Abstract
There can be no transforming of darkness into light and of apathy into movement without emotion.
Catatonia is under-diagnosed partly because its symptoms can be difficult to recognise in routine clinical settings. It is therefore important to be cognizant of its many manifestations, in particular stereotypies, mannerisms, echolalia and echopraxia, and their relevance to the clinical diagnosis (Box 1).
A proposed framework for grouping symptoms observed in catatonia.
Stereotypies
Stereotypies can occur in a number of neurological and psychiatric conditions but most commonly feature in psychoses and pervasive developmental disorders. Clinically, they can be confused with symptoms of obsessive compulsive disorders, such as tics or trichotillomania, and in pervasive developmental disorders and intellectual disability, stereotypies can be associated with self-injurious behaviour. But, it is important to remember that often stereotypies are ‘normal’, for instance as part of foot or finger tapping. Stereotypies are classified as motor or verbal.
Motor stereotypies are defined in Diagnostic and Statistical Manual of Mental Disorders 5th Ed. (DSM-5) as repetitive, abnormally frequent and non-goal-directed movements that may interfere with normal functioning. More eloquently, Lohr and Wisniewski (1987) described stereotypies as ‘fragments of normal actions that are continually repeated without purpose … without conscious control, although consciousness remains intact’.
Animal experiments in the 1950s showed that inflicting severe social and sensory deprivation on monkeys at a sensitive stage of brain development caused permanent motor stereotypies that could not be reversed (Ridley and Baker, 1982) and a large body of literature points to the involvement of dopamine and the basal ganglia as one possible mechanism for the development of stereotypies. Intriguingly, neuroleptics can both alleviate and induce (tardive) stereotypies, and amphetamines can lead to what is called ‘punding’, best described as a repetitive picking or sniffing. In an experiment with mice, Aliane et al. (2011) discovered a marked increase in dopamine secretion during the expression of stereotypies as well as a marked decrease in cholinergic transmission in the basal ganglia. Notably, the magnitude of this imbalance was shown to correlate with the severity of the motor stereotypies. More recently, a proton magnetic resonance imaging study in children with stereotypies revealed that lower levels of γ-aminobutyric acid (GABA) in the cingulate cortex predicted symptom severity (Harris et al., 2016). Thus, a biological basis for stereotypies is highly likely, and understanding the underlying pathophysiology may provide potential treatments.
Verbal stereotypies feature commonly in schizophrenia, but often late in the course of the illness. Interestingly, Eugen Bleuler described stereotypies in this context as ‘… the inclination to cling to one idea to which the patient then returns again and again’. This causes a ‘derailment of … associational activity’ leading to fixed answers to various questions and can also induce a fixed patterns of motor activity.
Verbigeration is a verbal stereotypy in which usually one or several sentences or strings of fragmented words are repeated continuously. Sometimes patients will produce incomprehensible jargon in which stereotypies are embedded. The tone of voice is usually monotonous. This can be produced spontaneously or precipitated by questioning. The term verbigeration was first used in psychiatry by Karl Kahlbaum in 1874, and it referred to a manner of talking which was very fast and incomprehensible. At the time verbigeration was seen as a ‘disorder of language’ and represented a central feature of catatonia. The word is derived from the Latin word ‘verbum’ (also the source of ‘verbiage’), plus the verb ‘gerĕre’, to carry on or conduct, from which the Latin verb ‘verbigerāre’, to talk or chat, is derived. However, clinically the term verbigeration never achieved popularity and as such has virtually disappeared from psychiatric terminology.
Mannerisms
Mannerisms are odd and idiosyncratic methods of performing a task that are unique to an individual and serve a function that is not always apparent (i.e. performing certain ritualistic acts for luck). They should not be confused with stereotypies. In schizophrenia, mannerisms can emerge from delusional ideas, but may also be regarded as an expression of catatonic motor disorder or a manifestation of negativism. A manneristic posture can be an exaggeration of a normal posture but is not rigidly preserved, in contrast to a stereotyped posture, which is rigidly maintained. The point where a postural mannerism becomes a stereotypy can be difficult to define, but Lohr and Wisniewski (1987) suggest that a mannerism should contain an ‘unusual or grotesque’ component that signals to people of the same culture that the behaviour is obviously abnormal. Overall, mannerisms are not diagnostic of any specific psychiatric disorder but need to be evaluated clinically, so as to differentiate them from stereotypies.
Perseverations
Perseverations are usually cued or imitated actions. These behaviours are set apart from stereotypies and mannerisms in that they generally occur immediately following a normal goal-directed action and then tend to break down into fragments of the original movement. Once the perseverated action stops, it is supplanted by a new and unrelated action, unlike a stereotypy in which it continues uninterrupted (Friedman and Jankovic, 2016).
Like stereotypies, perseverations are also classified as either motor or verbal. A motor perseveration is a repeated and induced (cued) movement, which deteriorates into the senseless repetition of a goal-directed action that has already served its purpose (for instance poking out one’s tongue out and repeatedly doing so long after it was requested). Another example of this is echopraxia. This usually occurs when an individual is visually cued by another person and imitates their behaviour. Occasionally individuals mimic the behaviour of another person without them being present. While this normally occurs automatically, individuals have been known to decide which person to imitate.
There are several examples of verbal perseveration. Echolalia is described as the patient echoing the whole or part of what has been said, irrespective of whether it has been understood. Interestingly, echoing of a foreign language has been observed. It has been suggested that echo speech in children is suppressed when voluntary speech takes over and therefore echolalia can be regarded as regression or disinhibition of childhood speech patterns. Echologia refers to echoing the content of a question using different words and in Logoclonia the last syllable of a word is repeated, for example: ‘I am well today-ay-ay-ay-ay-ay’. Palilalia simply refers to the repetition of a perseverated word with increasing frequency.
These descriptions suggest that these phenomena are distinct and easily distinguishable, but mannerisms are not specific to any particular diagnosis and are difficult to identify in clinical practice. Hence, they are not particularly reliable in establishing a diagnosis of catatonia. Similarly, stereotypies as a criterion of catatonia are reduced to motor phenomena alone in DSM-5, and verbigeration as a verbal expression of stereotypies is overlooked all together. Echopraxia and echolalia can be subsumed under the umbrella of perseveration, with a distinction drawn between motor and verbal aspects of this feature.
Conclusion
In order to improve the recognition of catatonia, DSM-5 made changes to the association of catatonia with various psychiatric and medical conditions. But, the specific criteria for catatonia, some of which are overlapping, have not changed, nor have they been critically evaluated in regard to their usefulness. The simple listing of individual criteria instead of grouping related features not only fails to facilitate diagnosis but instead creates confusion. Grouping criteria allows for an examination of important similarities and differences between clinical features, ensuring improved and prompt treatment and enhancing the coherence of the diagnostic system which is likely to increase recognition of catatonia in practice.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.