Catatonic schizophrenia

Catatonia was common in the 'classical' era of psychiatry, when such authors as Krapelin and Bleuler were writing; it was frequently seen in the old mental hospitals, and remains common in developing countries. It is now rare in UK

practice: I have not seen a full-blown case for several years. But it is important to be aware of, not least because it may pose diagnostic and management difficulty if staff have not encountered it before.

The patient's clinical picture is like no other; he may appear cut off from the external world, even though he has apparently an undiminished level of consciousness. This can progress to catatonic stupor. Patients may also have varying degrees of abnormal movement, especially the adoption of abnormal postures for prolonged periods of time; for example, keeping an arm outstretched for many hours in a way that would be impossible for most people. On examination, such a limb may exhibit the classical 'waxy flexibility'. This means an increase in muscle tone, which is continuous and progressive as the limb is passively moved. This is qualitatively different from the increased tone that is seen, for example, in upper motor neuron lesions such as stroke or Parkinsonism. The condition responds to medication and nursing care, but ECT may be necessary in emergencies.

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