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{{Short description|
{{Infobox medical condition (new)
| name = Waxy flexibility
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}}'''Waxy flexibility''' is one of the twelve symptoms<ref name=":0">{{Cite journal |last1=Wilcox |first1=James Allen |last2=Reid Duffy |first2=Pam |date=2015-12-09 |title=The Syndrome of Catatonia |journal=Behavioral Sciences |volume=5 |issue=4 |pages=576–588 |doi=10.3390/bs5040576 |issn=2076-328X |pmc=4695780 |pmid=26690229 |doi-access=free }}</ref> that can lead to the diagnosis of [[catatonia]]. It is a psychomotor symptom<ref>{{Cite journal |last1=Ungvari |first1=Gabor S. |last2=Goggins |first2=William |last3=Leung |first3=Siu-Kau |last4=Lee |first4=Edwin |last5=Gerevich |first5=Jozsef |date=February 2009 |title=Schizophrenia with prominent catatonic features ('catatonic schizophrenia') |url=https://linkinghub.elsevier.com/retrieve/pii/S0278584608003163 |journal=Progress in Neuro-Psychopharmacology and Biological Psychiatry |language=en |volume=33 |issue=1 |pages=81–85 |doi=10.1016/j.pnpbp.2008.10.010|pmid=18992297 |s2cid=24678086 }}</ref> that results in a decreased response to stimuli and a tendency to remain in an immobile posture.<ref>[http://www.online-medical-dictionary.org/Waxy+Flexibility.asp?q=Waxy+Flexibility Definition – Online Medical Dictionary]</ref> If one were to move the arm of someone with waxy flexibility, the patient would keep that arm where it had been positioned until moved again as if positioning malleable wax. Attempts to reposition the patient are met by "slight, even resistance".<ref name="Barlow, D. H. 2015 p. 485">Barlow, D. H., & Durand, V. Mark. (2015). Abnormal Psychology: An Integrative Approach. Stamford, CT: Cengage Learning, p. 485</ref>
== Symptoms ==
Waxy flexibility is a specific symptom of catatonia. It refers to the patient's body showing resistance to being moved. Alteration of an individual's posture is similar to bending a warm candle.<ref>{{Cite book |last1=Caroff |first1=Stanley N. |url=https://books.google.com/books?id=4cPp3Uj_xlYC&dq=waxy+flexibility&pg=PA51 |title=Catatonia: From Psychopathology to Neurobiology |last2=Mann |first2=Stephan C. |publisher=American Psychiatric Pub |year=2007 |isbn=9781585627127 |pages=51}}</ref>
Waxy flexibility often develops with other symptoms of catatonia, including:
* Immobility: showing no signs of motion<ref name=":3">{{Cite web |title=APA Dictionary of Psychology |url=https://dictionary.apa.org/ |access-date=2023-03-26 |website=dictionary.apa.org |language=en}}</ref>
* Posturing: holding in an inappropriate body position for an extended period of time<ref name=":3" />
* [[Mutism]]: lack or absence of speaking<ref name=":3" />
* Ambitendency: a pattern of incomplete motor responses in anticipation of a voluntary action<ref name=":3" />
* Withdrawal and refusal to eat
* Staring or no focus in eyes
* [[Pessimism|Negativism]]: persistent resistance to the suggestions of others or actions contrary to expectations or commands<ref name=":3" />
* Automatic obedience: excessive, uncritical, or mechanical compliance with the requests, suggestions, or commands of others<ref name=":3" />
* [[Stereotypy]]: persistent repetition of the same words, movements, or other behavior<ref name=":3" />
==
The exact cause of waxy flexibility, and catatonia, is unclear, but there are some reasonable possibilities. They are mainly believed to occur as a result of other underlying diseases.
Historically, waxy flexibility, and catatonia, have been linked to [[schizophrenia]]. A prospective and retrospective study that followed the DSM-3 criteria found that there was a 24.4% rate of catatonia to occur in schizophrenia patients.<ref>{{Cite journal |last1=Denysenko |first1=Lex |last2=Sica |first2=Nicole |last3=Penders |first3=Thomas M. |last4=Philbrick |first4=Kemuel L. |last5=Walker |first5=Audrey |last6=Shaffer |first6=Scott |last7=Zimbrean |first7=Paula |last8=Freudenreich |first8=Oliver |last9=Rex |first9=Nicole |last10=Carroll |first10=Brendan T. |last11=Francis |first11=Andrew |date=May 2008 |title=Catatonia in the medically ill: Etiology, diagnosis, and treatment. The Academy of Consultation-Liaison Psychiatry Evidence-Based Medicine Subcommittee Monograph |url=https://pubmed.ncbi.nlm.nih.gov/29697715/ |journal=Annals of Clinical Psychiatry|volume=30 |issue=2 |pages=140–155 |issn=1547-3325 |pmid=29697715}}</ref> However, recent research showed that there is a significant decrease in diagnosed catatonic subtypes among schizophrenic disorders during the past decades. This is believed to be the result of sociocultural developments and the use of neuroleptics.<ref>{{Cite journal |last1=Stompe |first1=T. |last2=Ortwein-Swoboda |first2=G. |last3=Ritter |first3=K. |last4=Schanda |first4=H. |last5=Friedmann |first5=A. |date=2002-05-01 |title=Are we witnessing the disappearance of catatonic schizophrenia? |url=https://www.sciencedirect.com/science/article/pii/S0010440X0216980X |journal=Comprehensive Psychiatry |language=en |volume=43 |issue=3 |pages=167–174 |doi=10.1053/comp.2002.32352 |pmid=11994832 |issn=0010-440X}}</ref> In addition, the symptoms were better to fit outside of schizophrenia, which results in the possibility of a distinct clinical entity of catatonia or a variant of mood disorder.<ref>{{Cite journal |last1=Peralta |first1=V. |last2=Cuesta |first2=M. J. |last3=Serrano |first3=J. F. |last4=Mata |first4=I. |date=1997 |title=The Kahlbaum syndrome: a study of its clinical validity, nosological status, and relationship with schizophrenia and mood disorder |url=https://pubmed.ncbi.nlm.nih.gov/8980874/ |journal=Comprehensive Psychiatry |volume=38 |issue=1 |pages=61–67 |doi=10.1016/s0010-440x(97)90055-9 |issn=0010-440X |pmid=8980874}}</ref>
Mood disorders such as [[bipolar disorder]] and [[Depression (mood)|depression]] are typical conditions in which catatonia manifests.<ref>American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (DSM-IV TR) 4th edition. USA: American Psychiatric Association</ref> Neurological injuries such as seizures, neoplasms, and other diseases like Parkinson's can also result in catatonia. Catatonia can also occur as a result of autoimmune, paraneoplastic, infectious, metabolic, and specific drug exposures and poisoning.<ref>{{Citation |last1=Burrow |first1=Jeffrey P. |title=Catatonia |date=2023 |url=http://www.ncbi.nlm.nih.gov/books/NBK430842/ |work=StatPearls |access-date=2023-03-26 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28613592 |last2=Spurling |first2=Benjamin C. |last3=Marwaha |first3=Raman}}</ref> Research<ref>{{Cite journal |last1=Tariq |first1=Maryam |last2=Afridi |first2=Muhammad Iqbal |last3=Saleem |first3=Dua |last4=Pirzada |first4=Sarmad |title=Catatonic Schizophrenia: Cases with Possible Genetic Predisposition |journal=Cureus |year=2019 |volume=11 |issue=4 |pages=e4525 |doi=10.7759/cureus.4525 |doi-access=free |issn=2168-8184 |pmc=6592464 |pmid=31263634}}</ref> suggests that genes do play a role, as the probability would be higher if close relatives have had this symptom.
According to research, the underlying mechanisms are linked to abnormalities in certain neurotransmitters, especially GABAergic (gamma-aminobutyric acid) neurotransmitters. These are the neurotransmitters that govern both emotional and cognitive functioning. Catatonic symptoms are possible outcomes of a disruption in the GABAergic neurotransmitter system.<ref>{{Cite journal |last1=Ellul |first1=Pierre |last2=Choucha |first2=Walid |date=2015 |title=Neurobiological Approach of Catatonia and Treatment Perspectives |journal=Frontiers in Psychiatry |volume=6 |pages=182 |doi=10.3389/fpsyt.2015.00182 |issn=1664-0640 |pmc=4689858 |pmid=26733892 |doi-access=free }}</ref> It is theorized that catatonia patients' brains exhibit decreased GABA action.<ref name=":2">{{Cite journal |last1=Wijemanne |first1=Subhashie |last2=Jankovic |first2=Joseph |date=2015-08-01 |title=Movement disorders in catatonia |url=https://jnnp.bmj.com/content/86/8/825 |journal=Journal of Neurology, Neurosurgery & Psychiatry |language=en |volume=86 |issue=8 |pages=825–832 |doi=10.1136/jnnp-2014-309098 |issn=0022-3050 |pmid=25411548|s2cid=5925700 |doi-access=free }}</ref>
== Diagnosis ==
Waxy flexibility can be usually confirmed through observation. It generally does not require lab testing or imaging, but certain testing such as [[EEG]]s, [[MRI]]s, or [[CT scan|CT]]s can help to confirm the underlying cause.<ref>{{Cite journal |last1=Walther |first1=Sebastian |last2=Stegmayer |first2=Katharina |date=June 2018 |title=[Diagnosis and treatment of motor phenomena in schizophrenia spectrum disorders] |url=https://pubmed.ncbi.nlm.nih.gov/29909765/ |journal=Therapeutische Umschau. Revue Therapeutique |volume=75 |issue=1 |pages=31–36 |doi=10.1024/0040-5930/a000963 |issn=0040-5930 |pmid=29909765|s2cid=196503332 }}</ref> Waxy flexibility alongside two or more than two other symptoms such as stupor or negativism is enough to warrant a diagnosis of catatonia.<ref name=":0" /><ref name="Barlow, D. H. 2015 p. 485"/>
== Treatment ==
The treatment for waxy flexibility requires treating the underlying disease, catatonia.
The most common treatment for catatonia is [[benzodiazepine]]s. Benzodiazepines are drugs that act on the GABA receptors and are believed to be the most effective medication for treating catatonia.<ref name=":1">{{Cite journal |last1=Sienaert |first1=Pascal |last2=Dhossche |first2=Dirk M. |last3=Vancampfort |first3=Davy |last4=De Hert |first4=Marc |last5=Gazdag |first5=Gábor |date=2014-12-09 |title=A Clinical Review of the Treatment of Catatonia |journal=Frontiers in Psychiatry |volume=5 |pages=181 |doi=10.3389/fpsyt.2014.00181 |issn=1664-0640 |pmc=4260674 |pmid=25538636 |doi-access=free }}</ref> They have properties that result in the reduction of anxiety, are relaxant in muscles, reduce excitement, and sleep inducing.<ref name=":1" /> A frequently used benzodiazepine is [[lorazepam]]. A previous study<ref>{{Cite journal |last1=Narayanaswamy |first1=Janardhanan C. |last2=Tibrewal |first2=Prashant |last3=Zutshi |first3=Amit |last4=Srinivasaraju |first4=Ravindra |last5=Math |first5=Suresh Bada |date=2012-05-01 |title=Clinical predictors of response to treatment in catatonia |url=https://www.sciencedirect.com/science/article/pii/S0163834312000138 |journal=General Hospital Psychiatry |language=en |volume=34 |issue=3 |pages=312–316 |doi=10.1016/j.genhosppsych.2012.01.011 |pmid=22387048 |issn=0163-8343}}</ref> has shown that 2 in 3 of the participants in a 107 people sample responded sufficiently to lorazepam.
Another common treatment is [[electroconvulsive therapy]] (ECT).<ref>Raveendranathan, D., Narayanaswamy, J., & Reddi, S. (2012). Response rate of catatonia to electroconvulsive therapy and its clinical correlates. European Archives Of Psychiatry & Clinical Neuroscience, 262(5), 425.</ref> ECT is mainly used when the patient's symptoms fail to respond to benzodiazepines for a week, and the underlying cause of catatonia either is unable to be treated or does not improve the symptoms after treatment.<ref>{{Cite journal |last1=Bush |first1=G. |last2=Fink |first2=M. |last3=Petrides |first3=G. |last4=Dowling |first4=F. |last5=Francis |first5=A. |date=February 1996 |title=Catatonia. II. Treatment with lorazepam and electroconvulsive therapy |url=https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1996.tb09815.x |journal=Acta Psychiatrica Scandinavica |language=en |volume=93 |issue=2 |pages=137–143 |doi=10.1111/j.1600-0447.1996.tb09815.x |pmid=8686484 |s2cid=137734 |issn=0001-690X}}</ref> ECT is effective in the resolution of both primary and secondary signs of catatonia.<ref>{{Cite journal |last1=Rohland |first1=Barbara M. |last2=Carroll |first2=Brendan T. |last3=Jacoby |first3=Robert G. |date=1993-12-01 |title=ECT in the treatment of the catatonic syndrome |url=https://dx.doi.org/10.1016/0165-0327%2893%2990015-C |journal=Journal of Affective Disorders |language=en |volume=29 |issue=4 |pages=255–261 |doi=10.1016/0165-0327(93)90015-C |pmid=8126312 |issn=0165-0327}}</ref> It is also found that catatonic patients with waxy flexibility responded faster to ECT compared to patients with other symptoms of catatonia.<ref>Raveendranathan, D., Narayanaswamy, J., & Reddi, S. (2012). Response rate of catatonia to electroconvulsive therapy and its clinical correlates. European Archives Of Psychiatry & Clinical Neuroscience, 262(5), 429.</ref> Despite that ECT is proven safe and effective by well-established data, there is still a stigma associated with it. Legal restrictions for its use in catatonia are also critical obstacles.<ref>{{Cite journal |last1=Lloyd |first1=Jenifer R. |last2=Silverman |first2=Eric R. |last3=Kugler |first3=Joseph L. |last4=Cooper |first4=Joseph J. |date=2020 |title=Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives |journal=Neuropsychiatric Disease and Treatment |volume=16 |pages=2191–2208 |doi=10.2147/NDT.S231573 |issn=1176-6328 |pmc=7526008 |pmid=33061390 |doi-access=free }}</ref>
== Prevention ==
The majority of people who are diagnosed with catatonia go through some form of psychiatric crisis. Therefore, lowering one's stress levels should be the initial action in the process of preventing catatonia and waxy flexibility from occurring. Because waxy flexibility is a psychomotor symptom, attention should be spread across both the psycho and the motor aspects of the condition, rather than focusing more on one aspect while neglecting the other.<ref>{{Cite book |last1=Fink |first1=Max |url=https://www.cambridge.org/core/books/catatonia/69332FA8D1721CEEDEF9396BCC702E8A |title=Catatonia: A Clinician's Guide to Diagnosis and Treatment |last2=Taylor |first2=Michael Alan |date=2003 |publisher=Cambridge University Press |isbn=978-0-521-03236-0 |location=Cambridge}}</ref> It is advised to stay in a bright, clean environment while having access to mental support.
== Others ==
=== Waxy flexibility vs. catalepsy ===
Waxy flexibility and [[catalepsy]] are both posturing symptoms of catatonia. Both are symptoms describing the patient posturing in a stiff and rigid state. However, there are still some fundamental differences. On one hand, waxy flexibility refers to the state in which a patient's limbs and joints remain in a certain position, but it emphasizes the slow release of the stiffness as if their limbs are made of wax.<ref name=":2" /> On the other hand, catalepsy focuses on fixed postures for prolonged periods of time with minimal movement regardless of external stimuli. This means that even if a posture were uncomfortable, the patient would stay in that position, not moving even if they experienced external pain.<ref name=":2" />
==References==
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[[Category:Schizophrenia]]
[[Category:Symptoms and signs of mental disorders]]
[[Category:Bipolar disorder]]
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