Catatonia induced by substances or medications

Essential (Required) Features:

• The general diagnostic requirements for Catatonia are met.
• The catatonic symptoms develop during or soon after intoxication with or withdrawal from a specified psychoactive substance or the use of a medication. Substances that may be associated with Catatonia include opioids, phencyclidine (PCP), cannabis, cocaine, MDMA or related drugs, and hallucinogens such as mescaline or LSD. Catatonia may also be associated with certain psychoactive and non-psychoactive medications (e.g., antipsychotic medications, benzodiazepines, steroids, disulfiram, ciprofloxacin).
• The intensity or duration of the catatonic symptoms is substantially in excess of similar symptoms that are characteristic of intoxication or withdrawal due to the specified substance (e.g., stupor during Opioid Intoxication; psychomotor agitation and autonomic hyperactivity during Alcohol Withdrawal).
• The specified substance, as well as the amount and duration of its use, must be capable of producing catatonic symptoms.
• The symptoms are not fully accounted for by Delirium, another mental disorder (e.g., Schizophrenia or Other Primary Psychotic Disorder, a Mood Disorder, Autism Spectrum Disorder), or to be the direct pathophysiological consequence of a medical condition.
• The symptoms are sufficiently severe to be a specific focus of clinical attention.

Specifiers for autonomic abnormalities in Catatonia:

Catatonia may be accompanied by vital sign abnormalities not fully accounted for by a comorbid medical condition that may signal potentially life-threatening complications and therefore require immediate attention. These include tachycardia or bradycardia; hypertension or hypotension; and hyperthermia or hypothermia. In these cases, as many of the following symptom codes as applicable should be applied.

• MG26 Fever of other or unknown origin
• MG28 Hypothermia, not associated with low environmental temperature
• MC80.0 Elevated blood-pressure reading, without diagnosis of hypertension
• MC80.1 Nonspecific low blood-pressure reading
• MC81.0 Tachycardia, unspecified
• MC81.1 Bradycardia, unspecified

Course Features:

• The onset of Catatonia Induced by Substances or Medications is typically rapid, often with fast deterioration. The duration of Catatonia strongly depends on the inducing substance. Catatonia is more often induced by substance withdrawal than intoxication. Once the effects of the substance or medication (including a withdrawal syndrome) have subsided, Catatonia typically remits within days.

Developmental Presentations:

• Catatonia may occur throughout the entire life span, but rarely develops before adolescence. However, severe cases in children aged 8 to 11 years have been reported.
• Early onset of Catatonia (before age 20) is associated with underlying medical conditions, particularly Diseases of the Nervous System, or Neurodevelopmental Disorders (e.g., Autism Spectrum Disorder).
• Catatonia Induced by Substances or Medications is more likely to occur after age 40; risk increases considerably after age 65.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with other types of Catatonia: Evidence supporting a diagnosis of non-substance induced Catatonia would include catatonic symptoms preceding the onset of the substance use, the symptoms persisting for a substantial period of time after cessation of the substance or medication use or withdrawal (e.g., 1 month or more depending on the specific substance), or other evidence of a pre-existing mental disorder that may be associated with catatonic symptoms.
• Boundary with Delirium Due to Diseases Classified Elsewhere: Both Delirium and Catatonia may be characterized by increased or decreased psychomotor activity. They are distinguished primarily by the disturbance of attention, awareness and arousal, as well as impairment in other cognitive domains, that characterize Delirium and are not features of Catatonia and the impairment of volition (e.g., ambitendency, negativism, mannerisms) and abnormal muscle tone (rigidity, waxy flexibility, catalepsy) that may occur in Catatonia but not Delirium.
• Boundary of Catatonia with autonomic abnormality with Neuroleptic Malignant Syndrome: Symptoms of Neuroleptic Malignant Syndrome include high fever, muscle stiffness, altered mental status, and autonomic dysfunction (e.g., wide swings of blood pressure, excessive sweating, excessive secretion of saliva), most of which may also occur in Catatonia with autonomic abnormality. A diagnosis of Neuroleptic Malignant Syndrome is based on the clinical judgment that exposure to an antipsychotic medication or other dopamine receptor blocking agents is the cause of the symptoms. This distinction can be difficult because many individuals who develop Catatonia take antipsychotic medication. It is made based on the timing of the symptoms in relation to medication use, prior history of multiple episodes of Catatonia (in which case Neuroleptic Malignant Syndrome is less likely), and sometimes the presence of certain medical complications that are not characteristic of Catatonia, such as hyperkalemia or liver or kidney failure.
• Boundary with Serotonin Syndrome: Symptoms of Serotonin Syndrome include agitation or restlessness and muscle rigidity as well as autonomic disturbances such as high fever and tachycardia, which may also occur in Catatonia. A diagnosis of Serotonin syndrome involves the clinical judgment that exposure to a serotonergic medication or an interaction between serotonergic medications (e.g., when increasing the dose of a medication or adding a new medication) is the cause of the symptoms, based on the timing of the symptoms in relation to medication use. Serotonin Syndrome is more likely to present with tremor, hyperactive muscle reflexes (including clonus) and nystagmus than Catatonia. However, the presence of these symptoms does not exclude the possibility of co-occurring Catatonia.
• Boundary with Malingering or Factitious Disorder: Malingering and Factitious Disorder are both diagnosed based on evidence of feigning of symptoms, which may include catatonic symptoms. Evidence for feigning often includes the observation that the symptoms occur only when the person is being watched. However, disturbances of volition in Catatonia (e.g., negativism) may only become apparent during social interactions, which should not by itself be interpreted as evidence of feigning.