Descriptive Psychopathology: The Signs and Symptoms of ...

159 Chapter 7: Disturbances of motor functiondisorder, toxic metabolic and drug-induced states, seizure disorder, disease ortrauma to frontal lobe circuits, and psychotic disorders. Why only some patientswith these conditions develop catatonia is unclear. 24When systematically examined, about 10% of consecutive admissions to acutepsychiatric hospitals exhibit two or more catatonic features. 25 Forty percent ormore of manic patients meet criteria for catatonia. Many patients with melancholiaexhibit several catatonic features. Institutionalized persons with developmentaldisabilities commonly exhibit catatonic features.The classic image of catatonia is the Kahlbaum’s syndrome, named to honorKarl Ludvig Kahlbaum who first defined catatonia in 1874. The patient is mute,immobile, stares off into space, and is in a prolonged posture (often mundane). Butthere are many gradations of this picture which can fluctuate with other behaviors,particularly depressive and manic symptoms. So-called “catatonic excitement” isthe emergence of an underlying mania and not a unique syndrome.Catatonia can be profound, presenting with extreme rigidity, the patient frozenin a posture and mute. Fever is common in such patients and can be high. Vitalsigns fluctuate dangerously. When described in the nineteenth and early twentiethcenturies as lethal catatonia, most sufferers died from renal or heart failure. Nowtermed malignant catatonia, the syndrome responds to proper treatment.Malignant catatonia is induced by the sudden withdrawal of dopaminergicdrugs, or the inappropriate prescription of antipsychotic and related D2 blockingdrugs or serotonergic agents. The neuroleptic malignant syndrome (NMS) isindistinguishable from malignant catatonia that occurs for other reasons. Musclerigidity and other catatonic features are always present. Fever, unstable vital signs,elevated serum creatinine phosphokinase, and a dropping serum iron are commonfindings. The serotonin syndrome is identical but may also be associated withcramping and diarrhea. NMS and the serotonin syndrome are successfully treatedas catatonia. 26 A recent case report illustrates.Patient 7.2A 15-year-old girl suffered a 5–25min period of asphyxia following attemptedsuicide by hanging. In the ER, a CT scan of the head and neck were considerednormal. Blood toxicology was negative, and serum alcohol was not present. Onexamination she could open her eyes, but not follow a moving target. Muscle toneand tendon reflexes were mildly increased. Plantar stimulation elicited extension,bilaterally. Over the next several days she had several daily 2–15min episodes ofextreme posturing into opisthotonus, hyperextension of the hips and “catatonicposturing of the upper extremities” associated with tachycardia and hypertension.She became diaphoretic, with hyperthermia and tachypnia. A repeat headCT showed generalized sulcal effacement, and an MRI revealed abnormalities in