What is Catatonia?

Next up in the ‘what is…’ series is something I’m intimately familiar with: catatonia.

What is Catatonia?
Catatonia is a state of advanced psychomotor retardation, whereby a person (usually) enters “stupor” which involves being unresponsive to most stimuli, usually with an impaired level of consciousness. Someone with catatonia may show signs such as:

  • Cataplexy or a posture held against gravity. One example of this is how some people with catatonia lay down but keep their heads slightly raised as if on an invisible pillow.
  • Waxy flexibility, whereby someone can position the limbs and body of the catatonic person, who then maintains that position.
  • Muteness
  • Negativism – where, upon given a command by someone, the person will instead do the opposite or otherwise not respond
  • Posturing, similar to waxy flexibility but the person takes a sudden and active roles in positioning themselves against gravity
  • Stereotypy – frequent and repetitive actions that serve no real purpose (often seen in autistic people)
  • Agitation
  • Grimacing
  • Echolalia (imitating the speech of another)
  • Echopraxia (imitating the motions of another)
Two people with catatonia related to schizophrenia

There are three subtypes of catatonia, each more dangerous than the last.

  • Stupor: as shown by the picture above, this is the most recognised form of catatonia, which involves the absence of motor activity and symptoms such as posturing and mutism. This is associated with dehydration and nutritional deficiencies and can lead to renal failure. It may require feeding tubes and/or intravenous fluids.
  • Catatonic excitement: This state is characterised by extreme purposeless movement, excitement and agitation. It may involve psychosis. Catatonic excitement is considered to be extremely dangerous to the individual with fever and hyperthermia being common.
  • Malignant catatonia: This involves autonomic instability, fever and delirium. If not treated correctly and quickly, it is often fatal.

Who gets catatonia?
Catatonia was originally highly linked to schizophrenia, however the causes of it have broadened in recent years as a result of clinical experience. It is now associated with.

  • Schizophrenia/psychotic spectrum disorders
  • Depression
  • Bipolar disorder
  • Autistic spectrum disorders

How is it treated?
The first-line treatment for catatonia is benzodiazepines, such as valium (diazepam) and ativan (lorazepam). This seems to work particularly well for stupor as it relaxes the muscles and some doctors use the effectiveness of this as a diagnostic tool, e.g. if it stops when given benzos, it’s probably catatonia. This is usually given via an injectable as many will be unable to take oral medication. The next stage if benzos don’t work (and usually first-line for malignant catatonia) is ECT (electro-convulsive therapy).

My experiences with catatonia
I have had catatonia twice, which puts me at risk of developing it again. Once before onset I was very depressed, in both cases, I was also psychotic. I displayed stupor, mutism, waxy flexibility and cataplexy. Because catatonia alters your level of consciousness, I am not able to tell you much about what it was like to have. I have been asked “what does it feel like?” but it’s almost like going to sleep for a period, although I have hazy recollections, snapshots here and there of what was going on – a kindly nurse whose hand I couldn’t relax enough to stop gripping, the hospital walls which I must have stared at for hours. In both cases I was hospitalised and in both cases I responded very well to benzodiazepine treatment, which I was given three times a day. It was like waking up from a weird dream. My body ached all over from being held in weird positions for a long time, and I was confused and disorientated. My psychosis also needed to be treated afterwards. In some ways I am lucky to respond so well to drug treatment but I always fear that if there’s a next time, I will wake up after being given ECT without my consent.

As always, I hope this was helpful and informative. If you have any questions, don’t hesitate to ask!

What is an ARMS?

ARMS stands for ‘at risk mental state’ and is a term used to describe people who are at a high risk of developing psychosis. The aim of identifying people with ARMS is to provide intervention as early as possible in order to decrease the severity of any psychotic illness that does occur and/or decrease the likelihood of one developing. Early Intervention in Psychosis services are more and more taking on people who have an ARMS. Sometime the terms ‘prodromal psychosis’ or “prodrome” are used interchangeable with ARMS, though there are subtle differences.

Who has an ARMS?
People are deemed to have an at risk mental state if they don’t meet the diagnostic criteria for any psychotic disorder but show the following signs:

  • Unexplained distress and agitation
  • Are within the age range when psychotic symptoms are most likely to occur
  • Recent decline in social functioning (e.g. social isolation)
  • A strong family history of psychosis
  • Very mild or brief (transient) psychotic symptoms
  • Having associated conditions such as Schizotypal Personality Disorder

What can be done to treat people with an ARMS?

  • CBT for psychosis has been shown to be very helpful in decreasing both distress and the number of people going on to develop a psychotic disorder.
  • Integrated therapies or counselling
  • Sometime it’s deemed appropriate to start an antipsychotic medication early on in order to prevent psychosis occurring.

I think ARMS is an interesting development in the world of mental health and it poses a number of questions. Like is it possible to identify risk factors for other disorders? Could we be looking out for early markers for mood and anxiety disorders also? Also, although this approach allows for early detection, something that’s of particular importance with psychosis due to the cognitive decline linked to it, is it right to start people who may never develop psychosis on potent medications like antipsychotics?

I hope this has been helpful. What do you think about ARMS?

What is OCD?

I thought I’d write about my other mental health diagnosis; OCD.

What is OCD?

OCD is an anxiety disorder comprised of two main elements: Obsessions and compulsions.

Obsessions are unwanted thoughts, images and urges that cause anxiety for the person experiencing them. These thoughts may include:

  • Harm OCD, where people either think they will, or have already hurt someone or something else.
  • Thoughts of a sexual nature that may be distressing, particularly if centred around family or children. Some people may worry that they are having thoughts about people of a different gender than they are usually orientated towards.
  • Religious or blasphemous thoughts.
  • Fears about contamination; that they may contract a certain disease or are spreading one.
  • Obsessions with symmetry, a preoccupation with patterns and orders

Whilst obsessions around symmetry and contamination are fairly well known due to their portrayal in the media and the more obvious compulsions related to them, it is obsessions of a violent, religious and sexual nature that are less talked about, more stigmatised and less understood.

Compulsions are actions or behaviours that a person feels compelled to do in response to their obsessive thoughts. They may include:

  • Washing hands and cleaning excessively, usually in response to contamination obsessions.
  • lining things up, making them symmetrical or putting them in a certain order
  • The need to touch things in a certain way
  • Seeking reassurance from others in order to combat obsessive thoughts, e.g. “I’ve not hurt anyone have I?”
  • Checking behaviours e.g. checking many times that the door is locked or the oven has been turned off.
  • Mental compulsions which seek to correct or neutralise intrusive thoughts/images, such as repeating words over and over in your head or outloud.

Intrusive thoughts and Delusions
Sometimes it can be difficult to extrapolate what is an obsessive thought and what is delusion, particularly in those who have both OCD and a psychotic disorder. Take for example someone who has a delusion they have hurt some one and someone who has an obsessive thought about having hurt someone. These thought may be equally vivid but there are differences. For one thing, delusions don’t usually involve repetitive compulsions in order to be neutralised. Secondly, delusions are fixed and rigid beliefs, usually people with OCD know they are being illogical but can’t help the thoughts or associated anxiety. Often you can get them to question their beliefs.

Types of OCD

There are different forms of OCD and OCD related disorders, sometimes known as “cousin” disorders. Some people think they should sit on the OCD spectrum. They include:

  • Pure “O” – This is a recognised form of OCD where there are no, or little, signs of external compulsions but there are unwanted and intrusive obsessional thoughts, images and/or urges. Sometimes people with pure O engage in mental compulsions as discussed above.
  • CSP (compulsive skin picking) and trichotillomania (pulling out hair)
  • Hoarding – where you keep and collect a large number of things to the extent it interferes with your life.
  • BDD – Body dysmorphic disorder where someone has repeated obsessive thoughts about the way they look and perceived flaws on their body. Compulsions related to how they look may accompany these.
  • OCPD – obsessive compulsive personality disorder – this is similar in some ways to OCD but it is its own condition

Treatments for OCD

There are ways to help people with OCD. These might include:

  • CBT (cognitive behavioural therapy)
  • A type of exposure therapy designed for OCD called exposure and response prevention (ERP), which helps people confront their fears and avoid submitting to compulsive behaviours.
  • Medications, usually antidepressants and primarily a class of antidepressants known as SSRIs. These often have to be at quite a high dosage (higher than those used to treat mood) in order to be effective for OCD.

My experiences with OCD.

I was diagnosed with OCD at a young age. I can remember have obsessions and compulsions at around age 8. At that age, I was sent to a Church of England school, and so they were mainly religious in form and would involved blasphemous thoughts and repeating phrases such as “I’m sorry, God” over and over in my head or aloud. As I got older, and moved away from from religion, they took the form of violent thoughts and harm OCD, which focused on my family and animals. I regularly get thoughts and urges to hurt my cats or to push people in front of trains or stab my own mother. These thoughts might be shocking to hear about, but they’re common, they don’t make me dangerous and they need to be talked about. My compulsions are mainly counting, touching things (usually wood), mental compulsions and seeking reassurance as well as some checking behaviours. I did initially get some, very limited, relief from Sertraline (Zoloft), a type of SSRI, but ending up not being able to take it. I tried CBT in the past for OCD and was unsuccessful but am having some breakthroughs now at the age of 26 with my current therapist. It’s a hard thing to cope with, especially when you have additional diagnoses but it’s a daily battle I’m used to fighting and I don’t plan to stop.

If you need help for your OCD, check out websites such as OCD action and the international OCD foundation!

What is Bipolar Disorder?

Before I was diagnosed with Schizoaffective Disorder, I was first diagnosed in hospital with Bipolar 1, so I learned a lot about it. Also, I am diagnosed with SZA-bipolar type so arguably, I still have it! I’m writing this to inform people about what bipolar is and what it isn’t.

What is Bipolar disorder?
Bipolar (formerly “manic-depression”) is first and foremost a mood disorder, meaning it’s a mental health problem that affects your mood. Although everyone has variations in their mood, in Bipolar Disorder these can be extreme highs and lows that go well beyond the norm. People with BP can experience Hypomanic or manic episodes, depressive episodes, mixed episodes and sometimes some psychotic symptoms.

What you might feel and do during Hypo/Manic Episodes

  • Feeling a sense of extreme happiness, euphoria or elevated and expansive mood
  • Talking a lot, sometimes very fast. Occasionally speech may be loud or so fast it’s hard to understand or interrupt. This is called “pressure of speech”.
  • Being agitated and irritable
  • Having a high sex drive which may lead to risky or inappropriate behaviour.
  • Experiencing racing thoughts
  • An inability to focus for long or concentrate
  • Hyperactivity and restlessness
  • Sleeping very little or not at all
  • Being very confident
  • Spending a lot of money
  • Taking risks, sometimes very serious risks that may be life threatening (usually seen more in manic episodes)
  • Having grandiose believes or delusions (seen in manic episodes)

What you might feel or do during depressive episodes:

  • Feel down, sad or numb
  • Feel tired and lethargic
  • Anhedonia or a lack of pleasure in normally pleasurable activities
  • Low self esteem
  • Guilt, hopelessness or agitation
  • Suicidal thoughts and ideation
  • Self harm
  • Difficulty eating and sleeping as normal (either too little or too much)

There are also mixed episodes where people experience a mix of the manic and depressive symptoms listed above. These are considered particularly dangerous as having suicidal thoughts (depression) but impulsivity and lots of energy (mania) make suicide more likely. It can also be hard to diagnose or to recognise because of the incongruity of symptoms. These are more common in Bipolar 1.

What are the types of Bipolar Disorder?

There are two main types of Bipolar disorder, bipolar 1 and bipolar 2.

People with Bipolar 1 have experienced symptoms of full-blown mania for at least a week. They may also experience psychotics symptoms, usually when in a manic episode but sometimes also during a depressive episode. These may include feeling like they have special powers or abilities or are someone particularly important. People with bipolar 1 are more likely to be hospitalised for their symptoms. It is also possible to have this diagnosis with just manic symptoms alone and no depressive episodes, though this is more unusual.

People with bipolar 2 experience a milder (but still serious!) form of mania known as “hypomania”. They may have symptoms of mania listed above but less intense. People with this diagnosis usually have to have had depressive episodes as well as hypomania. Someone with bipolar 2 does not experience psychotic symptoms during hypomania.

In additional to Bipolar 1 and 2 there is a third “type” of Bipolar known as “Cyclothymia”. This is usually described as a milder form of bipolar, though the impact on peoples lives can still be serious. People with this condition usually have had some hypomanic symptoms and mild to moderate depressive symptoms.

It is also possible to have something called ‘rapid cycling’. This is a subtype that can occur within Bipolar 1 and 2, when a person has four or more episodes of depression or hypo/mania within one year. Some people have episodes that cycle so quickly they may feel hypo/manic and depressive within the space of a week. This form of bipolar is poorly understood.

What can help and treat bipolar disorder

Bipolar disorder is often treated with a combination of medications and psychosocial treatment. You can also help control your own disorder by:

  • Monitoring your own moods. This can be done in the form of a diary or I’ve found apps such as Daylio and eMoods very helpful.
  • Learning your own early warning signs for an episodes
  • Avoiding your triggers, such as staying up late or using drugs or alcohol.
  • Engaging in therapies such as CBT or DBT
  • Manage your stress where possible as this is a major trigger
  • Getting good sleep, exercise and eat healthily
  • Making use of your support network. This might consist of friends, professionals or a peer support.

Most people with bipolar disorder are put on some type of medication to alleviate their symptoms. I have listed some of these below.

  • Mood stabilisers. These are one of the main drugs given to people with bipolar disorder and they work by balancing a person’s mood so that it doesn’t swing too high or too low. These usually are also anti-epileptic medications such as Lamotrigine (Lamictal), Carbamazepine (Tegretol) and Sodium Valporate (Depakote). Another common drug used is Lithium, which is a kind of salt. Some mood stabilisers work more to prevent depressive episodes, like Lamotrigine and some, like Lithium are used more to control mania.
  • Antipsychotics. These include drugs like Olanzapine (Zyprexa), Aripiprazole (Abilify) and Quetiapine (Seroquel). Some people with Bipolar 1 find that these help keep psychotic symptoms away, however, as some antipsychotics are also licensed for use as mood stabilisers, people with both types of bipolar may be put on them.
  • Antidepressants. Theres include drugs such as Sertraline (Zoloft), Fluoxetine (Prozac) and Citalopram (Celexa). These are used to treat depressive episodes when mood stabilisers aren’t enough. However, these need to be used with extreme caution in those with BP as antidepressants can trigger a hypo/manic episode.

I hope that was helpful. If you have any more questions about bipolar disorder, let me know and I will try to answer them! Disclaimer: I am not a Dr! I would also be interested in hearing your own experiences with bipolar disorder in the comments.

What is Tardive Dyskinesia?

I thought I’d write about something that has been worrying me lately and might be informative for those of you on antipsychotic medications. I’ll first state that I don’t have TD – but I have noticed my thumbs involuntarily twitching recently, which has put me on edge. Why? Hopefully this post will explain.

What is Tardive Dyskinesia?
Tardive means ‘late coming’ and Dyskinesia refers to involuntary movements, which is a good summary of what TD is. It often appears after someone has been on antipsychotic medication for months or sometimes years. It causes non-repetitive movements such as:
o Sticking out your tongue or moving your jaw and lips
o Twisting or jerking movements of limbs
o Less jerky movements like wiggling or writhing
o Spasming of the muscles
o And more!

Okay so say these symptoms start occurring, why is that so scary? Because they can be permanent and can impact on your life. Some people feel very self conscious or embarrassed about TD and it may have continued even after they ceased taking medication.

Who gets it?
Tardive Dyskinesia affects those who take antipsychotic medications. It is more likely to occur in people taking “typical” antipsychotics, an older class of APs including Haloperidol (Haldol) and Flupentixol (Depixol), than in those taking “atypical” APs such as Aripiprazole (Abilify) and Quetiapine (Seroquel). The incidence of TD in those taking typical APs is estimated at around 30% (Pierre-Michel et al, 2002). However, there is still a risk with the latter medications. You may be more likely to develop TD if you are:
o On a high dose
o Have been on your medication for a long time
o Have your medication in the form of a depot injection (like me!)

What can be done about it?
Dealing with Tardive Dyskinesia seems to be tricky. It may stop upon withdrawal of the medication, withdrawal may actually worsen it or trigger it in the first place, or it may be permanent. Additional medications may help. Some studies suggest vitamin E is helpful and other people have noted Melatonin (often used for sleep) can be helpful. Switching your antipsychotic medication may also help or you may wish to withdraw from it completely. With the last option it is vital you do this under the careful supervision of a doctor as withdrawal may need to be done over a long time to avoid making TD worse.

So maybe I don’t need to worry about my twitching thumbs since upping my dose, but right now, I know I need to be on this dose to avoid becoming unwell. I’m willing to take the risk for now whilst keeping a careful eye out for further movements! Hope this was a helpful run down!

Llorca, Pierre-Michel; Chereau, Isabelle; Bayle, Frank-Jean; Lancon, Christophe (2002). “Tardive dyskinesias and antipsychotics: A review”. European Psychiatry17 (3): 129–38

What actually is Schizoaffective Disorder?

I don’t know about you, but when I was diagnosed, I was a little confused about what exactly Schizoaffective Disorder actually was. So I did three things: I asked four independent professionals, I asked other people with the diagnosis, and I did some online research of my own. What I got was…a whole load of conflicting answers, which was incredibly frustrating. After a while I was able to categorise these into three main schools of thought around SZA.

  1. Schizoaffective disorder is somewhere between Schizophrenia and Bipolar Disorder (or depression) on a linear continuum. It therefore encompasses some aspects of each but not necessarily all of them. People may also “lean” more to one end than the other. This was the first explanation I was given and seems to be favoured by professionals (in the UK anyway).
  2. Schizoaffective disorder is a duel diagnosis of Schizophrenia and a mood disorder (bipolar or depression). This was the favoured explanation by online communities with the disorder and is supported by the fact that if you took one element away, you would likely be diagnosed with the other one. For example, due to the perseverance and presentation of my psychosis, if I hadn’t had a mood element to my disorder, I would have been diagnosed with Schizophrenia and vice versa.
  3. From my online research I came across the third school of thought: that Schizoaffective is a disorder in it’s own right. This is supported by the fact that it has a general prognosis that is “better” than Schizophrenia and “worse” than Bipolar or depression (although this is very individual). It is posited as slightly more inclined towards Schizophrenia than mood disorders in that it is classed as a psychotic or schizophrenia spectrum disorder as opposed to a mood disorder.

What seems to be consistent across all explanations is that SZA has both elements of psychosis and of mood disturbances, hence the name. Schizo – referring to the psychotic element and Affective – referring to the mood element of the condition. There seems to be more than one type: Schizoaffective Bipolar type (or manic/mixed type) and Schizoaffective depressive type. What also seems to be persistent is the recommended treatment is an antipsychotic medication paired with either a mood stabiliser (for bipolar type) or an antidepressant (for depressive type). In addition, psychotic symptoms seems to echo mood disturbance. Manic people tend to have grandiose delusions and depressed people may have more persecutory delusions although this varies and I’ve certainly had both together at different times.

It’s a confusing diagnosis and one I’m getting used to still but I’m getting there. Despite the different opinions about what I actually have, it doesn’t change my own experiences or my treatment so really, it’s not of great importance.

I’d be interested to know which school of thought you subscribe to in the comments!