Malignant Catatonia: An Often Misdiagnosed Condition
Malignant catatonia (MC) is a diagnosis that even the most seasoned of care providers doesn't come across regularly. However, the obscurity of this potentially life-threatening neuropsychiatric condition is one of the things making it so dangerous. Missing a malignant catatonia diagnosis can lead to a life-threatening outcome.
Catatonia is a disorder that disrupts a person’s awareness of their surroundings. Those who are afflicted may have minimal to absent reactions to stimuli from their surroundings. This is what's known as being in a "catatonic" state. As one of the somewhat common bipolar disorder symptoms, catatonia can sometimes be dismissed as being purely psychiatric. However, an escalated form of this condition, called malignant catatonia, can be lethal. Here's what care providers need to know.
Understanding Catatonia
Catatonia is often an extreme manifestation of anxiety and depression. Risk factors for catatonia can include having bipolar disorder, schizophrenia, major depressive disorder (MDD), autism spectrum disorder (ASD), down syndrome, epilepsy, encephalitis, Tourette syndrome, an autoimmune disorder, or a degenerative brain disorder.
Catatonia is most commonly seen in people with bipolar 1 disorder (43% in studies), and schizophrenia (30%). The 12 officially recognized symptoms of catatonia in the DSM-5 are:
Agitation/Irritability
Catalepsy
Echolalia
Echopraxia
Grimacing
Mutism
Negativism
Posturing
Stereotypy/Repetitive Movements Lacking Purpose
Stupor
Waxy Flexibility
The general public often thinks of someone who is catatonic as being in a still, coma-like state. As you may already know, catatonia can either be excited (hyperkinetic) or withdrawn (hypokinetic). In the first case, a person might pace, appear agitated, or act out aggressive or violent behaviors. They may even attempt to harm themself or others. In the latter case, a person may not respond to anything happening around them even though they are clearly wide awake. They are typically silent and expressionless. It's also common for people who are catatonic to hold themselves in a single posture for an uncomfortably long amount of time.
Catatonia usually isn't considered a life-threatening condition. However, a subset of this condition called malignant catatonia can quickly turn deadly without proper interventions. It's important to understand the specific signs and risks associated with malignant catatonia.
What Is Malignant Catatonia?
Once called lethal catatonia, malignant catatonia is considered the most extreme manifestation within the catatonic spectrum. Malignant catatonia has a high mortality and morbidity rate. A person experiencing an episode of malignant catatonia is experiencing dysautonomia. Their nervous system is in an acute state of dysfunction.
Malignant catatonia symptoms include:
Dangerously high body temperature and fever (hyperthermia)
Unstable blood pressure
Rapid heart rate (tachycardia)
Excessive sweating
Tremor
Unstable blood pressure
Low blood oxygen (cyanosis)
These symptoms come in addition to the 12 symptoms of general catatonia. As a condition that involves suppression or deregulation of the nervous system, malignant catatonia has the potential to disrupt brain messaging and automatic bodily processes. This is what makes it such a dangerous and life-threatening condition. For this reason, immediate and acute medical care will be required when a patient presents with a suspected case of malignant catatonia.
Life-threatening catatonia is often misdiagnosed or diagnosed late in a patient's hospital course. This is mostly due to the fact that its nuanced cause or set of causes can allow it to easily slip through standard screening tools. The average delay in treatment for malignant catatonia is believed to be around 15 days. Delayed treatment with this condition is associated with worse outcomes.
Poor diagnosis contributes to why malignant catatonia has a mortality rate of up to 20%. A long-held association with purely psychiatric symptoms is one of the reasons why malignant catatonia treatments are often delayed. While catatonia has historically been associated with schizophrenia, it's now understood that it can be present with primary mood disorder, bipolar type 1, neurological diseases, and other medical conditions.
How Is Malignant Catatonia Diagnosed?
Both catatonia and malignant catatonia are often diagnosed based on the presentation of symptoms and the patient's health history. Healthcare providers will often use electroencephalogram (EEG) brain-activity testing to potentially rule out a seizure or epileptic episode. Additionally, CT scans and MRI testing may sometimes be used. Chemical changes in bodily fluids indicating catatonia can be detected using blood, urine, and fluid tests.
How Is Malignant Catatonia Treated?
Malignant catatonia treatment includes early critical care consultation. This is essential for guidelines on the appropriate fluid-electrolyte balance, thermoregulation, and cardiopulmonary stabilization, according to a published review on early interventions for malignant catatonia.
Pharmacologically, benzodiazepines are usually the first-line treatment for malignant catatonia. A clinical review of treatment for catatonia found that benzodiazepines created the most dramatic and immediate effects compared to other pharmacological agents. In this review, lorazepam and zolpidem were specifically named. Other research shows benzodiazepines as being effective in 70% of malignant catatonia cases.
Another life-saving treatment for malignant catatonia is electroconvulsive therapy or ECT. Electroconvulsive therapy has been found to be quite effective for catatonia. However, ECT can be limited in certain settings.
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