Functional neuroimaging in patients with catatonia: A systematic review

BACKGROUND

Catatonia is a challenging and heterogeneous neuropsychiatric syndrome of motor, affective and behavioral dysregulation which has been associated with multiple disorders such as structural brain lesions, systemic diseases, and psychiatric disorders. This systematic review summarized and compared functional neuroimaging abnormalities in catatonia associated with psychiatric and medical conditions.

METHODS

Using PRISMA methods, we completed a systematic review of 6 databases from inception to February 7th, 2024 of patients with catatonia that had functional neuroimaging performed.

RESULTS

A total of 309 studies were identified through the systematic search and 62 met the criteria for full-text review. A total of 15 studies reported patients with catatonia associated with a psychiatric disorder (n = 241) and one study reported catatonia associated with another medical condition, involving patients with N-methyl-d-aspartate receptor antibody encephalitis (n = 23). Findings varied across disorders, with hyperactivity observed in areas like the prefrontal cortex (PFC), the supplementary motor area (SMA) and the ventral pre-motor cortex in acute catatonia associated to a psychiatric disorder, hypoactivity in PFC, the parietal cortex, and the SMA in catatonia associated to a medical condition, and mixed metabolic activity in the study on catatonia linked to a medical condition.

CONCLUSION

Findings support the theory of dysfunction in cortico-striatal-thalamic, cortico-cerebellar, anterior cingulate-medial orbitofrontal, and lateral orbitofrontal networks in catatonia. However, the majority of the literature focuses on schizophrenia spectrum disorders, leaving the pathophysiologic characteristics of catatonia in other disorders less understood. This review highlights the need for further research to elucidate the pathophysiology of catatonia across various disorders.

Historical postmortem studies on catatonia: Close reading and analysis of Kahlbaum's cases and scientific texts between 1800 and 1900

In the 19th century, postmortem brain examination played a central role in the search for the neurobiological origin of psychiatric and neurological disorders. During that time, psychiatrists, neurologists, and neuropathologists examined autopsied brains from catatonic patients and postulated that catatonia is an organic brain disease. In line with this development, human postmortem studies of the 19th century became increasingly important in the conception of catatonia and might be seen as precursors of modern neuroscience. In this report, we closely examined autopsy reports of eleven catatonia patients of Karl Ludwig Kahlbaum. Further, we performed a close reading and analysis of previously (systematically) identified historical German and English texts between 1800 and 1900 for autopsy reports of catatonia patients. Two main findings emerged: (i) Kahlbaum's most important finding in catatonia patients was the opacity of the arachnoid; (ii) historical human postmortem studies of catatonia patients postulated a number of neuroanatomical abnormalities such as cerebral enlargement or atrophy, anemia, inflammation, suppuration, serous effusion, or dropsy as well as alterations of brain blood vessels such as rupture, distension or ossification in the pathogenesis of catatonia. However, the exact localization has often been missing or inaccurate, probably due to the lack of standardized subdivision/nomenclature of the respective brain areas. Nevertheless, Kahlbaum's 11 autopsy reports and the identified neuropathological studies between 1800 and 1900 made important discoveries, which still have the potential to inform and bolster modern neuroscientific research in catatonia.

Microglia ablation alleviates myelin-associated catatonic signs in mice

The underlying cellular mechanisms of catatonia, an executive "psychomotor" syndrome that is observed across neuropsychiatric diseases, have remained obscure. In humans and mice, reduced expression of the structural myelin protein CNP is associated with catatonic signs in an age-dependent manner, pointing to the involvement of myelin-producing oligodendrocytes. Here, we showed that the underlying cause of catatonic signs is the low-grade inflammation of white matter tracts, which marks a final common pathway in Cnp-deficient and other mutant mice with minor myelin abnormalities. The inhibitor of CSF1 receptor kinase signaling PLX5622 depleted microglia and alleviated the catatonic symptoms of Cnp mutants. Thus, microglia and low-grade inflammation of myelinated tracts emerged as the trigger of a previously unexplained mental condition. We observed a very high (25%) prevalence of individuals with catatonic signs in a deeply phenotyped schizophrenia sample (n = 1095). Additionally, we found the loss-of-function allele of a myelin-specific gene (CNP rs2070106-AA) associated with catatonia in 2 independent schizophrenia cohorts and also associated with white matter hyperintensities in a general population sample. Since the catatonic syndrome is likely a surrogate marker for other executive function defects, we suggest that microglia-directed therapies may be considered in psychiatric disorders associated with myelin abnormalities.

[Mechanisms of catatonia]

BACKGROUND

Catatonia is being increasingly viewed as a unique syndrome consisting of specific motor signs that respond characteristically and uniformly to benzodiazepines and electroconvulsive therapy. This interpretation is also reflected in changes in the classification of catatonia in DSM-5. An all-embracing pathogenesis of catatonia remains elusive.

AIM

To review the mechanisms of catatonia.

METHOD

We reviewed the literature.

RESULTS

Certain aspects of catatonia can be explained by a number of different mechanisms. We present a new, more comprehensive model involving the vagal nerve.

CONCLUSION

Further research into the underlying mechanisms of catatonia is needed in order to to find new therapies.

Catatonia after cerebral hypoxia: do the usual treatments apply?

BACKGROUND

Neurologic deterioration occurring days to weeks after a cerebral hypoxic event accompanied by diffuse white matter demyelination is called delayed posthypoxic leukoencephalopathy (DPHL). Manifestations of DPHL are diverse and include dementia, gait disturbance, incontinence, pyramidal tract signs, parkinsonism, chorea, mood and thought disorders, akinetic mutism, and rarely catatonia.

METHODS

We report a case of malignant catatonia in a patient diagnosed with DPHL that was refractory to electroconvulsive therapy (ECT) and review the literature on catatonia in DPHL.

RESULTS

The patient was a 56-year-old woman with schizoaffective disorder who was admitted with catatonia 2 weeks after hospitalization for drug overdose and respiratory failure. Her catatonic symptoms did not respond to treatment of lorazepam, amantadine, methylphenidate, or 10 sessions of bilateral ECT at maximum energy. Repeat magnetic resonance imaging revealed extensive periventricular white matter lesions not present on admission scans, and she was diagnosed with DPHL.

DISCUSSION

No treatment for DPHL has been proven to be widely effective. Hyperbaric oxygen treatments may reduce the rate of development, and symptom improvement has been reported with stimulants and other psychotropic agents. Review of literature reveals rare success with GABAergic agents for catatonia after cerebral hypoxia and no cases successfully treated with ECT. There are 7 case reports of neurologic decompensation during ECT treatment after a cerebral hypoxic event.

CONCLUSION

Caution is advised when considering ECT for catatonia when delayed sequelae of cerebral hypoxia are on the differential diagnosis, as there is a dearth of evidence to support this treatment approach.

Quetiapine responsive catatonia in an autistic patient with comorbid bipolar disorder and idiopathic basal ganglia calcification

BACKGROUND

Bipolar disorder (BD) has been linked with the manifestation of catatonia in subjects with autism spectrum disorders (ASD). Idiopathic basal ganglia calcification (IBGC) is characterized by movement disorders and various neuropsychiatric disturbances including mood disorder.

CASE

We present a patient with ASD and IBGC who developed catatonia presenting with prominent dystonic feature caused by comorbid BD, which was treated effectively with quetiapine.

CONCLUSION

In addition to considering the possibility of neurodegenerative disease, careful psychiatric interventions are important to avoid overlooking treatable catatonia associated with BD in cases of ASD presenting with both prominent dystonic features and apparent fluctuation of the mood state.

[Selection for catatonic reaction in rats: a study of interstrain differences by magnetic resonance imaging]

Brain studies by magnetic resonance imaging, angiography, and spectroscopy have been performed with rat strains Wistar, GC (genetic and catatonia), and PM+ (pendulum movements). Both GC and PM+ rats show similar deviations from the ancestral Wistar population in having smaller areas of the right striatum (coronal slice). The anterior horns of lateral ventricles in GC rats are smaller than in the control strain. The maximum blood flow velocity in the common carotid arteries of PM+ rats is greater. The GC and PM+ strains differ in myo-inositol level in the hippocampus. The PM+ strain is characterized by a lower taurine level in the hippocampus, which may be one of the participants regulated the predisposition to audiogenic seizures.

Increased advanced glycation end-products (AGEs) assessed by skin autofluorescence in schizophrenia

BACKGROUND

Oxidative stress has been intensively studied as a key biochemical system in the pathophysiology of schizophrenia. However, little is known about the implication of oxidative stress in the development of physical illnesses in schizophrenia patients, who are characterized by high cardiovascular risk and decreased life expectancy. Advanced glycation end-products (AGEs) are considered to be markers of oxidative stress and are linked to the development of atherosclerosis.

METHODS

We investigated AGE levels determined by a noninvasive skin autofluorescence (skin AF) method (AGE-Reader™) in schizophrenia patients. Skin AF was assessed in 55 schizophrenia patients without diabetes or renal disease and 55 healthy controls matched for age, gender and smoking status. Nineteen of the 55 schizophrenia patients had a severe form of the disease (Kraepelinian schizophrenia).

RESULTS

Skin AF was significantly higher in schizophrenia patients compared to controls (2.46 ± 0.52 and 1.90 ± 0.21, respectively, p < 0.0001). Kraepelinian schizophrenia patients had significantly higher skin AF than non-Kraepelinian schizophrenia patients (p = 0.05).

CONCLUSIONS

This is the first study to demonstrate high AGE levels assessed by a noninvasive method in schizophrenia patients.

Lorazepam modulates orbitofrontal signal changes during emotional processing in catatonia

OBJECTIVE

Catatonia is a psychomotor syndrome characterized by concomitant emotional, behavioural and motor symptoms. In many cases clinical symptoms disappear almost immediately with administration of lorazepam, which acts on GABA(A) receptors.

METHODS

Using functional magnetic resonance imaging (fMRI) we investigated prefrontal activation patterns during emotion processing in catatonic patients with and without lorazepam in a double-blind study design. For emotional stimulation the International Affective Picture System (IAPS) was used. BOLD-signals were determined using regions of interest (ROI) and were statistically compared between groups.

RESULTS

For negative emotional pictures lorazepam induced higher signal decreases in the orbitofrontal cortex (OFC) in catatonic patients than in healthy subjects resulting in a regularization of activity patterns comparable to healthy subjects with placebo.

CONCLUSIONS

Results indicate disturbances in the functioning of OFC in catatonia. GABAergic modified emotion regulation with decreased inhibition of affective stimuli could lead to the intense emotions reported by many catatonic patients.

Role of adenosine in drug-induced catatonia in mice

Parkinson's disease is one of the most common neurodegenerative disorders affecting large majority of population who are older than age of 65. Apart from dopamine, acetylcholine and glutamate, adenosinc has also been identified in the basal ganglia. Adenosine modulates the release of a variety of neurotransmitters including dopamine. In order to establish adenosine-dopamine interactions in drug-induced catatonia we studied the effect of adenosine in drug-induced catatonia in mice. In the present study adenosine dose dependently produced catatonia when assessed on rota-rod and bar tests in mice. Adenosine also potentiated the catatonic effect of perphenazine. L-dopa plus carbidopa or OR-486 (a potent centrally acting COMT inhibitor) completely reversed adenosine-induced catatonia. Since reversal by scopolamine of adenosine-induced catatonia was not to the same extent as with l-dopa and OR-486 it appears that catecholamines particularly dopamine rather than cholinergic modulation is more important in adenosine induced catatonia. The motor dysfunction (catatonia) could be easily assessed using rota-rod test apparatus in mice.

[Structural disruption of the myelin sheaths in the CNS of adult rats with hereditary catatonia]

Ultrastructural studies have been made on the medio-dorsal region of n. caudatus and ventromedial part of the corpus callosum in rats with hereditary catatonia. In most of the nervous fibres, structural abnormalities were revealed in myelin sheaths. Dense myelin is split into several layers at the intraperiod line, terminal loops being swollen. Proliferation of oligodendroglia is also observed. Most of the mitochondria, both in the glia and nervous fibers, almost completely lack cristae. Proportional relationship between two main components of the cytoskeleton, i.e. neurofilaments and microtubuli, increases, which may be taken as an indication of a compensatory reaction. The observed morphological changes may play significant role in disturbances of sleep-wakefulness cycle in rats with hereditary catatonia.

Structural brain abnormalities in catatonia

In this study, the ventricle to brain ratios of catatonic subjects were compared and evaluated with respect to the underlying diagnoses. Catatonic individuals with the diagnosis of schizophrenia were more likely to have greater ventricle to brain ratios than other catatonic subjects. The association of large ventricles with chronic, deteriorating psychosis is maintained and the heterogeneity of the syndrome of catatonia is apparent. It is possible that the presence of large ventricles may be useful to predict the chronicity of disability for some cases of catatonia.

Brain neurotransmitter changes in three patients who had a fatal hyperthermia syndrome

The authors examined the autopsied brains from three patients who had a fatal hyperthermia syndrome. There was marked hypothalamic noradrenaline depletion in all three patients, severe brain choline acetyltransferase deficiency with nucleus basalis cell loss in two patients, and mild to moderate brain choline acetyltransferase loss in one patient. Striatal dopamine metabolite/dopamine ratio was below normal in two patients and not elevated, as would be expected after short-term neuroleptic administration, in the third. This suggests that reduced capability (aggravated by the cholinergic deficit) of the nigrostriatal dopamine system to respond adequately to stress and/or neuroleptic-induced receptor blockade may be important in the development and course of fatal hyperthermia syndrome.

Brainstem and vermis atrophy in catatonia

The computerized tomographic scans of five catatonic patients and five matched controls were blindly assessed. The catatonic patients showed preponderant atrophy of the brainstem and cerebellar vermis. Catatonia may be associated with lesions in these areas.