Secondary catatonia syndrome

Essential (Required) Features:

• The general diagnostic requirements for Catatonia are met.
• The symptoms are judged to be the direct pathophysiological consequence of a medical condition, based on evidence from the history, physical examination, or laboratory findings. This judgment depends on establishing that:
• The medical condition is known to be capable of producing the symptoms of Catatonia;
• The course of the catatonic symptoms (e.g., onset, remission, response of the symptoms to treatment of the etiological medical condition) is consistent with causation by the medical condition; and
• 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), the effects of a medication or substance, including withdrawal effects, or a primary Movement Disorder classified in the chapter on Diseases of the Nervous System (e.g., Parkinson Disease, Huntington Disease).
• 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

Additional Clinical Features:

• Catatonia symptoms that often cluster together in critically ill adults with Secondary Catatonia include mutism, staring, and immobility.

Course Features:

• The onset of Secondary Catatonia Syndrome is related to the underlying medical condition and duration is also determined by the underlying medical condition and its treatment.
• In cases in which the underlying disease course is severe and progressive (e.g., Alzheimer disease), Secondary Catatonia Syndrome due to a Disease of the Nervous System or other medical condition may be chronic (lasting for weeks or months) and may fail to fully resolve with treatment of the underlying medical condition.

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).
• Secondary Catatonia Syndrome is more likely to occur after age 40; risk increases considerably after age 65.
• In medically ill adults, the prevalence of Secondary Catatonia Syndrome increases with age and is strongly associated with co-occurring Delirium or coma.

Potentially Explanatory Medical Conditions:

The identified etiological medical condition should be diagnosed separately.

Medical conditions that have been shown to be capable of producing Catatonia syndromes include:

Primary brain disorders (examples)

• Neoplasms
• Cerebrovascular lesions, including cortical venous thrombosis, subarachnoid hemorrhage, subdural hematoma, bacillar aneurysms
• Anoxias, including stroke
• Viral encephalitis, encephalitis lethargica
• Brain stem, diencephalic and basal ganglia disorders, as well as frontal lobe or parietal lobe lesions
• Epilepsy
• Traumatic brain injury
• Dystonia
• Multiple sclerosis
• Parkinson disease
• Lewy body disease
• Creutzfeldt-Jacob disease

General medical conditions affecting the brain (examples)

• Autoimmune conditions
• Systemic lupus erythematosus
• Hashimoto encephalopathy or autoimmune encephalitis
• Infectious diseases
• Typhoid fever
• Infectious mononucleosis
• Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)
• HIV/AIDS
• Genetic conditions
• Prader-Willi syndrome
• Fatal Familial Insomnia
• Tay-Sachs disease
• Wilson disease
• Metabolic conditions
• Hypercalcemia from a parathyroid adenoma
• Hepatic encephalopathy
• Homocystinuria
• Diabetic ketoacidosis
• Acute intermittent porphyria
• Membranous glomerulonephritis
• Hyponatremia
• Hypo- and hyperthyroidism
• Hypo- and hyperadrenalism
• Nutritional deficiencies
• Pellagra
• Nicotinic acid deficiency
• Wernicke’s encephalopathy (Thiamine deficiency)
• Vitamin B12 deficiency

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary of Secondary Catatonia with Delirium due to Psychoactive Substances Including Medications 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.