Manifestations of catatonic stupor
The stuporous state is characterized by an extreme decrease in motor activity. The patient may remain in the same position for hours and days without reacting to external stimuli.
Main symptoms:
- Waxy flexibility (catalepsy) — the patient freezes in any position, even the most uncomfortable one, imparted by the physician. Muscles are in a state of sharp tonic contraction, and resistance is felt upon attempting to change posture.
- Negativism — meaningless resistance. It can be passive (simple inaction in response to a command) and active/paradoxical (performing actions opposite to the request, or active resistance).
- Mutism — complete silence and refusal of verbal contact, one of the most frequent signs.
- Pavlov's symptom — a paradoxical reaction: the patient ignores loud speech but begins to answer questions asked in a whisper.
- Echo-symptoms — blind, automatic copying of other people's words (echolalia), actions and gestures (echopraxia), and facial expressions (echomimia).
- Mannerisms and bizarre behavior — mismatch between facial expressions and emotions (e.g., a suffering face with a foolish smile), prolabium symptom / snout sign (pursed lips with knitted eyebrows), unnatural gait (walking without bending knees, with a "fox-like" step).
- Passive obedience — an extreme degree of automatism when a completely indifferent patient instantly carries out any specific instruction (often paradoxically combined with negativism).
Catatonic agitation
Motor agitation in catatonia is devoid of purpose and meaning; movements are chaotic and unpredictable. Agitation may manifest simultaneously with symptoms of stupor.
Key manifestations:
- Stereotypies — rhythmic, monotonous repetition of the same actions. They can be motor (rocking, jumping) or verbal (monotonous laughter, howling).
- Verbigeration — a variant of verbal stereotypy in which the patient ceaselessly repeats the same words or entirely meaningless sound combinations.
- Impulsive actions — sudden acts not dictated by external circumstances or internal motives. The patient may unexpectedly jump up, break a window, or attack a person toward whom they felt favorably a minute ago.
Types of catatonia and etiology
Most often, the syndrome is a manifestation of schizophrenia. Less commonly, it occurs in organic brain lesions (e.g., atrophic processes or von Economo epidemic encephalitis).
Based on the state of consciousness, two fundamentally different forms are distinguished:
- Lucid catatonia (from Lat. lucidus — clear). Develops against the background of completely clear consciousness. Indicates a malignant variant of schizophrenia without remissions. The prognosis is extremely unfavorable.
- Oneiric catatonia. Proceeds against the background of dream-like (oneiric) clouding of consciousness. This is an acute, dynamically developing psychosis. In contrast to the lucid form, it has a more favorable prognosis.
Care and treatment specifics
Patients in a stupor are completely helpless: they do not feel pain, do not react to cold, and are incapable of avoiding danger. Their lives depend entirely on the medical staff.
Care specifics: Due to prolonged immobility, there is a high risk of pressure ulcers and muscle contractures. The second serious problem is food refusal. While patients used to be fed via a nasogastric tube, the modern approach is to compensate for fluids and nutrients using intravenous infusions.
Pharmacotherapy: Neuroleptic (antipsychotic) agents, benzodiazepine tranquilizers, and barbiturates are used. The main goal of intensive care in the first days is to rapidly overcome negativism so that the patient begins to eat independently.
Briefly: answers to topical questions
In what diseases, apart from schizophrenia, can catatonic syndrome develop?
Catatonic syndrome, apart from schizophrenia, can develop in organic lesions of the central nervous system and severe somatic pathologies. Such conditions include:
- Organic brain diseases — atrophic processes and von Economo epidemic encephalitis.
- Systemic collagenoses (systemic lupus erythematosus) — can cause psychoses of complex structure, including catatonia-like states.
- Renal failure — capable of provoking the development of catatonia-like stupor.
Which drug groups and non-pharmacological methods are used to arrest catatonia?
To arrest catatonic syndrome, psychopharmacological agents and hardware intervention methods are used. Drug therapy includes the following drug groups:
- Neuroleptics — antipsychotic agents that allow rapid overcoming of negativism and restoration of the ability to eat.
- Tranquilizers — drugs of the benzodiazepine series.
- Barbiturates — used as part of complex pharmacotherapy.
As a non-pharmacological treatment method:
- Electroconvulsive therapy (ECT) — indicated for the management of catatonic disorders, especially febrile catatonia.
What somatic complications can occur in a patient during prolonged catatonic stupor?
During prolonged catatonic stupor, the patient develops severe somatic complications associated with immobility and food refusal. The main consequences include:
- Trophic and muscular disorders — high risk of pressure ulcer formation and contractures.
- Complications of prolonged starvation — progressive emaciation, hypoglycemia, arterial hypotension, acetone breath odor, decreased skin turgor, and absence of stool.
- Gross somatic disorders (in a malignant course) — fever above 40 °C, tachycardia, symptoms of dehydration, petechiae, bruises, and signs of incipient cerebral edema.
The classical triad of stupor can be remembered as "MNV": Mutism (silent), Negativism (resists), Waxy flexibility (freezes).
Class and exam questions
What is the difference between catatonic agitation and manic agitation?
In manic syndrome, speech and actions are always purposeful (the patient wants to help, interferes in affairs) and are never stereotyped. In catatonia, agitation is senseless, chaotic, and full of stereotypies.
What is the snout sign?
This is a specific mannered facial expression in catatonia where the patient's lips are pursed forward like a snout, while the eyebrows are angrily knitted.
How can a patient exhibit negativism and passive obedience simultaneously?
Within the framework of catatonic syndrome, mental processes are paradoxical. The patient may actively resist attempts to feed them, but at the same time automatically go to the toilet or execute another command due to passive obedience.
What else to study on this topic
- Hebephrenic syndrome: symptoms of infantilism and connection with catatonia
- Oneiric syndrome: specifics of clouding of consciousness
- Differential diagnosis of types of psychomotor agitation
- Malignant neuroleptic syndrome as a complication of therapy
- Management tactics for patients with prolonged food refusal
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