Catatonia as a feature of down syndrome: An under-recognised entity?

Catatonia in Preadolescent Children

OBJECTIVE

The aim of the study is to describe prepubescent catatonia in very young children, which is poorly documented in the current literature and, as a result, overlooked in medical settings.

METHODS

We examined a convenience sample of 10 patients at an academic center who were younger than 12 years and met criteria for catatonia. After institutional review board approval, we extracted from the electronic medical records demographic and diagnostic information, comorbidity, developmental history, and laboratory testing. Bush Francis Catatonia Rating Scales at initial presentation and other symptomatology were gathered in addition to treatment received. Fifty percent of patients in this group were seen and diagnosed with catatonia at their presentation in an outpatient clinic, whereas the remaining 50% were diagnosed upon hospitalization, by the psychiatry consultation liaison team.

RESULTS

All patients but one was diagnosed with a comorbid condition before the diagnosis of catatonia, including 70% with a previous diagnosis of autism spectrum disorder. Three patients had concurrent anti-N-methyl-D-aspartate receptor encephalitis, and one initially presented with seizures. All patients were treated for catatonia with lorazepam, and two patients additionally received electroconvulsive therapy. Regardless of the presence of early regression invariably associated with an autism spectrum diagnosis, secondary symptoms of regression were noted in each case at the time of diagnosing catatonia.

CONCLUSIONS

Similar to previous observations in adolescents, prepubescent catatonia seems strongly associated with neurodevelopmental disorders, secondary regression, variability in presentation, and comorbidity with other neurological conditions. Delayed recognition of catatonia can hinder rapid and effective treatment in young children.

Catatonia: A Narrative Review for Hospitalists

Background

Catatonia is a complex psychomotor syndrome commonly associated with psychiatric disorders. However, hospitalists encounter this condition on medical floors, where it is typically due to an underlying medical, especially neurological, etiology. Delays in the diagnosis of catatonia are common and lead to worsened outcomes for patients, including a multitude of medical complications, such as venous thromboembolism and stasis ulcers. Catatonia due to a medical condition is less likely to respond to benzodiazepine therapy; identification and treatment of the underlying cause is crucial.

Methods

This article provides a practical review of the catatonia literature, with a focus on diagnosis, workup, and management of catatonia for patients admitted to medical hospitals.

Conclusions

With greater knowledge about catatonia, internists are uniquely positioned to recognize and initiate treatment.

Genetic syndromes are prevalent in patients with comorbid neurodevelopmental disorders and catatonia

Catatonia occurs at high rates in idiopathic and syndromic neurodevelopmental disorders. At our institution's multidisciplinary catatonia clinic, clinical genetic testing (including microarray, fragile X PCR and methylation, autism/ID expanded panels, and exome sequencing) was commonly completed as part of clinical workup on patients with co-occurring neurodevelopmental disorders and catatonia (performed in 36/48 cases or 75%). This testing identified a pathogenic or likely pathogenic finding in 15/36 patients (42%). Testing identified a VUS (variant of uncertain significance) in 9/36 patients (25%). On review of the VUS findings, 4/9 were felt to be suspicious and potentially diagnostic. Testing was negative for 12/36 patients (33%). Many of the variants identified in this cohort were found in genes involved in gamma aminobutyric acid (GABA) and glutamatergic synaptic signaling; imbalances of these neurotransmitters are hypothesized to be drivers of catatonia. More work is needed to further characterize the molecular underpinnings of catatonia in the setting of neurodevelopmental disorders, including expanding genetic testing to larger cohorts in the future.

Diagnostic overshadowing clouding the efficient recognition of pediatric catatonia: a case series

Catatonia is a neuropsychiatric condition that causes disruption of movement, emotion, and behaviors. Children and adults with underlying psychiatric conditions are particularly susceptible to developing catatonia, which may result in medical and psychiatric complications. Although catatonia research has been growing at a rapid rate in the last 20 years, it continues to be met with inefficiencies in its diagnosis and incertitude in its treatment. In the pediatric population, catatonia is plagued by diagnostic overshadowing, where the catatonia is erroneously attributed to existing pathologies that lead to a prolonged disease state. This paper describes three pediatric patients with catatonia that fell victim to diagnostic overshadowing. More rigorous training and education are imperative to improve the efficient recognition and treatment of children with catatonia.

Down syndrome regression disorder: updates and therapeutic advances

PURPOSE OF REVIEW

Down syndrome regression disorder (DSRD) is a symptom cluster consisting of neuropsychiatric regression without cause. Although knowledge of this condition has accelerated over the last decade, prior studies have been limited by heterogenous nomenclature, diagnostic approaches and therapeutic interventions. This review highlights recent advances in the diagnosis and clinical approach to DSRD and reviews the most up-to-date literature on therapeutic interventions for this condition.

RECENT FINDINGS

Several multicentre studies have reported exciting findings on the presence of neurodiagnostic study abnormalities and responses to a variety of therapeutics, including psychotropics (including benzodiazepines), electroconvulsive therapy and immunotherapy. Differential response rates have been observed in the presence and absence of a variety of clinical and diagnostic factors.

SUMMARY

Individuals with DSRD are responsive to a variety of psychiatric pharmacotherapy and immunotherapy underscoring this phenotype may have multiple causes. Multidisciplinary care is helpful in the evaluation and management of individuals with this condition.

ECT Utilization in the Treatment of Catatonic Patients in the United States: A Nationwide In-Patient Sample Analysis

INTRODUCTION

Primary objective was to evaluate baseline characteristics for catatonic patients treated with and without electroconvulsive therapy (ECT). We also studied the trends of ECT utilization in catatonia patients.

METHODS

The Nationwide Inpatient Sample data were used to compare patients and hospital-level characteristics between catatonic patients treated with and without ECT in the United States. Multivariate and trend analysis were performed.

RESULTS

Electroconvulsive therapy was performed in 8.3% in patients with the diagnosis of catatonia (n = 24,311; mean age, 43.1; 38% White; 52.1% male). Racially, more patients in the ECT group were White (47% vs 38%) and had a comorbid diagnosis of major depressive disorder. In the multivariate analysis, the odds of receiving ECT was more with increase in age (P = 0.007). Urban area hospitals had 3 times higher odds of receiving ECT (P = 0.001) compared with rural hospitals. The odds of receiving ECT for catatonia were the highest for large bed hospitals compared with small/medium size (P < 0.001). In the trend analysis, catatonia patients undergoing ECT decreased initially from 7.0% in 2002 to 2005 to 5.2% in 2006 to 2009. After that, there was an upward trend with 10.6% patients undergoing ECT in the quarter 2014 to 2017. There was an upward trend in ECT utilization for catatonic patients with comorbid bipolar disorders and psychotic disorders.

CONCLUSIONS

Electroconvulsive therapy is underutilized for catatonia treatment in the United States. White catatonic patients are most likely to get ECT at an urban large bed hospital. In recent years, there is an upward trend in the use of ECT. Additional controlled clinical trials are warranted.

Case of paediatric catatonia precipitated by antipsychotic withdrawal in a child with autism spectrum disorder

A 13-year-old girl with moderate intellectual disability and autism spectrum disorder (ASD) was admitted to the paediatric high-dependency unit following an 8-week history of altered mental status and motor behaviour. Her symptoms emerged followed shortly after discontinuation of risperidone, an atypical antipsychotic previously commenced to manage disruptive behaviour associated with ASD. On physical examination, the patient presented with negativism, grimacing, automatic obedience, waxy flexibility and ambitendency. Blood tests, neuroimaging and lumbar puncture failed to reveal an acute infectious or neurological precipitant. She responded immediately to a trial of intramuscular lorazepam titrated to a total daily dose of 12 mg. This case presents challenges of accurately diagnosing and managing catatonic symptoms in adolescent patients with ASD. We also discuss the potential risk of precipitating catatonia following the discontinuation of antipsychotic treatment that has been prescribed for a prolonged duration.

Neurologic complications of Down syndrome: a systematic review

Down syndrome (DS) is one of the most well-recognized genetic disorders. Persons with DS are known to have a variety of co-morbid medical problems, affecting nearly all organ systems. Improved healthcare interventions and research have allowed for increased life span of persons with DS, although disorders of the neurologic system remain underexplored. The purpose of this systematic review is to provide clinically pertinent information on the neurological phenotypes of frequently occurring or clinically relevant conditions. A retrospective review of MEDLINE, Scopus, and Pubmed were used to identify sources among seventeen, clinically relevant, search categories. MeSH terms all contained the phrase "Down Syndrome" in conjunction with the topic of interest. 'Frequently-occurring' was defined as prevalent in more than 10% of persons with DS across their lifespan, whereas 'clinically-relevant' was defined as a disease condition where early diagnosis or intervention can augment the disease course. In total, 4896 sources were identified with 159 sources meeting criteria for inclusion. Seventeen clinical conditions were grouped under the following subjects: hypotonia, intellectual and learning disability, cervical instability, autism spectrum disorder, epilepsy, cerebrovascular disease, Alzheimer's disease and neuropsychiatric disease. The results of this review provide a blueprint for the clinical neurologist taking care of persons with DS across the age spectrum and indicate that there are many underrecognized and misdiagnosed co-occurring conditions in DS, highlighting the need for further research.