Catatonic syndrome: From detection to therapy

Analysis of risk factors for pneumonia in patients with catatonia: a cross-sectional analysis

Objective

The clinical management of catatonia has always been a focus of psychiatric nursing. Unfortunately, there is still limited research on the risk factors and nursing methods for patients with catatonia and bacterial pneumonia. Few studies have identified and analyzed the clinical risk factors for catatonia patients with bacterial pneumonia. This study aims to explore the risk factors and preventive nursing measures for pneumonia in patients with catatonia.

Methods

A total of 88 patients with catatonia treated in the emergency department of a psychiatric hospital from January 2019 to October 2021 were selected. They were divided into bacterial pneumonia group (n=17) and non-pneumonia group (n=71) based on whether they had pneumonia. The demographic data and clinical characteristics of the two groups were compared. Logistic regression analysis and point-biserial correlation were used to analyze the risk factors for developing pneumonia in patients with catatonia.

Results

The incidence of pneumonia in patients with catatonia was 19.32%. Correlation analysis showed that age (r=0.216, p=0.043), The Activities of Daily Living Scale (ADL) score (r=0.265, p=0.013), cell count of white blood (r=0.591, p<0.001), neutrophil count (r=0.599, p<0.001), percentage of neutrophils (r=0.311, p=0.003), C-reactive protein (r=0.558, p<0.001), bedridden days (r=0.470, p<0.001), and albumin level (r=-0.288, p=0.007) were significantly associated with pneumonia. Multivariate logistic regression analysis showed that smoking, bedridden days, family support, and nutritional status were risk factors for pneumonia in patients with catatonia.

Conclusion

Reducing smoking and bedridden days, improving nutrition, and providing timely preventive nursing care by family members can reduce the occurrence of pneumonia in patients with catatonia.

The Effect of Electroconvulsive Therapy on Specific Catatonia Symptoms and Predictors of Late Response

INTRODUCTION

Electroconvulsive therapy (ECT) is known to be effective in the treatment of catatonia, reaching response rates of about 80 to 100%. It is indicated in cases of treatment resistance to benzodiazepines and in life-threatening conditions such as malignant catatonia. Beneficial effects on specific symptoms or predictors of response are less clear. The objective of this retrospective study is to examine the ECT effect on specific catatonia symptoms in the acute phase of the illness and to identify predictors of response.

METHODS

A retrospective study examined data from 20 patients with catatonia, 18 associated with schizophrenia and 2 with bipolar disorder, who underwent ECT from 2008 to 2021. Ten subjects had more than one ECT-series, resulting in a total of 31 ECT-series. Catatonia symptom severity was assessed with the Bush Francis Catatonia Rating Scale (BFCRS).

RESULTS

ECT yielded excellent response. Nineteen of 20 patients and 30 of 31 ECT-series achieved response. The mean number of ECT sessions to response was 4.2. Response to ECT was more pronounced for motor inhibition symptoms such as stupor and mutism, while echophenomena, dyskinesia, stereotypy and perseveration responded less well. A predictor of late response was the presence of grasp reflex.

DISCUSSION

The present study corroborates the high and rapid effectiveness of ECT in the treatment of catatonia. Focus on single catatonia signs may help to identify those who are most likely to achieve remission quickly, as well as those who might need longer ECT-series.

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.

High-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) in the First Episode of Catatonia: A Series of Four Cases

Four patients with benzodiazepine non-responsive catatonia were administered repetitive transcranial magnetic stimulation (rTMS) at the left dorsolateral prefrontal cortex at 120% of resting motor threshold, frequency of 10Hz, with a total of 3,000 pulses/session. Patients with mood disorders showed good responses. One patient with chronic resistant schizophrenia had worsening catatonic symptoms during rTMS that responded to electroconvulsive therapy. Maximum response was observed between sessions 8 and 12.

Molecular and cellular mechanisms leading to catatonia: an integrative approach from clinical and preclinical evidence

This review aims to describe the clinical spectrum of catatonia, in order to carefully assess the involvement of astrocytes, neurons, oligodendrocytes, and microglia, and articulate the available preclinical and clinical evidence to achieve a translational understanding of the cellular and molecular mechanisms behind this disorder. Catatonia is highly common in psychiatric and acutely ill patients, with prevalence ranging from 7.6% to 38%. It is usually present in different psychiatric conditions such as mood and psychotic disorders; it is also a consequence of folate deficiency, autoimmunity, paraneoplastic disorders, and even autistic spectrum disorders. Few therapeutic options are available due to its complexity and poorly understood physiopathology. We briefly revisit the traditional treatments used in catatonia, such as antipsychotics, electroconvulsive therapy, and benzodiazepines, before assessing novel therapeutics which aim to modulate molecular pathways through different mechanisms, including NMDA antagonism and its allosteric modulation, and anti-inflammatory drugs to modulate microglia reaction and mitigate oxidative stress, such as lithium, vitamin B12, and NMDAr positive allosteric modulators.

Paralyzed by Fear?-A Case Report in the Context of Narrative Review on Catatonia

In ICD-11, catatonia is a complex syndrome that includes psychomotor disorders (negativity, catalepsy, wax flexibility, mutism, automatism, mannerisms, or echolalia) and volitional processes affect modulation and action planning, which leads to hypofunctional, hyperfunctional, or parafunctional motor action. This is a very important clue that this state can be associated with both mental and somatic diseases. In order to create a narrative review, authors analyzed the diagnostic criteria of ICD-10 and ICD-11 and searched the PubMed medical base for articles on the diagnosis and different approaches to the treatment of catatonia. The treatment of catatonia is not standardized. It is based on the use of benzodiazepines, GABAa receptor antagonists, NMDA receptor antagonists, D2 receptor antagonist, and electroconvulsive therapy (ECT). The authors also would like to present the case of a patient in whom the diagnosis of catatonia was not so clear according to the diagnostic criteria, emphasizing the importance of the key diagnosis for the patient's recovery. The authors would also like to point out that the topic of catatonia should be of interest not only to psychiatrists, but also to doctors of other specialties, who may encounter cases of catatonia complicating somatic states in hospital wards.

rTMS and tDCS for the treatment of catatonia: A systematic review

BACKGROUND

Catatonia is a potentially life threatening syndrome in various psychiatric disorders. As first line treatment, benzodiazepines and electroconvulsive therapy (ECT) are recommended. In some cases, benzodiazepines are ineffective and ECT is not available or contraindicated. Therefore, the search for new and alternative treatment strategies is of great importance.

OBJECTIVE

To review the evidence for alternative neurostimulation treatment strategies (rTMS and tDCS) for catatonia according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

METHOD

We performed a systematic literature search in several electronic databases. We also searched the WHO International Clinical Trials Registry Platform (ICTRP) and the ClinicalTrials.gov database to detect registered studies.

RESULTS

We identified nine publications on rTMS treatment and four publications on tDCS in catatonia. Most of the publications reported clinically relevant improvement of catatonic symptoms. Only two publications reported insufficient improvement. The available Bush-Francis Catatonia Rating Scale scores showed statistical significant improvement following rTMS and tDCS. We could not identify any finished clinical studies or case series, dedicated to this topic. We also could not identify any publications that compared first line treatment options with rTMS or tDCS.

CONCLUSIONS

Based on the case report literature, rTMS and tDCS might be promising alternative treatment strategies for patients who do not respond to benzodiazepines or in case ECT is not available or contraindicated. There are even hints that rTMS or tDCS might be an option in patients who respond to ECT but need long-term treatment to control catatonic symptoms. Further clinical trials are needed to allow for an evidence-based evaluation of potential risks and benefits of rTMS and tDCS for catatonia.

The Presentation and Treatment Response of Catatonia in Patients Admitted to the Psychiatric Inpatient Unit at Jimma University Medical Center, Ethiopia

BACKGROUND

Catatonia is among the most mysterious and poorly understood neuropsychiatric syndrome. It is underresearched and virtually forgotten but still a frequent neuropsychiatric phenotype in both developed and low-income countries. Catatonia is associated with a number of medical complications like pulmonary embolism, dehydration, or pneumonia if it is not treated and managed adequately. In Ethiopia, however, almost no studies are available to describe the symptoms and the response to treatment in patients with catatonia. The aim of this retrospective study was therefore to describe the symptom profile of catatonia and to evaluate the treatment and outcome of catatonia in patients admitted to the psychiatric inpatient unit at Jimma University, Ethiopia.

METHOD

Detailed treatment records of all inpatients were reviewed for the period from May 2018 to April 2019. All patients with catatonia at the inpatient unit of Jimma University Medical Center were assessed with the Bush-Francis Catatonia Rating Scale (BFCRS), and all comorbid psychiatric diagnoses were made according to the criteria of the Diagnostic Statistical Manual V. The presence and severity of catatonia were assessed by using the BFCRS at baseline and at discharge from the hospital.

RESULT

In the course of one year, a total of 18 patients with the diagnosis of catatonia were admitted. The mean age of the participants was 22.8 years (SD 5.0; range: 15 to 34 years). The most common diagnosis associated with catatonia was schizophrenia (n = 12; 66.7%), followed by severe depressive disorders (n = 4; 22.2%). Mutism, posture, and withdrawal were registered in all patients (n = 18, 100%). All patients received an injection of diazepam and had improved at discharge.

CONCLUSION

Our study provides further evidence that catatonia is most commonly associated with schizophrenia, followed by major depressive disorder, and that mutism, posturing, and withdrawal are the most common signs and symptoms of catatonia.

[Catatonia in clinical reality: underdiagnosed and forgotten]

BACKGROUND

Catatonia is still a poorly understood, quite common, but often overlooked clinical picture. Consequences for patients are inadequate treatment, prolonged hospital stays and more serious complications.

METHOD

In this overview, the causes for an underdiagnosis are presented and measures for their prevention named, help for the differential diagnostic classification of catatonia is offered and the treatment is briefly explained.

RESULTS AND CONCLUSIONS

Catatonia is primarily associated with schizophrenia, but is also observed in other diseases such as neuroleptic malignant syndrome (MNS), in encephalitis and also in systemic diseases. Underdiagnosis can be avoided by simple measures such as a thorough physical examination, observance of verbal and non-verbal signs of catatonia, and psychiatric consultations in general hospitals. For the treatment of acute catatonia, the high-dose administration of benzodiazepines and electroconvulsive therapy are recommended.

Structure and neural mechanisms of catatonia

Catatonia is a psychomotor syndrome associated with several psychiatric and medical conditions. Psychomotor signs range from stupor to agitation, and include pathognomonic features such as verbigeration and waxy flexibility. Disturbances of volition led to the classification of catatonia as a subtype of schizophrenia, but changes in nosology now recognise the high prevalence in mood disorders, overlap with delirium, and comorbidity with medical conditions. Initial psychometric studies have revealed three behavioural factors, but the structure of catatonia is still unknown. Evidence from brain imaging studies of patients with psychotic disorders indicates increased neural activity in premotor areas in patients with hypokinetic catatonia. However, whether this localised hyperactivity is due to corticocortical inhibition or excess activity of inhibitory corticobasal ganglia loops is unclear. Current treatment of catatonia relies on benzodiazepines and electroconvulsive therapy-both effective, yet unspecific in their modes of action. Longitudinal research and treatment studies, with neuroimaging and brain stimulation techniques, are needed to advance our understanding of catatonia.

[Catatonia education in France: A cross-sectional study]

OBJECTIVES

Catatonia is a transnosographic syndrome described by K. Kahlbaum in 1874. Catatonia can be life-threatening due to its complications and in case of malignant catatonia. Safe and effective treatments have been identified (benzodiazepines and electro-convulsive-therapy). The prevalence of this syndrome is important and represents about 10% of inpatients in an acute psychiatric ward. However, this syndrome appears to remain under-diagnosed and poorly known. We were, therefore, interested in the current knowledge of French psychiatry residents and young psychiatrists as well as the education they had received about catatonia.

METHODS

A questionnaire was submitted to French psychiatry residents and young psychiatrists with fewer than 5 years of experience. It included questions about knowledge of the symptoms, complications, causes and treatments of catatonia. Participants were also asked about their confidence in the management of a patient with catatonia and about the number of catatonic patients they had already met. The type of lecture and teaching about catatonia was also assessed.

RESULTS

Among the 376 psychiatrists that completed the questionnaire, 37.5% never had received any specific teaching about catatonia. Concerning the 62.5% who benefited from a specific lecture, this was mainly delivered as part of psychiatry DES. Heterogeneity in the education delivery on the French territory had been highlighted. In addition, participants' knowledge of catatonic syndrome seems incomplete. However, knowledge of catatonic symptoms and first intention treatments was significantly better among respondents who were part of the "with education" group. The confidence in catatonia recognition and management, as well as the number of catatonic patients they met, are also significantly higher in the group "with education".

CONCLUSION

Specific education seems to improve the knowledge of young doctors and their ability to diagnose and treat catatonic patients. This education remains poorly provided and heterogeneous on the French territory. Catatonia deserves a place in the teaching program of the psychiatry DES, thus to become systematic.

[Catatonic melancoly and venous thromboembolism: A risky combination]

Catatonia is defined as a psychiatric syndrome. This syndrome is strongly associated with venous thromboembolism. As a difficult diagnosis in these patients, psychiatrists and vascular physicians should be aware of this association. We report here a clinical case of this association and discuss the diagnosis difficulties and therapeutics options.

Catatonia with schizophrenia: From ECT to rTMS

BACKGROUND

Electroconvulsive therapy is indicated in cases of catatonic schizophrenia following a failure of the challenge test with lorazepam or Zolpidem^®. Some patients need maintenance treatment with ECT. Repetitive Transcranial Magnetic Stimulation (rTMS) and anodal Transcranial direct-current stimulation (tDCS) might be effective against catatonia.

OBJECTIVE

Consider an alternative to ECT for a refractory patient.

REVIEW

Twenty-one articles were identified mainly based on case reports series were found using search on Medline, Google Scholar, PsychInfo, CAIRNS. Key words were:"catatonia", and "rTMS", and more generally with"ECT","tDCS","Zolpidem^®". At the end there were only six case reports with rTMS and three with tDCS. We discussed the alternative to ECT and follow up rTMS strategies illustrated by these case reports.

FINDINGS

Patients mean age was 35; numbers of previous ECT vary from zero to 556; the most common motor threshold (MT) is 80%, with two patients with 110%, the most common treatment placement is L DLPFC. In one of them, ECT was the only acute-state or maintenance treatment effective in this patient, who underwent 556 ECT sessions over 20 years. High-frequency rTMS was considered as a possible alternative, given the potential adverse effects of chronic maintenance ECT in a patient with comorbid epilepsy. rTMS treatment was 3-4×/week and over time extended to once every two weeks. A persistent objective improvement in catatonia was observed on the Bush-Francis Catatonia Rating Scale.

CONCLUSION

rTMS is helpful for acute and maintenance treatment for catatonic schizophrenia who both failed multiple pharmacologic interventions and had safety concerns with continuing maintenance ECT. Clinicians should consider rTMS as a potential treatment option for refractory catatonia.

Catatonia Secondary to Sudden Clozapine Withdrawal: A Case with Three Repeated Episodes and a Literature Review

A literature search identified 9 previously published cases that were considered as possible cases of catatonia secondary to sudden clozapine withdrawal. Two of these 9 cases did not provide enough information to make a diagnosis of catatonia according to the Diagnostic and Statistical Manual, 5th Edition (DSM-5). The Liverpool Adverse Drug Reaction (ADR) Causality Scale was modified to assess ADRs secondary to drug withdrawal. From the 7 published cases which met DSM-5 catatonia criteria, using the modified scale, we established that 3 were definitive and 4 were probable cases of catatonia secondary to clozapine withdrawal. A new definitive case is described with three catatonic episodes which (1) occurred after sudden discontinuation of clozapine in the context of decades of follow-up, (2) had ≥3 of 12 DSM-5 catatonic symptoms and serum creatinine kinase elevation, and (3) required medical hospitalization and intravenous fluids. Clozapine may be a gamma-aminobutyric acid (GABA) receptor agonist; sudden clozapine withdrawal may explain a sudden decrease in GABA activity that may contribute to the development of catatonic symptoms in vulnerable patients. Based on the limited information from these cases, the pharmacological treatment for catatonia secondary to sudden clozapine withdrawal can include benzodiazepines and/or restarting clozapine.

[Reversible catatonia after the abrupt discontinuation of clozapine: Case report]

In this paper, we report the case of a patient, aged 26, with schizophrenia who was admitted to psychiatric emergencies for catatonia, one week after abrupt discontinuation of clozapine. An improvement was seen after only two days of the reintroduction of clozapine alone. This catatonia is reversible and it responds magnificently to the reintroduction of clozapine. And we conclude that patients and their caregivers need to be educated about the effects of abrupt cessation of clozapine administration.