Catatonia

CATATONIA, katatonia (from Greek katatei-pon-napryagayu). The identification of C. as an independent psychosis was made by Kahlbaum in 1869. In describing this form, the author applied for the first time the principle he had put forward of studying mental illnesses throughout the entire course of the disease, based on changes in characteristic signs during the development of the disease, thereby rejecting the old narrow symptomatic principle. This method of study, later used so brilliantly by Kraepelin, was prompted by Kahlbaum's teaching on progressive paralysis, the clinical picture of which he took as a model, mainly in its motor disorders. Noting in a number of cases a peculiar motor syndrome in the form of muscle tension, Kahlbaum traced the entire course of such cases, giving them the name catatonia or tension insanity (Spannungsirresein). The author himself, taking into account the entire course of C., defines it as a brain disease with cyclically changing course, in which mental symptoms in their sequence present a picture of melancholia, mania, stupor, confusion and finally dementia, while along with mental symptoms there appear symptoms in the motor divisions of the nervous system in the form of stupor, convulsions, etc. Kahlbaum worked during the period of development of psychiatry when melancholia and mania were recognized as independent entities, when every depression and every excitement was diagnosed as melancholia and mania, and when the possibility of one mental disease passing into another was widely admitted. Further research (Kraepelin, Osipov) showed that in C. all the phases noted by Kahlbaum (depression, excitement, stupor, confusion, dementia) can indeed be observed, but that they are only phases of development and course of one general disease, and by no means a combination of different diseases, and that C. in its development does not always pass through all the indicated phases and not always in the indicated order. The independence of C. was not recognized by all clinicians, but after the establishment of Kraepelin's teaching on dementia praecox (early dementia) and Bleuler's on schizophrenia, it was necessary to include C. in the general extensive group of schizophrenic psychoses under the name of catatonic syndrome; although individual elements of this syndrome can also be expressed in other varieties of schizophrenia, in catatonia they appear fully, sharply and for a long time. According to Kraepelin's statistics, the disease begins acutely in 41% of cases, subacutely or gradually in the rest, and in 47% it begins with depression. In the prodromal period there are indefinite complaints: irritability, insomnia, headaches, loss of working capacity; there is noted withdrawal, unsociability, a desire for solitude, immobility; at the same time, an impression is often gained of a morbid intensification of the inherent human character traits. Later develop affects of melancholy, fear, delusional ideas of various content and direction-persecution, poisoning, hypochondriacal, nihilistic (there is no head, no body, only a shell), self-accusations, religious; hallucinations, illusions, paresthesias are observed, especially the sensation of the body being bound as if by ropes or springs; change in the sense of reality; increasing negativism to the point of complete refusal of food, complete immobility, mutism; facial expression is poor, mask-like. Highly characteristic is the rapid and unexpected or gradual transition into a state of excitement, often in the form of short flashes with absurd, coarse, impulsive behavior: patients jump, tumble, sing, swear, commit attacks. Speech excitement in catatonia is not loquacity (as in mania), but stereotyped repetitions, muttering of the same words and cries (see Verbigeration). The same character is also found in stereotyped, repetitive movements, often extremely bizarre: jumping on one leg, tumbling, grimacing, etc. Orientation in time, space, in the surroundings is usually satisfactory. Sometimes, however, clouding of consciousness with speech confusion, often with hallucinatory phenomena, developing gradually or suddenly, is also possible. In many cases, epileptoid seizures are observed. Hallucinations in catatonia are extremely diverse, with objective signs. In severe cases of the disease, sharp negativism, mutism, negative suggestibility, and persistent refusal of food, forced, unnatural postures, and more or less long-lasting attacks of rigidity or continuously increasing verbigeration come to the fore. Attention is drawn to changes in vascular innervation: spasm of blood vessels unexpectedly gives way to their general or partial paralysis: the pale patient suddenly flushes, or some part of the body flushes, half of the face, ear, hand. Extremely typical is the loss of body weight, persistent insomnia. Sometimes after excitement and hallucinatory confusion, remission occurs, in most cases brief, but there are also prolonged remissions bordering on recovery. More often, however, a stuporous state of greater or lesser depth and duration, even chronic, developing with fluctuations and with frequent and unexpected flashes of excitement with absurd actions and speeches, gradually or suddenly develops. In almost all cases of stupor, a state of muscle tension is observed, sometimes reaching extreme limits, to the complete impossibility of passive movements. Facial expression is frozen, sometimes affective, wrinkling of the forehead, spasmodic contraction of the eyelids, tension of the neck and jaw muscles, clonic convulsions; lips are drawn out into a trunk (Schnauzkrampf). The cataleptic state with waxy flexibility of the limbs (see Catalepsy) is one of the constant phenomena of this period; patients usually lie in bed on their back, head raised, covered to the head. Negativism to the extreme is a constant companion of stupor; patients are untidy, but sometimes the urge to urinate or defecate forces them to get up and go to the toilet. Forced postures, theatrical, pathetic postures and gestures, peculiar movements, e.g. walking on turned-up feet, on heels, with crossing of legs, etc., are characteristic of these patients; impulsive acts, phenomena of hyperhedonia, affectless laughter, unexpected oral or written addresses (e.g. the patient writes: 'Wishing to end life by suicide, I request to be transferred to the aviation service'), speech-mutism-patients consciously answer incorrectly to the questions asked. Suggested automatism, which is expressed not only in maintaining the postures given to the patient, but also in the long repetition of movements passively performed by his limbs; imitative movements in simple and complex groupings are often noted-echopraxias or echokinesias-echolalia, echography, echomyopia, echolalia. Somatic symptoms: spasms and paralysis of blood vessels, variability of heart rate rhythm, dermographism, hyperhidrosis, salivation, increased tendon reflexes, change in pupil size and their reaction, abdominal, superficial type of breathing, sometimes inverted type of morning and evening fluctuations in t⁰.-- The course of the disease in terms of the sequence of the described phases varies: sometimes periodicity is observed (catatonic seizures). With the passage of time, the characteristic catatonic dementia gradually increases, however, in general, C. represents the most favorably progressing variety of schizophrenia due to remissions, which in approximately 14-15% border on recovery. Fatal outcomes in C. occur from various complications, more often from tuberculosis, but also exhaustion in deep, prolonged stupor with refusal of food can be the cause of death.-Microscopic study of the brains of catatonics (Alzheimer, Nissl, Josephy) revealed diffuse changes mainly in the nerve elements of the cortex of the large hemispheres, more strongly in the frontal, temporal and parietal lobes, to a lesser degree in the area of the subcortical ganglia. Particularly sharp changes are found in the 3rd, 5th and 6th layers of the cerebral cortex: honeycomb appearance of ganglion cells, fatty degeneration, wrinkling, sclerotic changes; cells are often surrounded by young glial elements, in older cases foci of proliferated glia are noted. The character of the microscopic changes more speaks for a toxic process. Various authors have noted a number of changes in the endocrine glands-in the thyroid, in the sex glands, in the adrenal glands. The etiology of the disease has not been established to a sufficient degree, but the influence of heredity must undoubtedly be recognized, especially taking into account the fact noted by many authors, starting with Kahlbaum, that catatonics even before the onset of the disease show pathological peculiarities of character or represent schizoid types of Kretschmer, being people with a predominance of asthenic (leptosomatic) body build. Apparently, the insufficiency of the endocrine system is of great importance.

An inadequate organism under the influence of various exogenous factors (infection, exhaustion, overwork, childbirth, mental shocks) becomes disabled, falls ill, being unable to maintain its status quo. The hypothesis of the influence of hereditary syphilis (Ostankov and others) is not sufficiently substantiated. The age of onset is young, often around 25 years, but K. can also occur earlier; much less frequently does the disease develop at a later age and even in old age. The origin of the phenomena of the catatonic syndrome cannot be explained from a psychological point of view, as some psychiatrists (Kraepelin, Bleuler) attempted to do; it is explained from a pathophysiological point of view, being a consequence of a violation of the innervational interrelationships between the cortex and subcortical areas (Osipov); weakening of the influence of the gray matter of the cortex leads to an increase in muscle tone to varying degrees - from waxy rigidity to a sharply expressed tension of the musculature (subjectively - a feeling of being bound); hence the retardation of movements, negativism, and when the inhibition breaks through - an impulsive and violent character of the movements. Catatonic phenomena (catalepsy and echokinesias) are also observed in infectious diseases (typhus) during the period of elevated temperature with clouded consciousness. A number of catatonic-like phenomena observed in encephalitic parkinsonism confirms the above justification of the catatonic syndrome, which also corresponds to the pathoanatomical picture. Therapeutic measures are limited and coincide with those used in schizophrenia in general.