Catatonia presents as a neuropsychiatric syndrome characterized by mutism, stupor, food and drink refusal, posturing, and excitement or hypokinesis.1 A 2003 estimate proposed that approximately 90,000 catatonia cases occur in US hospitals each year.2 The reported prevalence ranges widely from 7.6% to 38%.3 In 2018, a meta-analysis calculated 9.2% as the mean prevalence in people diagnosed with various psychiatric or medical conditions.4 This meta-analysis concluded that this syndrome does not present as rarely as conventional wisdom believes in both medical and psychiatric cases.4
Previously, experts suggested that catatonia occurs most commonly in psychiatric patients who experience mood disorders.1,5 More recent data, on the contrary, reveals that it may occur more frequently in patients with a medical, rather than a psychiatric, condition.4 In fact, about 75% of catatonic patients do not present with any psychiatric disorder.6 Nevertheless, experts believe that catatonia likely remains an under-diagnosed clinical syndrome.1,5,7
No large-scale analyses exist to examine catatonia in postoperative patients. Currently, the existing literature consists of approximately ten or so case studies of the condition in a postoperative environment. A number of these cases occurred after liver transplantation specifically.8–10 Liver transplantation patients potentially experience more neuropsychiatric conditions than a general surgical patient.1 These patients’ relationships to alcohol, hepatitis C, and immunosuppressant medications may affect the development of catatonia.1
Generally, the rest of the postoperative case studies vary in operation type and patient history. Two cases report no history of neuropsychiatric illness nor any medical contraindications besides the reason for the operation.6,11 Conversely, three cases report a history of psychiatric illness in the patient.12–14 Two cases, moreover, describe patients who experienced previous catatonic episodes: one reported unconscious episodes during her menstrual cycle and the other experienced a catatonic episode after a previous breast biopsy.15,16 In addition, two patients appeared notably significantly stressed and anxious prior to their surgeries.11,15 All catatonic patients, except one, recovered with no apparent long-term ramifications. The one patient suffered a jaw dislocation, potentially due to abnormal posturing during her catatonic episode.14
Experts do not believe only a single cause exists for catatonia and the case studies do not suggest one either. A medical, neurological, or psychiatric illness, however, has so far always been found to underlie the condition.1 There is also no consensus for the pathophysiology of this condition. One hypothesis proposes that dysregulation of the γ-aminobutyric acid (GABA)-A, glutamate, and dopamine neurotransmitter systems may contribute to its development.1
Clinicians diagnose the syndrome primarily through a careful history, clinical examination, and the exclusion of organic causes.16,17 Several life-threatening conditions can mimic catatonia (e.g., encephalitis, cardio-embolic stroke, severe metabolic disorders), so clinicians need to rule these causes out first.8,15,16 In the absence of any organic causes, clinicians are recommended to consult with a neurologist and psychiatrist to propose a diagnosis of catatonia.1
Catatonic patients typically present behavioral, motor, cognitive, affective, and autonomic disturbances.1 Waxy flexibility – a rigid body position for a considerable time period – appears as the best-known sign for catatonia.12 Two subtypes exist: withdrawn-type and excited-type. Minimal spontaneous speech and movement describes the withdrawn-type and excessive purposeless motor activity the excited-type.18 Malignant (previously termed “lethal”) catatonia occurs when the patient experiences escalating fever and autonomic instability.19,20 Benzodiazepines, primarily lorazepam, and ECT serve as first-line treatment for catatonia.1,16 N-methyl-D-aspartic acid (NMDA) antagonists, atypical antipsychotics, and repetitive transcranial magnetic stimulation potentially offer newer treatment options, though they are currently used less commonly.1 All treatment, however, should begin with supportive care to reduce the risk of morbidity and mortality because of immobility and poor nutrition in catatonic patients.1
1. Daniels, J. Catatonia: Clinical Aspects and Neurobiological Correlates. J. Neuropsychiatry Clin. Neurosci. 21, 371–380 (2009). https://doi.org/10.1176/jnp.2009.21.4.371.
2. Taylor, M. A. & Fink, M. Catatonia in Psychiatric Classification: A Home of Its Own. Am. J. Psychiatry 160, 1233–1241 (2003). https://doi.org/10.1176/appi.ajp.160.7.1233.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (American Psychiatric Press, Inc., 2000).
4. Solmi, M. et al. Prevalence of Catatonia and Its Moderators in Clinical Samples: Results from a Meta-analysis and Meta-regression Analysis. Schizophr. Bull. 44, 1133–1150 (2018). https://doi.org/10.1093/schbul/sbx157.
5. Bhati, M. T., Datto, C. J. & O’Reardon, J. P. Clinical Manifestations, Diagnosis, and Empirical Treatments for Catatonia. Psychiatry Edgemont 4, 46–52 (2007). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2922358/.
6. Chowdhry, V., Biswal, S., Mohanty, B. B. & Bhuyan, P. Catatonic stupor after off-pump coronary artery bypass grafting. Ann. Card. Anaesth. 19, 758–759 (2016). http://doi.org/10.4103/0971-9784.191574.
7. van der Heijden, F. M. M. A. et al. Catatonia: disappeared or under-diagnosed? Psychopathology 38, 3–8 (2005). https://doi.org/10.1159/000083964.
8. Cottencin, O., Debien, C., Vaiva, G., Thomas, P. & Pruvot, F.-R. Catatonia and Liver Transplant. Psychosomatics 43, 338–339 (2002). https://doi.org/10.1176/appi.psy.43.4.338.
9. Koff, J. M., Matsumoto, C. S. & Holtzmuller, K. C. Echolalia in a Liver Transplant Recipient. Transplantation 78, 486–487 (2004). https://doi.org/10.1097/01.TP.0000128624.03384.0D.
10. Seetharam, P. & Akerman, R. R. Postoperative Echolalia and Catatonia Responsive to Gamma Aminobutyric Acid Receptor Agonists in a Liver Transplant Patient. Anesth. Analg. 103, 785–786 (2006). https://doi.org/10.1213/01.ANE.0000227163.12053.BE.
11. O’Regan, D., Wong, K., Bouras, I., Foot, C. & Wigmore, T. Falling in and out of consciousness: catatonia in a postoperative patient. J. R. Soc. Med. 103, 107–108 (2010). https://doi.org/10.1258/jrsm.2009.090332.
12. Shaikh, M. Catatonia in a 39-Year-Old Patient after Post-hysterectomy and Post-salpingo-oopherectomy. Anaesth. Crit. Care Med. J. 2, 1–4 (2017). https://doi.org/10.23880/ACCMJ-16000124.
13. Chacko, C. J., Paul, J. T., Li, Y. W. & Bhaskaran, S. Catatonia after routine orthopaedic surgery. Internet J. Anesthesiol. 23, (2009). https://ispub.com/IJA/23/1/8199.
14. Parida, S., Allampalli, V. & Krishnappa, S. Catatonia and jaw dislocation in the postoperative period with epidural morphine. Indian J. Anaesth. 55, 184 (2011). https://doi.org/10.4103/0019-5049.79904.
15. Rafizadeh, S., Kerry-Gnazzo, A. R. & DeWalt, K. An Unresponsive Patient in Postanesthesia Care Unit: A Case Report of an Unusual Diagnosis for a Common Problem. AA Pract. 14, e01293 (2020). https://doi.org/10.1213/XAA.0000000000001293.
16. Hegde, H. V. & Kumar, V. A case report of menstrual catatonia causing delayed emergence from anaesthesia: a diagnostic dilemma. J. Anesth. Crit. Care Open Access 10, 159–160 (2018). https://doi.org/10.15406/jaccoa.2018.10.00382.
17. Mann, S. C. et al. Lethal Catatonia. Am. J. Psychiatry 143, 1374–1381 (1986). https://doi.org/10.1176/ajp.143.11.1374.
18. Wilcox, J. A. & Reid Duffy, P. The Syndrome of Catatonia. Behav. Sci. Basel Switz. 5, 576–588 (2015). https://doi.org/10.3390/bs5040576.
19. Fink, M. & Taylor, M. A. Catatonia is measurable and common. in Catatonia: A Clinician’s Guide to Diagnosis and Treatment 129–130 (Cambridge University Press, 2003).
20. Moskowitz, A. K. ‘Scared stiff’: catatonia as an evolutionary-based fear response. Psychol. Rev. 111, 984–1002 (2004). https://doi.org/10.1037/0033-295X.111.4.984.