Stupor: meaning, causes, complications and treatment

Photo: https://psihodoc.ru/shizofreniya/katatonicheskaya.html Considering movement disorders from the point of view of psychiatry at first glance seems absurd and thankless. After all, movement disorders are more the province of neurologists and neurosurgeons. But, on the other hand, understanding the fact that motor function disorders are a manifestation of the internal emotional background rightfully places these disorders in the rank of psychiatric syndromes.

Although in a number of cases one can observe a certain paradox between the internal emotional component and its manifestation in the form of not always logical, inexplicable motor disorders.

Catatonic syndrome was first described by the famous psychiatrist Kalbaum at the end of the 19th century as an independent disease. Subsequently, Kraepelin and Bleuler classified catatonia as one of the syndromes most often observed in schizophrenia.

What reasons lead to the development of catatonia?

Until recently, it was believed that the catatonic syndrome is most often an integral component of the catatonic form of schizophrenia. However, recent studies increasingly indicate that catatonia is the destiny of affective disorders (affecting the emotional background of the individual).

Currently, possible causes of the development of catatonic syndrome may include:

• Mental disorders: affective disorders (most often mania, less often depression);
• schizophrenia;
• autism spectrum disorders;
• postpartum disorders;
• conversion (hysterical) disorders;
• post-traumatic stress disorder, etc.

1. various endocrinopathies, metabolic disorders;
2. cerebrovascular diseases;
3. past infectious diseases;
4. hepatic encephalopathy, homocystinuria;
5. autoimmune diseases;
6. paraneoplastic syndromes, etc.

• Taking certain medications and drugs:
• taking antipsychotics, corticosteroids, some antibacterial drugs;
• cocaine addiction;
• lead poisoning, carbon monoxide poisoning, etc.

As you can see, there are many reasons leading to the development of catatonic syndrome. However, most often catatonia is a manifestation of mental illness.

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In a rare percentage of cases, it is impossible to determine the exact cause of the catatonic syndrome; in such situations it is customary to talk about idiopathic (primary) catatonia.

Manifestations of catatonic syndrome

The most common manifestations of catatonic syndrome are catatonic agitation and catatonic stupor. At the same time, each of these conditions is accompanied by a number of clinical signs and symptoms.

Common manifestations of catatonic syndrome include:

• complete or partial immobility of the patient (stupor);
• strange, unnatural positions (symptom of “air cushion”, symptom of “hood”, uterine position);
• general increase in muscle tone;
• catalepsy, or waxy flexibility, is the ability to stay in one position (sometimes very uncomfortable and unnatural) for a long time;

With catalepsy, the doctor can give the patient any position in which the patient can remain for quite a long time. The presence of this phenomenon gave the name to the symptom – “waxy flexibility”.

• disinhibition of ancient, primitive reflexes (sucking, grasping, etc.);
• echololalia, echopraxia, echomimia - repetition of words, movements, facial expressions after the interlocutor;
• motor and speech stereotypies;
• negativism – resistance and failure of the patient to comply with the doctor’s commands;
• mutism – complete absence of speech;
• passive submission;
• pretentiousness of gestures and movements;
• pretentious facial expressions;
• impulsiveness.

Catatonic stupor

Catatonic stupor is characterized by complete or partial immobility, in which the patient can freeze in the most unnatural positions. Most often, stupor is characterized by a uterine position with knees bent and legs pulled up to the stomach. Also, patients who are in a catatonic stupor can stand near the window, sit with their hands clasped around their knees, lie on the floor, etc.

You can often observe other symptoms characteristic of catatonic stupor: disinhibition of ancient, primitive reflexes, such as grasping, sucking, etc.

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In some cases, the “air cushion” symptom is observed - the patient’s ability to hold his head in the air above the head of the bed for a long time when the pillow is removed from under the patient’s head. The presence of a “hood” symptom is often characteristic when patients pull a sheet, shirt, etc. over their heads.

Catatonic stupor is also characterized by an increase in general muscle tone, which manifests itself in the fact that the researcher (doctor) can give such a patient an unnatural position in which the patient freezes without feeling any signs of physical discomfort (catalepsy, or waxy flexibility).

Catatonic stupor is often combined with negativism - the patient’s resistance or refusal to follow the doctor’s commands and instructions.

Negativism

There are 2 types of negativism.

• Passive negativism , in which simple inaction is noted (the patient simply does not follow the doctor’s instructions, continuing to remain in one position);
• Active negativism - in this case, the patient actively resists the doctor (for example, strains the arm muscles when the doctor tries to bend the arm at the elbow joint). In some cases, with active (paradoxical) negativism, the patient may begin to perform exactly the opposite actions (turn away and walk away when extending his hand to shake hands).

Along with negativism, one can also observe the presence of passive obedience in the patient, in which the patient carries out any, sometimes absolutely ridiculous, commands of the doctor.

Mutism

Mutism, or complete silence, is another characteristic symptom of catatonic stupor. The patient is silent and does not answer the questions asked in a loud voice. However, when repeating a question in a very quiet voice (whisper), sometimes you can observe a certain revival of the patient when he suddenly gives a clear and understandable answer. This phenomenon is called Pavlov's symptom.

Echo symptoms include:

• echolalia - repetition of syllables, words or individual phrases spoken by the interlocutor;
• echopraxia – repetition of the interlocutor’s gestures;
• Echomimicry - copying facial expressions.

Pretentious facial expressions during catatonia introduce a certain paradox into the understanding of the catatonic syndrome. Thus, pretentious facial expressions manifest themselves in a combination of emotions on the patient’s face that are directly opposite to each other. You can often observe raised eyebrows and angry pursed lips, a sad drooping of the corners of the lips and joyful “crow’s feet” in the corners of the eyes, etc.

Catatonic agitation

Agitation with catatonia is a psychopathological syndrome characterized by a number of clinical manifestations. First of all, these are chaotic, unfocused movements. Often such movements are characterized by stereotyping and lack of a logical component. This includes jumping, swinging, waving your arms, etc.

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Along with motor stereotypies, speech stereotypies are also of great importance in the diagnosis of catatonic excitation. In this case, patients repeat the same syllables or words, or make various unfocused sounds in the form of howls, laughter, etc.

Speech stereotypies often manifest themselves as verbigerations - meaningless repetitions of sounds, syllables or individual phrases (“I’m sitting and groaning,” “I’m writing and writing,” etc.). According to scientists, such meaningless repetition is caused by a closed impulse of certain electrochemical signals through the system of neurons in the brain. There is a kind of “running” of the impulse along a closed neural loop.

Catatonic excitation is also characterized by the occurrence of impulsive actions: for example, the patient may suddenly rush to run, hit, throw a chair, etc. These actions are devoid of their logical content and reflect the same well-known paradox that is so characteristic of the catatonic syndrome.

Syndromokinesis catatonia

Syndromokinesis is a certain dynamics of the syndrome, a certain path that the syndrome goes through in its development.

As always, the catatonic syndrome is riddled with paradox. There are no clear dynamics characteristic of this syndrome. While in a catatonic stupor, the patient may suddenly start running towards the door or begin repeating incoherent phrases lacking a logical structure. And now we are faced with catatonic excitement with its impulsiveness, which was born from a completely harmless and quiet stupor. A sudden impulsive impulse can quickly fade into silent or negative peace.

Also in the syndrome of catatonia, one can observe the transition of some symptoms and psychopathological phenomena to others; however, it is impossible to trace a clear connection between such a transition and a change in the patient’s emotional background or the influence of surrounding factors.

Symptoms of catatonia

Clinical signs of the disease depend on the age of the patient and the form of the disease. For example, in young children, pathology can manifest itself in the form of repeating words and movements after those around them. In older children, adolescents and adults, this condition has clear symptoms, which may be accompanied by hysteria, loud screams, crying or stupor, which can last for several hours. Based on their manifestations of the syndrome, the clinical picture of the disease is divided into two categories, each of which has its own characteristic signs.

Catatonic agitation

With catatonic arousal, there is inappropriate human behavior, increased anxiety and unmotivated actions. A person with such a diagnosis can sometimes be dangerous to himself and others because he behaves inappropriately. They are hyperactive and hyperactive, too noisy and loud.

In the prodromal period, when there are no exacerbations or the patient is undergoing treatment, the condition is calmer. The person becomes withdrawn, spends a lot of time alone, complains of insomnia and headaches.

Catatonic stupor

The second clinical sign of the disease is catatonic stupor, in which there is lethargy and lack of speech. In this state, the patient takes strange and unnatural positions, and can remain in them for hours. Characteristic signs of the disease include the “air cushion” symptom, when the patient can lie with his head elevated for several hours.

The patient in a substuporous state does not speak; occasionally he may wrinkle his forehead and clench his eyelids. A person can remain in this state for several hours, days or weeks. The perception of sounds is impaired and there is a complete lack of reaction to both whispers and loud sounds. In a stuporous state, there is increased muscle tension, sensitivity also decreases, the patient does not react to cold or hot objects.

Changes that occur in the body during catatonic syndrome

Currently, science cannot explain the clear developmental mechanisms in connection with which the catatonic syndrome arises and progresses its way. There are various theories that in one way or another explain the changes that occur in the body during catatonia.

1. According to one hypothesis, catatonia occurs due to insufficient GABA content in the cerebral cortex. GABA (gamma-aminobutyric acid) is one of the most important inhibitory neurotransmitters in the brain.
2. According to another version, sudden blockade of dopamine receptors, which occurs for various reasons, plays an important role in the mechanism of development of catatonic syndrome. In this case, the reduced content of dopamine in the brain leads to catatonic symptoms.
3. Other studies show that in catatonia, metabolic changes occur in the frontal lobes and thalamus.
4. According to another hypothesis, catatonia is the result of a disruption in the functioning of the cholinergic and glutamatergic systems of the brain (and, accordingly, the result of a disturbance in the metabolism of choline and glutamate).

It is very obvious that catatonic syndrome is a complex and multifaceted process, which is characterized by all of the above changes.

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There is an equally interesting hypothesis that considers catatonic stupor from an evolutionary point of view. According to this hypothesis, stupor is nothing more than a manifestation of the fear reaction in herbivores when encountering a predator. Stupor and freezing in this case are considered as a typical reaction that occurs in an animal when faced with imminent death.

Varieties

Catatonic stupor is a pathology that includes several main forms of stupor:

• Numbness. This form is characterized by pronounced inhibition. Muscle tone is increased, patients lie motionless in the fetal position.
• Negativistic. The form is accompanied by motor retardation, the patient resists when people around him try to change his position.
• Catalytic. The patient freezes in an uncomfortable position and does not react in any way to loud speech. Sometimes the patient responds to a whisper or whistle. Stupor may be relieved at night.

There are also 3 main types of pathology based on the type of manifestation: oneiric, lucid and empty.

Empty catatonia

Empty catatonia is characterized by:

• Negativism. The patient may perform other actions instead of those proposed or ignore requests.
• Echosymptoms. The patient reproduces the sounds and movements of another person.
• Verbigeration. The patient repeats the same word or sentence.
• Stereotypy. The patient repeats the same movements or postures after another person.

Empty catatonia may be accompanied by delusional, affective or hallucinatory disorders.

Lucid and oneiric catatonia

With the lucid form of catatonia, the patient retains memory, spatial, personal and temporal orientation. The exact reasons for the development of pathology have not been identified.

Psychiatrists suggest that the onset of the disease is triggered by an imbalance of neurotransmitters, which are responsible for the process of inhibition and transmission of excitation along the fibers of the nervous system. Catatonia most often develops against the background of schizophrenia, brain pathologies, psychoses of organic and infectious etiology.

There are no productive symptoms. People do not suffer from hallucinations, obsessions and delusions. They do not have seizures.

Characteristic symptoms of the disease include:

• numbness and immobility;
• ignoring words and requests;
• strong excitement.

The patient is fully aware of what is happening. During stupor, tension is observed. The accepted position is maintained for a long time.

Oneiric catatonia is considered a type of recurrent (periodic) schizophrenia. The deterioration increases gradually. It is characterized by somatogenic reactions. The apogee comes after a couple of hours: the patient may have an expression of horror on his face, which after a few minutes will be replaced by laughter.

This form is not characterized by foolishness, pretentiousness, malice, or rudeness. There is a speech disorder, the patient cannot clearly formulate thoughts. The pathology is characterized by confusion, the patient experiences negative emotions.

Diagnosis and differential diagnosis of catatonic syndrome

To diagnose catatonia, special attention should be paid to anamnestic information obtained from the patient himself or from the words of relatives. It is important to note the presence or absence of mental disorders in the patient, the presence of concomitant somatic or neurological pathology. It is equally important to identify a history of episodes of psychoactive substance use or the fact that the patient is registered at a drug treatment clinic.

No less important is the analysis of the clinical manifestations of catatonic syndrome. Waxy flexibility, negativism, mutism, echo symptoms are the main milestones on which catatonia is based.

Differential diagnosis should be carried out with the following diseases and conditions:

• Parkinson's disease;
• muscle stiffness syndrome;
• conversion (hysterical) disorders;
• malignant hyperthermia;
• dementia, etc.

Clinical manifestations

In children and adults, mental illness is accompanied by a number of characteristic symptoms. Clinical signs enable the specialist to diagnose catatonia in the patient.

Excitation

One of the main signs of catatonic syndrome is agitation. There are three distinct forms of this condition:

1. Pathetic. Accompanied by moderate speech and motor agitation. The patient's mood becomes elevated, and laughter may occur that does not have an adequate reason. In this case, the person has no symptoms of a disorder of consciousness.
2. Impulsive. It appears quickly and acutely. The patient speaks in separate words or phrases, and is characterized by perseveration and echolalia. He may cause physical harm to himself.
3. Not mine. Characterized by unfocused and chaotic arousal. The patient exhibits aggression, which makes him dangerous to himself and those around him.

This symptom is easily recognized during observation of a patient with catatonia.

Stupor

The syndrome is accompanied by stupor. With catatonia, obvious lethargy, muscle hypertension and causeless silence occur. A person can remain in this state for a long period, which can be calculated in weeks. There are three types of stupor in catatonia:

1. With waxy flexibility. It is characterized by a person freezing in one position, which may seem extremely uncomfortable to a healthy person.
2. Negativistic. In addition to motor retardation, in this state the patient tries to resist changing the position he is currently taking.
3. With numbness. With this type of stupor, severe motor retardation is noted. For a long time, the patient takes the fetal position.

This sign causes concern among loved ones of a patient with catatonia and forces them to immediately seek medical help.

Syndromokinesis

Stupor can turn into excitement and back

Stupor can change from one type to another over time. Although this condition is observed in rare cases. Pathetic excitement can also turn into cataleptic, and impulsive excitement can be replaced by negativity or complete stupor.

In this state, the patient often experiences hallucinations and delusions. The absence of productive symptoms cannot be ruled out. In this case, patients remember their surroundings and remember what happened around them.

What complications can be expected to develop with catatonia?

To predict complications, it is important to understand the essence of the catatonic syndrome.

Catatonic arousal is a sudden, impulsive process. Throwing household items, a sudden impulse to run, an uncontrollable desire to break a window - all this is accompanied by the risk of causing harm not only to yourself, but also to those around you.

Catatonic stupor, on the contrary, is characterized by prolonged freezing in one position, which leads to the development of complications such as refusal to eat, the occurrence of bedsores and contractures, the addition of pneumonia and other complications.

Description

The term "stupor" (Latin for "hardening") refers to a state of extreme degeneration: those affected respond generally or only minimally to environmental stimuli, although they perceive processes in their environment with particular sensitivity - they simply cannot participate or respond to her. Thus, they do not turn their heads or look at other people, for example, who are approaching or touching them.

Communication or contact with patients occurs due to the so-called mutism, only very limited or impossible. People in a stupor are silent or seriously limited in their linguistic communication.

Some patients also experience a high fever.

Complications

A serious complication of stupor is the dissolution (disintegration) of striated muscle fibers (rhabdomyolysis). Such muscle fibers are found mainly in skeletal muscles. Rhabdomyolysis can cause acute renal failure.

Other possible complications include pneumonia with blood poisoning (sepsis), thrombosis of the leg veins, skin ulcers due to bedsores, and water and salt (electrolyte) disorders.

The longer the stupor lasts, the more likely such complications are and the higher the mortality rate for patients.

Treatment

Therapy for catatonic syndrome should be aimed at treating the underlying disease that resulted in catatonia. For catatonia caused by affective disorders, it is advisable to use mood stabilizers - drugs that stabilize mood. In catatonic schizophrenia, treatment is aimed at the main cause-and-effect links of the disease.

Various groups of antipsychotic drugs are used; if necessary, antidepressants, tranquilizers, etc. are added to therapy.

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What does the doctor do?

The doctor will first take the patient's medical history (anamnesis). If communication with the patient is not possible, relatives should be provided with all valuable information. In particular, the doctor will ask about previous mental illnesses (such as depression, schizophrenic psychosis).

This is followed by a medical examination. For example, the doctor checks muscle tone and whether the patient responds to painful stimuli or speech.

Other important information may include laboratory tests (blood, cerebrospinal fluid, cerebrospinal fluid), electrical brain wave (EEG) measurements, neurological tests, and imaging tests (such as magnetic resonance imaging, MRI). They can serve to further clarify stupor and exclude other causes.

This is how a doctor treats stupor

Therapeutic measures for organically induced stupor include treatment of the underlying disease (such as cerebral edema, encephalitis). Patients with catatonic stupor are treated with antipsychotic medications such as haloperidol or fluphenazine. Ultimately, lorazepam (sedative and anxiolytic) is additionally prescribed. The latter can also be given as a test with psychogenic stupor. Patients with depressive stupor are treated with antidepressants such as doxepin, clomipramine, amitriptyline or citalopram. Antipsychotics are also used.

Some cases of stupor may require electroconvulsive therapy (ECT): under a short anesthesia, the patient receives electrical impulses that cause a generalized seizure. Treatment is usually repeated over several consecutive days. Before starting treatment, any given antipsychotics and antidepressants will be discontinued.

In the case of Stupor, it is also important to have the same amount of attention from all persons involved in the treatment - despite the absence of apathy in the patient, he should have the home address with him, even if the patient does not speak or hardly speaks.

Especially with psychogenic stupor, a calm atmosphere with low irritation is very important. Only then is a therapeutic conversation possible.

Patients receive comprehensive monitoring with monitoring of vital signs and measures to prevent the formation of blood clots (thrombosis) and bedsores. Patients who refuse to eat are given artificial nutrition.

Treatment in the ICU is necessary for complications such as rhabdomyolysis, high fever and signs of inflammation (eg, increased white blood cells), pneumonia, and sepsis. Even with an uncertain diagnosis, potential patients with stupor should receive intensive treatment.

Important Research

These studies help to find out the reasons for complaints:

• blood collection
• blood analysis
• EEG
• fMRI
• MRI

Forecast

The prognosis for catatonic syndrome depends on a number of factors:

• the underlying disease that resulted in catatonia;
• degree of severity of catatonic symptoms;
• presence of complications, etc.

The prognosis worsens when complications occur, such as refusal to eat, the addition of concomitant pathology in the form of pneumonia, bedsores. With mild manifestations of catatonic stupor - substupor - patients can take food from the hands of medical staff and can move around the department, which reduces the risk of developing the above complications and significantly improves the prognosis.

Predicting the course of catatonic syndrome is unique in each specific case and depends on many other factors and conditions.

Diagnostics

Substupor or stupor is diagnosed due to clinical manifestations and other specific symptoms (impaired motor activity, speech, behavioral disorders). The psychiatrist, in addition to confirming the fact that the patient is in a stupor, must determine the exact cause and identify the diseases that led to the development of the pathology.

The specialist examines the patient, interviews his relatives and prescribes a series of hardware studies and tests. Patients suspected of having catatonic stupor should undergo EEG testing.

Screening can identify other neurological conditions. The results are usually satisfactory, provided that there are no concomitant conditions that cause the development of the disease.

Catatonia can be provoked by various neurological conditions, so the patient is prescribed an MRI. Brain imaging can reveal circulatory problems or other organic damage.

Diagnostic tests include:

• blood analysis;
• Analysis of urine;
• examination of the endocrine system;
• Ultrasound of the adrenal glands, thyroid gland;
• angiography of neck and brain vessels;
• analysis for human immunodeficiency virus;
• blood clotting test;
• culture of blood and urine for pathogenic microflora.

Differential diagnosis makes it possible to identify a disease whose symptoms are similar to catatonia.

These include:

• selective mutism;
• conversion disorder;
• rigidity syndrome;
• malignant hyperthermia;
• Parkinson's disease.

During the examination, the specialist must differentiate all possible causes that could provoke stupor.