Catatonic excitement

One of the manifestations of acute psychosis is excitement - excessive and inadequate physical activity, expressed in varying degrees: from excessive fussiness and verboseness to destructive impulsive actions. In this case, the patient has a pronounced disturbance of affect. Catatonic agitation is a type of hyperkinetic acute psychosis with specific manifestations: motor restlessness is characterized by chaos, lack of purposefulness, stereotyped, sometimes pretentious, movements, meaningless and incoherent speech. In severe cases of catatonic excitement, speech is absent. Characterized by sudden and unmotivated rage directed at others, auto-aggression, when the patient poses a real danger to himself and others.

Any manifestation of catatonia - both stupor and agitation is considered an indicator of the severity of the mental disorder.

Epidemiology

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The statistics of cases of the development of catatonia are not known, since this condition develops with completely different diseases. Research data varies widely.

It is only known that in psychiatric hospitals there are one or two patients with catatonic syndrome for every 10 patients. Among schizophrenics, catatonic symptoms are less common than one in ten. Although catatonia is associated with schizophrenia, the syndrome is three times more common in autistic people and 9-10 times more common in mood disorders. [1]

Causes catatonic excitement

Catatonic agitation is one of the manifestations of the syndrome, the name of which comes from the ancient Greek word catatonia, meaning a tense, tense state. Currently, it is not considered as an independent disease, since the development of the syndrome is observed in various mental disorders, neurological and bodily (somatic) diseases, intoxications and brain injuries. It is believed that the symptoms of catatonia indicate the severity of the patient's condition.

For a long time it was associated mainly with schizophrenia. Modern psychiatry recognizes that the development of the syndrome is possible and even more likely in other mental disorders. It has already been established that catatonic excitement occurs much more often in the violation of affect, especially mania, and is a consequence of the neurotoxic effect of certain substances: psychotropic drugs - neuroleptics, anticonvulsants and dopaminergic drugs, benzodiazepines; drugs of other groups - glucocorticosteroids, the antibiotic ciprofloxacin, less often others. Catatonia is often manifested by narcotic intoxication with opiates, cocaine, amphetamines; poisoning with carbon monoxide or exhaust gas. In the new ICD-11 classifier, separate codes have been assigned to the most frequent cases of catatonia: caused by mental pathologies, psychoactive substances, including medicinal ones, and secondary catatonia in severe forms of neurological and bodily diseases.

Risk factors

Risk factors for the development of catatonic arousal are summarized in a list of diseases and conditions in which the development of catatonic syndrome, the so-called "catatonic spectrum", was observed. This does not mean that the symptoms of catatonia cannot appear in other cases, rather rarely their causes remain undetected, then the patient is diagnosed with idiopathic catatonia.

Mental disorders in which catatonic agitation develops most often include: mood disorders (especially manic), schizophrenic and autistic spectrum disorders; mental disorders after trauma and childbirth; hysteria. Also, catatonic excitement is characteristic of children with mental retardation and developmental disorders. [2]

The spectrum of neurological diseases in which this symptom complex develops includes uncontrolled tics (Turrett's syndrome), epilepsy, the consequences of encephalitis, stroke, traumatic brain injury, neoplasms and other lesions of cerebral structures (basal nuclei, visual hillocks, frontal and parietal cortex) brain). 

Organ pathologies and conditions that trigger the pathogenesis of catatonic excitement are diverse. Almost any somatic disease that occurs in a severe form can lead to complications - disorders of neurochemical processes in the structures of the brain, leading to increased activity of neurotransmitters of excitation. The list of diseases of the catatonic spectrum includes acute and chronic disorders of cerebral circulation, endocrinopathies and autoimmune processes leading to metabolic disorders, deficiencies of vitamins, in particular cyanocobalamin, minerals, for example, sodium deficiency, adrenaline, thyroid hormones, calcium. Risk factors that increase the likelihood of developing psychomotor agitation include severe viral and bacterial infections, complications of decompensated diabetes mellitus (ketoacidosis), severe renal and hepatic failure, any conditions leading to hypoxia, heatstroke. [3]

Pathogenesis

There are many theories regarding the mechanism of development of catatonic excitement, but all of them are still in the field of assumptions. It is obvious that excitatory neurotransmitters are activated and inhibitory neurotransmitters are inhibited, which leads to the development of specific psychomotor symptoms. They try to explain motor disorders by disorders of neurotransmitter metabolism in the basal nuclei, in particular, by inhibition of the activity of γ-aminobutyric acid. This assumption is based on the pronounced effectiveness of drugs of the benzodiazepine group, which increase the activity of this mediator. Hypothetically, hyperactivity of the glutamatergic system may also underlie catatonic arousal.

The ineffectiveness of neuroleptics in a state of catatonic excitement gave rise to the hypothesis that it is caused by a massive blockade of the dopaminergic system. These drugs, which block dopamine receptors, successfully stop psychomotor agitation of a different genesis, however, in cases of catatonia, they can worsen the patient's condition, which is explained by the double effect - the effect of the drug is superimposed on an acute dopamine deficiency caused by metabolic disorders. [4]

Catatonic arousal that occurs after the withdrawal of clozapine, which blocks cholinergic receptors and serotonin receptors, is considered to be due to a surge in the activity of these systems.

In patients with chronic catatonia with mutism, the tomogram showed bilateral disorders of neurotransmitter metabolism in the thalamic zone and frontal lobes of the brain.

Catatonic arousal is not considered separately. With the syndrome of the same name, it usually alternates with a state of stupor.

Symptoms catatonic excitement

Catatonic agitation, according to the observations of the outstanding Soviet psychiatrists A.V. Snezhnevsky, O.V. Kerbikov and many other authors, is developing in stages. One type turns into another, more complex one.

The first signs appear as confused pathetic excitement. During this period, the patient performs many very expressive actions, which can be characterized as reactions to external stimuli, and they do not make sense, but the objects are used for their intended purpose. For example, patients open and close doors and windows, but situationally this action is unreasonable; postage stamps are glued, but not on envelopes, but on the wall or on your forehead. At this stage, the patient practically does not close his mouth, his statements are meaningless, torn, enthusiastic and pathetic. Patients often sing or recite poems soulfully, the actions resemble "one-actor theater", which greatly overestimates. At the same time, the patient himself is noticeably confused, as if he cannot remember and understand something. He can inspect and feel objects that fall into his field of vision, throw them or pull them out of the hands of others.

Further, the excitement grows and the symptoms of hebephrenia join it - antics, unmotivated fun, childishness, silly, ridiculous actions, wanton laughter, dancing. Impulsive actions, exaltation are possible. At this stage, the patient is still conscious, but he can already show sudden and intense rage. [5]

With an increase in symptoms, a period of impulsive actions begins, which are very aggressive in nature, dangerous for the patient himself, since his aggression is often directed at himself. He can grab objects that are nearby, throw them into windows, at standing people, pull objects out of the hands of others, try to run somewhere, hit someone. The patient's speech consists of shouts, he often repeats phrases or individual words after others, their actions, gestures and postures. At this point, the patient is also a serious danger to others. He can start breaking mirrors, glass in windows or doors, grabbing and throwing improvised objects at the surrounding, jump from a high floor, etc. [6]

Then comes the most difficult phase - mute arousal (the highest degree of impulsivity), when the patient silently and violently performs destructive meaningless actions, fiercely resists verbal and physical attempts to stop him. The rhythmicity of the patient's movements is characteristic, reminiscent of choreic hyperkinesis or the dance of St. Vitus.

Not all psychiatrists agree with this syndrome. Some believe that an impulsive and even dumb stage can come without a prior confused-pathetic phase. Although, perhaps she just passed unnoticed. Catatonic agitation can also end at the first or second stage, especially if the patient is provided with timely medication. It can proceed quite moderately or be very intense, but in any case, the patient does not remain at rest for a second. Periods of arousal at any stage can be replaced by periods of stupor (sub-stupor), when the patient freezes and becomes silent. [7]

Catatonic agitation is an increase in psychomotor activity with clinical manifestations characteristic of catatonia: echo effects - repetition of words and phrases behind the surrounding (echolalia), facial expressions (echomimia), movements and actions (echopraxia); negativism - providing active or passive resistance to external influences; passive obedience; waxy flexibility (cataleptic manifestations); various stereotypes - motor, speech, etc.

Catatonic excitement can proceed with dimness of consciousness (oneiroid form) or without it (lucid). Hebephrenic, ecstatic excitement can occur in two forms, impulsive and mute - in oneiric.

In the prodrome and the initial stage of catatonic excitement, there are clear symptoms of autonomic disorders - changes in the size of the pupil (alternation of miosis and mydriasis) and skeletal muscle tone, arrhythmia and tachycardia. The pallor of the patient's face is replaced by his sharp redness, sweating - by dry skin. Laboratory tests can show the presence of hyper / hypoglycemia, minor leukocytosis, azotemia, and during wakefulness. There are also jumps in blood pressure. This complex of somatic symptoms is called compensation syndrome.

In the clinical picture of lethal catatonia, the stage of excitement first begins. By itself, catatonic excitement is not classified as malignant catatonia, but it can go into the final stage - stupor. An alarming symptom is hyperthermia and the following manifestations: characterized by a constant and continuous increase in symptoms with an impressive increase in physical capabilities, which leads to destructive consequences, rhythm of movements, logoria. The patient's hands and feet are cold and damp, and the skin on them is cyanotic. Rapidly yellowing bruises appear on the body in places of impacts and pressure. At the moment of excitement, the patient's blood pressure and body temperature increase (up to hyperpyretic values with cold extremities). When the patient becomes weak, and the pressure and temperature begin to decrease, the excitement turns into a stupor. Without treatment, death occurs. [8] Postmortem examinations do not reveal physiological changes indicating the patient's cause of death. [9]

Catatonic excitement in children

Psychotic conditions in childhood are most often manifested by speech and motor disorders, similar to catatonic agitation. Children of three to four years old find it difficult to confidently diagnose schizophrenia by identifying delusional ideas or hallucinations in them. Therefore, in most studies it is noted that at an early age, catatonic excitement develops with organic brain damage and exogenous psychosis, as well as with severe oligophrenia. Characterized by such manifestations as stereotypes, rhythmic repetitive movements and shouts, foolishness, echo effects, waxy flexibility, mutism.

Catatonic syndrome in children, especially young children, is most often manifested by agitation. Although there are descriptions of sub-stupor states and stupor, especially in autistic people, when parents note that their children are becoming slower and slower.

At an older age (after 10 years), catatonic excitement in children often precedes rapid degradation and a state of emotional dullness in the development of juvenile malignant schizophrenia. Catatonic disorders are more common in hebephrenia. In their development, they pass in stages a phase of melancholic mood, manic, catatonic excitement, darkened consciousness and the outcome in the final defective phase.

Catatonic excitement in children is most often manifested by impulsive running, aimless movement from one object to another, stereotypical movements, impulsive drives, flight, throwing away or damaging objects. Over time, speech regresses in children and a deep mental defect forms.

In children, catatonic syndrome is rarely observed, so a small number of pediatric patients are usually involved in the samples. The authors note that impulse disorders are observed in the premorbid period, and after 4 years - impoverishment of emotions, monotonous games and catatonic excitement. Akinetic disorders (stupor) are not typical for children. Although the general symptoms in children and adults are practically the same. Small children generally make monotonous repetitive movements: they run in circles, bang their heads on the floor or wall, fiddle with clothes, and bite their nails. In an older age, symptoms of choreic hyperkinesis appear, mannerisms, grimacing, negativism and mutism. [10]

In general, there is currently not enough information about the catatonic syndrome in children, there are no clear descriptions of the characteristics of speech and motor disorders in the age aspect, that is, they are very ambiguous.

Complications and consequences

Catatonic agitation is a sign of a severe course of a variety of painful conditions that require special care and treatment. It can threaten the health and life of both the patient himself and people who are in direct contact with him. Especially dangerous are patients with dim consciousness, contact with whom is difficult. Their impulsive actions are almost impossible to predict. [11]

At the first signs of its development, it is necessary to seek emergency specialized psychiatric help. Patients in a state of catatonic excitement are usually hospitalized.

Diagnostics catatonic excitement

The team that arrived at the call needs to assess the stage of catatonic excitement and the degree of aggressiveness of the patient. In addition, you need to try to avoid aggression directed directly at others and yourself. Patients are usually not in contact, therefore prehospital diagnosis is carried out visually according to clinical manifestations.

Relatives can help clarify the situation and indicate the direction of the search by telling whether the patient has had manifestations of catatonia before, whether he has a psychiatric or neurological disease, dependence, which immediately preceded the onset of symptoms of catatonic agitation (taking drugs, other psychoactive substances, getting injured, the possibility of poisoning etc.).

In addition to establishing the fact that the patient is in catatonic excitement, the main diagnosis - the type and determination of the cause of the development of this condition is carried out when observing the patient in a hospital and after performing research - laboratory and hardware. A clinical and biochemical blood test is prescribed, the function of the kidneys, liver and thyroid gland, the level of glucose, autoantibodies and CO₂, heavy metals in the blood, creatine phosphokinase and drugs in the urine are examined. Blood and urine culture tests may be ordered, and the patient is checked for HIV and syphilis. [12]

With the help of an electroencephalogram, the activity of certain areas of the brain is assessed, an electrocardiogram is prescribed to assess the work of the heart, ultrasound of internal organs, CT and MRI, and other studies necessary to identify the cause of catatonic excitement can be prescribed.

Differential diagnosis

Differential diagnosis is carried out between the reasons that caused the development of the syndrome, which is important for the choice of treatment tactics and the determination of the patient in a psychiatric or somatic department.

First of all, catatonic schizophrenia and autism are excluded , as well as affective disorders in the manic phase. In addition, monopolar episodes are differentiated from intermittent manic and depressive episodes ( bipolar disorder ). The post-stress state also needs to be differentiated from mental illness, and the severity of the response to the stressor indicates what action should be taken. [13]

Exogenous delirium caused by the ingestion of psychoactive substances and requiring neutralization of their action is differentiated from a condition caused by other causes - trauma, neuroinfections, epilepsy, tumors. Magnetic resonance imaging allows to exclude or confirm brain tumors, the consequences of traumatic injuries, neurochemical disorders. Laboratory research - intoxication, hormonal and metabolic disorders.

Differential diagnosis is carried out with seizures of epilepsy (according to electroencephalography data), other manifestations of hyperkinetic syndromes in mental disorders.

Catatonic arousal, unlike other types of psychomotor agitation (affective, delusional , hallucinatory, manic), is characterized by meaninglessness of actions and a complete lack of motivation. 

The patient automatically performs unrelated, aimless and disparate actions. They can be directed to external objects or to the patient himself. At the same time, it is difficult to determine whether he retains awareness of himself or whether he perceives his body as an external object.

Lucid catatonia is differentiated from the oneiric state. It presents certain difficulties to distinguish between the catatonic-hebephrenic phase and hebephrenic excitement, in which the patient also manages to play the fool, shows childishness and emotional lability.

After a comprehensive examination, the patient is prescribed a course of treatment in accordance with the identified pathology. It happens that the cause of catatonia remains unknown (idiopathic catatonic agitation).

Treatment catatonic excitement

The general tactics of the actions of the ambulance team, called to the patient with catatonic agitation, is reduced to preventive measures to ensure the safety of himself, others and medical personnel. In large cities, a specialized psychiatric team comes to the call, in small and rural areas - more often a linear one.

The main task at the prehospital stage is reduced to the safe delivery of the patient for consultation with a psychiatrist. The approach is symptomatic. Catatonic excitement has a number of specific features - the monotony of movements and statements, their meaninglessness, automatic repetition. Emergency care includes physical restraint of the patient, if necessary, fixation and pharmacotherapy. Moreover, physical influences should be given preference, since pharmacotherapy can "lubricate" the symptoms and complicate further diagnosis in the emergency room of the hospital. [14]

Acute catatonic excitement and its severity are detected when trying to establish initial contact and establish a trusting relationship with the patient, during which tactics of further action are determined, which sometimes makes it possible to replace medication or calm the patient somewhat and make it possible. Nevertheless, the medical staff who came to a call to a patient in a state of acute psychosis should not lose their "psychiatric vigilance" for a second, since the patient's behavior at any moment can be diametrically changed.

The actions of the nurse with catatonic excitement must fully correspond to the actions of the doctor. It is necessary to ensure that in the immediate vicinity of the patient there are no objects suitable for attack or self-harm. If the patient is aggressive, it is better to be closer to the door, which should not be locked, and the patient should not be allowed to approach the window. It is advisable to enlist the support of relatives, police officers, an orderly, an ambulance driver, etc.

When providing medication, the nurse gives an intramuscular injection or, if possible, gives an oral drug, while making sure that the patient has swallowed it.

With catatonic agitation, it is preferable to use tranquilizers of the benzodiazepine group. Medicines are used in the form of intramuscular injections of a 0.25% solution of lorazepam in a single dose from 2 to 8 ml or a 0.5% solution of diazepam - from 2 to 6 ml. If the patient comes into contact, you can give him the medicine in tablets to swallow: lorazepam from 5 to 20 mg or diazepam from 10 to 30 mg. [15]

The same drugs in low doses are used in the further treatment of catatonia in the hospital. Sometimes catatonic manifestations disappear after taking just one dose. [16]

Patients who do not respond to drugs of the benzodiazepine group are prescribed electroconvulsive therapy.

In the hospital, after a complete examination of the patient, further treatment is prescribed based on the diagnosis.

Prevention

Catatonic arousal is caused by a variety of pathological conditions of the body, therefore, preventive measures are of a general nature. First of all, it is a responsible attitude to one's health, mental and physical: the elimination of bad habits, an increase in stress resistance and positivism, adherence to an active lifestyle, and optimization of the daily diet. It is possible to do this on your own, but if it does not work out, then there is a wide network of psychotherapeutic assistance, as well as health groups, nutritionists, psychosomatics. Such measures will significantly reduce the risk of both mental and physical ailments.

People from the risk group, that is, those suffering from diseases of the catatonic spectrum, need to undergo regular examinations with the attending physician and follow his recommendations for maintaining the state of remission. As practice shows, acute catatonic excitement is removed very quickly, sometimes with a single dose of the appropriate drugs, therefore, at the first symptoms of trouble, it is necessary to seek professional help.

Forecast

In general, the prognosis is favorable for the majority of patients who have experienced catatonic excitement. Especially if the cause has been eliminated.

The acute clinical stage can be stopped quickly enough. However, there is a danger of recurrence of catatonic episodes and the development of cognitive deficits in the future in patients with chronic diseases - schizophrenia, epilepsy, severe clinical depression. Long-term prognosis depends on the pathology that caused the appearance of catatonia.