.
Catatonic syndromes are observed at schizophrenia, infectious, organic and other psychoses. According to two researches, catatonic symptoms are observed at 12-17% of young people with autism.
Stereotypies (uniform repetitions) of movements and pose are characteristic of a catatonic syndrome; verbigeration (uniform repetition of words and phrases); ekhosimptoma - repetition of movements of other person (an ekhopraksiya, or an ekhokineziya) or his words and phrases (an echolalia, or an ekhofraziya); negativism (at passive negativism of the patient does not satisfy the requests turned to it, at active - makes others instead of the offered actions, at paradoxical negativism makes actions, opposite to those which ask to execute it); a katalepsy - the disorder of motive function which is that separate parts of a body of the patient (the head, hands, legs) can keep the situation given them; besides, the patient can stiffen for a long time in any, even inconvenient pose.
In certain cases the clinical picture is exhausted by the listed symptoms (a "empty" catatonia), but quite often at a catatonic syndrome also affective, hallucinatory and crazy frustration are noted. Consciousness at one patients remains undisturbed (a lyutsidny catatonia), at others symptoms catatonic синдромп appear against the background of stupefaction, is more often than oneiroid (a oneiric catatonia). After an acute state at the patient amnesia of real events is observed, but he can tell (fragmentary or rather in detail) about the frustration observed during this period.
Disturbance of movements in the form of a stupor at a catatonic syndrome (a catatonic stupor) is expressed in the raised tone of muscles. The patient moves a little and slowly (a substruporous state) or lies, sits or is motionless for hours and days (a struporous state). Quite often catatonic stupor is accompanied by somatic and vegetative frustration: cyanosis and hypostasis of extremities, the hypersalivation, the increased perspiration, seborrhea lowered by the ABP. Against the background of a stupor other catatonic symptoms in various combinations and different intensity appear. In the most hard cases of the patient lies in an embryo pose, all his muscles are extremely strained, lips are extended forward (a stupor with muscular catalepsy).
Disturbance of movements in the form of excitement at a catatonic syndrome (catatonic excitement) is expressed as unmotivated (impulsive) and inadequate acts; in the movements and verbal expressions of the patient ekhosimptoma, active negativism, stereotypies are noted. Excitement suddenly for a short time can be replaced by a catatonic stupor and a mutism (lack of speech communication); quite often it is followed by the expressed affective frustration (rage, rage or indifference and indifference). Sometimes at excited excitement patients act up, grimace, wriggle, make unexpected, ridiculous tricks (a hebephrenic syndrome).
The catatonic syndrome meets at a catatonic form of schizophrenia more often; at the same time it is, as a rule, combined with hallucinations, nonsense and mental avtomatizm. Sometimes the "empty" catatonia is observed at organic injuries of a brain (for example, at tumors), traumatic, infectious and intoksikatsionny psychoses, etc.
Catatonia reasons:
The exact reason of a catatonia is unknown, however many hypotheses were offered.
According to Northoff (2002), "modulation from top to down" in basal gangliya, caused by insufficiency in bark of piperidic acid (GAMK), the main inhibitory neurotransmitter of a brain, can explain motive symptoms of a catatonia. This explanation, perhaps, is based on the expressed therapeutic effect of benzodiazepines which cause increase in activity of GAMK. Similarly believe that a superactivity of a glutamate, the main exciting neurotransmitter, also lies
at the heart of neurochemical disturbances (Northoff et al, 1997).
Osman and Khurasani (1994) believe that the catatonia is caused by sudden and massive blockade of dopamine. These can explain why the antipsychotic drugs blocking dopamine generally do not bring benefit at a catatonia. Really, at acute shortage of dopamine these means actually lead to an aggravation of symptoms.
Claim that the catatonia is caused by resuming of a superactivity of cholinergic and serotonergic systems after clozapine cancellation (Yeh et al, 2004).
At a chronic catatonia with explicit disturbances of the speech of the positron emisionnaya tomography (PET) revealed bilateral disturbances of metabolism in a thalamus and frontal lobes (Lauer et al, 2001).
According to very interesting hypothesis offered Moskowitz (2004), the catatonia can be understood as evolutionary fear reaction at herbivorous at a meeting with carnivorous whose instincts of a predator are started by the movement. Such response which still remained is now expressed at many heavy mental or somatopathies at which the catatonic stupor can represent the typical, caused by "a final state" reaction in response to feeling of inevitable death.
Treatment of the Catatonia:
Treatment is carried out in a psychiatric hospital; it is directed to a basic disease.
Benzodiazepines are choice drugs at a catatonia. Patients who do not react or react to benzodiazepines insufficiently, need electroconvulsive therapy (EST).
(Ungvari et al, 1994a) 18 patients with a catatonia underwent treatment in a prospective open research either lorazepam orally, or diazepam intramusculary: at 16 significant clinical improvement within 48 hours was observed, and at two there occurred full remission after only one dose. However carrying out EST was required from nine patients in the subsequent to reach further improvement. Rosebush and colleagues (1990) reported even about more expressed and bystry therapeutic reaction to lorazepam - at 12 of 15 patients with a catatonia symptoms within two hours completely disappeared. Low doses of benzodiazepines are effective both at a catatonic stupor, and at catatonic excitement (Ungvari et al, 1994b). The organic catatonia will also well respond to treatment benzodiazepines (Rosebush et al, 1990, 1995).
Like benzodiazepines, EST it is effective at the catatonia caused or functional mental disorders (including schizophrenia), or the organic reasons (Rohland et al, 1993); it is effective even at a hysterical catatonia (Dabholkar, 1988). Benegal and coauthors (1993) reported about good therapeutic reaction to EST in the selection of 65 patients with the catatonia including 30 individuals with an idiopathic catatonia, 19 with schizophrenia and 16 with a depression. Duration of a disease was shorter in group of patients with an idiopathic catatonia. Besides, the number of sessions of EST necessary for improvement did not depend on the main diagnosis.
Urgent use of EST is treatment of the choice at a malignant catatonia (Pommepuy & Januel, 2002). In methodical recommendations about EST of Royal college of psychiatrists (Scott, 2005) it is specified that at a catatonia it is possible to carry out EST if treatment by lorazepam was inefficient.
Usually antipsychotic drugs are not recommended during treatment of a catatonic stage even if it is caused by a psychotic disease, for example schizophrenia as the risk of provoking of a malignant antipsychotic syndrome significantly increases. However they can be effective at therapeutic resistant catatonia: Hesslinger and colleagues (2001) reported about the patient with a catatonia, resistant to treatment by benzodiazepines at which there occurred amazing and permanent improvement after use of a risperidon. In the review of literature of Van Den Eede and the colleague (2005) made the conclusion that atypical antipsychotic drugs can be useful in treatment of a nonmalignant catatonia.
Kritzinger and Jordaan (2001) believe that carbamazepine is effective in a stage both the urgent, and supporting treatment of a catatonia: in their selection of nine patients four completely responded to treatment carbamazepine, one - partially, and at remained four significant improvement it was not noted.
The combination of lithium and antipsychotic drug can be treatment option therapeutic of a resistant catatonic stupor (Climo, 1985).
Mastain and colleagues (1995) reported that zolpidy the patient had an effective it with a catatonia, resistant to benzodiazepines and EST.
According to descriptions of specific cases, at a catatonia are effective амантадин (Northoff et al, 1999) and мемантин (Thomas et al, 2005). They are antagonists of a receptor of N-methyl-d-aspartate (NMDA). The glutamate affects a NMDA receptor, and if this receptor is blocked, neurochemical balance is displaced towards GAMK. Thus, as pro-GAMK, and anti-glutamate drugs, apparently, are useful at a catatonia.
The catatonia, undoubtedly, almost always demands hospitalization. Intensive nursing leaving and regular monitoring of the main indicators of the vital functions of an organism is necessary for the patient, in case of catatonic excitement transfer in department of intensive mental health services can be necessary. The somatic condition of the patient, especially at a long catatonia, can justify intravenous administration of liquid and parenteral food. If the diagnosis of a malignant antipsychotic syndrome is made, then it is more preferable to continue treatment in somatic department. Treatment methods at a malignant antipsychotic syndrome, in addition to benzodiazepines and EST, include muscle relaxants (for example, дантролен sodium) and dopamine agonists (for example, бромкриптин).
