Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making

Variable presentation and outcomes of primary hyperparathyroidism in children and adolescents

OBJECTIVES

Primary hyperparathyroidism (PHPT) in paediatric and adolescent age group presents with some unique challenges for clinicians. While the disease in the adult counterparts presents with symptoms which are described quite extensively in literature, children/adolescents have manifestations which are quite different and severe compared to the former. The present case series aimed to highlight the peculiarities of presentation of PHPT in children and adolescents.

CASE PRESENTATION

In this case series, we present experience of 5 cases of PHPT in children and adolescents from our centre. We compared our data with the data already available in literature. We have also described salient presenting features of PHPT in individuals less than 19 years old previously reported in literature and pointed out the specificities of this disease at this age group.

CONCLUSIONS

PHPT in children and adolescents should be considered as a separate entity compared to that in adults, given its unique features, such as rachitic features, and severity of different presenting phenotypes. Persistence of rachitic features despite vitamin D correction, pancreatitis, bilateral nephrolithiasis and otherwise unexplained psychiatric abnormalities of insidious onset require greater clinical vigilance and serum/urine calcium testing to rule out this uncommon yet possible entity.

Psychiatric Manifestations in Children and Adolescents with Inherited Metabolic Diseases

Background: Inherited metabolic disorders (IEMs) can be represented in children and adolescents by psychiatric disorders. The early diagnosis of IEMs is crucial for clinical outcome and treatment. The aim of this review is to analyze the most recurrent and specific psychiatric features related to IEMs in pediatrics, based on the onset type and psychiatric phenotypes. Methods: Following the PRISMA Statement, a systematic literature review was performed using a predefined algorithm to find suitable publications in scientific databases of interest. After removing duplicates and screening titles and abstracts, suitable papers were analyzed and screened for inclusion and exclusion criteria. Finally, the data of interest were retrieved from the remaining articles. Results: The results of this study are reported by type of symptoms onset (acute and chronic) and by possible psychiatric features related to IEMs. Psychiatric phenomenology has been grouped into five main clinical manifestations: mood and anxiety disorders; schizophrenia-spectrum disorders; catatonia; eating disorders; and self-injurious behaviors. Conclusions: The inclusion of a variety of psychiatric manifestations in children and adolescents with different IEMs is a key strength of this study, which allowed us to explore the facets of seemingly different disorders in depth, avoiding possible misdiagnoses, with the related delay of early and appropriate treatments.

Electroconvulsive Treatment Utilization for Inpatient Management of Catatonia in Adolescents With Schizophrenia Spectrum Disorders

OBJECTIVE

The aim of this study was to determine rates of electroconvulsive therapy (ECT) use for catatonia in schizophrenia spectrum disorders, stratified by patient demographics and hospital characteristics, and its impact on inpatient length of stay and cost.

METHODS

We found 155 adolescents (aged 12-18 years) with principal discharge diagnosis of schizophrenia spectrum disorders with catatonia from the National Inpatient Sample. They were subgrouped into ECT (n = 20) and non-ECT (n = 135) groups. We used descriptive statistics to evaluate the utilization of ECT for catatonia and independent-sample t test for continuous variables with statistical significance at P ≤ 0.05.

RESULTS

The overall utilization rate of ECT in adolescents for catatonia was 12.9%. A high rate of ECT use was evident for Whites (30.8%) compared with the other race/ethnicities and also was seen in private health insurance beneficiaries (20%). The rate of ECT use varied by the region, with highest for the Northeast (20%), followed by the South (18.2%), and the West (14.3%). Adolescent inpatients with catatonia in public and teaching type, and large bed-size hospitals were more likely to receive ECT than their counterparts. The mean number of ECT sessions required during the inpatient stay was 5.2 (range, 1-15), and the mean number of days from admission to initial ECT was 2.5 (range, 0-6).

CONCLUSIONS

Electroconvulsive therapy is used for approximately only 13% of adolescents with catatonia when comorbid schizophrenia spectrum disorders are present, suggesting that many patients may not get evidence-based treatment. Future studies in this area are needed.

Case Report: Anti-NMDAR Encephalitis Presenting With Catatonic Symptoms in an Adolescent Female Patient With a History of Traumatic Exposure

INTRODUCTION

Catatonia is a severe syndrome associated with a high proportion of underlying organic conditions including autoimmune encephalitis. The link between catatonia and psychiatric conditions such as mood disorders and schizophrenia spectrum disorders is well established while the causative effect of Post-Traumatic Stress Disorders and stress related disorders remains speculative.

CASE REPORT

Here we describe the clinical case of a 14-year-old female patient presenting to the Emergency Department of a Pediatric University Hospital with acute changes in behavior five days after a sexual abuse. Acute stress reaction was suspected. Afterwards she developed catatonic symptoms alternating from stupor to excitement, resistant to the usual treatment with benzodiazepines. The first line examinations (PE, MRI, EEG) were inconclusive. The final diagnosis of anti-NMDARE was made 22 days after her admission in a University Department of Child and Adolescent Psychiatry. Her state improved after first- and second-line immunotherapy, with no signs of relapse at this day (8 months of clinical follow-up).

DISCUSSION

The diagnosis of anti-NMDARE is challenging, involving a multidisciplinary approach. The neuropsychiatric features are complex, with no specific psychiatric phenotype. Several hypotheses are discussed to determine the role of an acute environmental stressors in the emergence of such complex neuropsychiatric clinical presentation (i.e., shared vulnerability, precipitators, consequences of preexisting psychiatric symptoms).

CONCLUSION

Child and adolescent psychiatrists and pediatricians should be aware of the overlap between neurological and psychiatric features in the setting of anti-NMDARE. Catatonia should not be dismissed as a primary psychiatric disorder even in the context of recent traumatic exposure.

Autoantibody-associated psychiatric syndromes in children: link to adult psychiatry

Studies show that psychiatric symptoms in adults and children are sometimes associated with serum neural autoantibodies. The significance of serum neural autoantibodies associated with psychiatric symptoms in children remains often unclear, but might be relevant for the extent and occurrence of psychiatric disease manifestation in later life, as well as therapy and outcome. For this narrative review, we sought articles listed in PubMed and published between 1988 and 2020 addressing the maternal-fetal transfer of neural autoantibodies and psychiatric disorders associated with serum neural autoantibodies. We identified six major subgroups of psychiatric disorders in children that are associated with serum neural autoantibodies: patients with attentional deficit hyperactivity disorder, autism spectrum disorder, obsessive compulsive disorder, Gilles de la Tourette syndrome, psychosis and catatonia. Furthermore, we summarized study findings from maternal-fetal transfer of Contactin-associated protein-like 2, N-methyl-D-aspartate receptor and fetal brain autoantibodies associated with behavioral effects in animals and humans. We hypothesize that the maternal transfer of serum neuronal autoantibodies during or after birth could result (1) in the ignition of an autoimmune-mediated inflammation having neurodevelopmental consequences for their children (autoimmune-priming-attack hypothesis) and (2) has a potential impact on the later manifestation of psychiatric disorders. Through this narrative review, we propose a diagnostic pathway for the clinical diagnosis of a potentially autoimmune origin of psychiatric symptoms in children while considering recent guidelines.

Onset of psychiatric signs and impaired neurocognitive domains in inherited metabolic disorders: A case series

Inherited metabolic disorders (IMDs) can present with psychiatric signs that vary widely from one disease to another. This picture is further complicated by the fact that these features occur at very different illness time points, which may further delay appropriate diagnosis and treatment. In this case series of 62 children and adolescents suffering from IMDs, we clustered psychiatric signs (on the basis of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders classification) as well as impaired cognitive domains (on the basis of the Research Domain Criteriamatrix) according to their mean age of onset (5.7 ± 4 years). We observed consistent patterns of occurrence across disorders. Externalizing symptoms, sleep problems, and cross-domain self-regulation deficits were found to precede the IMD diagnosis. Repetitive thoughts and behaviors as well as emotional dysregulation were found to occur around the disease onset. Finally, late-onset features included dissociative or eating disorders, together with impaired emotion knowledge. Clinicians should specifically look for the co-occurrence of age-specific atypical signs, such as treatment resistance or worsening with psychotropic medication in the earliest stages and symptom fluctuation, confusion, catatonia, or isolated visual hallucinations. We believe that the combined characterizations of psychiatric signs and impaired neurocognitive domains may enable the earliest detection of IMDs and the appropriate care of these particular manifestations.

KEY POINTS

Psychiatric signs are common in inherited metabolic disorders (IMDs) and may occur in the same age-range as other clinical manifestations.Three clusters of psychiatric signs and two clusters of neurocognitive domains can be defined according to their mean age of onset.Warning signs to be used in liaison psychiatry should include age-specific cognitive impairments.

Psychiatric autoimmune conditions in children and adolescents: Is catatonia a severity marker?

OBJECTIVES

Patients with autoimmune encephalitis (AE) are likely to exhibit an acute onset of severe psychiatric features, including psychosis and/or catatonia. Based on the high prevalence of catatonia in AE and our clinical experience, we hypothesized that catatonia might be a marker of severity requiring more aggressive treatment approaches.

METHODS

To reach a sufficient number of cases with brain-autoimmune conditions, we pooled two samples (N = 58): the first from the French National Network of Rare Psychiatric diseases and the second from the largest Italian neuro-pediatrics center for encephalopathies. Autoimmune conditions were diagnosed using a multidisciplinary approach and numerous paraclinical investigations. We retrospectively compared patients with and without catatonia for psychiatric and non-psychiatric clinical features, biological and imaging assessments, type of immunotherapy used and outcomes.

RESULTS

The sample included 25 patients (43%) with catatonia and 33 (57%) without catatonia. Forty-two patients (72.4%) had a definite AE (including 27 anti-NMDA receptor encephalitis) and 16 (27.6%) suspected autoimmune encephalitis. Patients with catatonia showed significantly more psychotic features [18 (72%) vs 9 (27.3%), p < 0.001)] and more movement disorders [25 (100%) vs 20 (60.6%), p < 0.001] than patients without catatonia. First line (corticoids, immunoglobulin and plasma exchanges) and second line (e.g., rituximab) therapies were more effective in patients with catatonia, with 24 (96%) vs 22 (66.7%) (p = 0.006) and 17 (68%) vs 9 (27.3%) (p = 0.002), respectively. However, those with catatonia received more combinations of first and second line treatments and had more relapses during outcomes.

CONCLUSION

Despite its exploratory design, the study supports the idea that autoimmune catatonia may be a marker of severity and morbidity in terms of initial presentation and relapses, requiring the need for early and aggressive treatment.

Case Report: A Case of Pediatric Catatonia: Role of the Lorazepam Challenge Test

A case of a 12-year-old boy who developed catatonia is presented. He had no previous psychiatric history but has a family history of affective disorder. An extensive medical workup was negative. Despite a negative lorazepam challenge test, lorazepam was titrated up to 24 mg/day, with resolution of most catatonic symptoms. The case highlights an important point in the management of catatonia that may be a source of confusion, i.e., a positive lorazepam challenge test corroborates the diagnosis of catatonia; however, a negative lorazepam challenge test does not negate the diagnosis of catatonia, and subsequent focused benzodiazepine treatment may still be effective.

Catatonia secondary to anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis: a review

Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.

Treatment Withdrawal Following Remission in Juvenile Idiopathic Arthritis: A Systematic Review of the Literature

BACKGROUND

Early diagnosis and treatment of juvenile idiopathic arthritis (JIA) with conventional and biologic disease-modifying anti-rheumatic drugs have vastly improved outcomes for children with these diseases. Currently, a large proportion of children with JIA are able to achieve clinical inactive disease and remission. With this success, important questions have arisen about when medications can be stopped and how to balance the risks and benefits of continuing medications versus the potential for flare after stopping.

AIM

The aim was to conduct a systematic review of the available literature to summarize current evidence about medication withdrawal for JIA in remission.

METHODS

We conducted a systematic literature search in PubMed and Embase from 1990 to 2019. References were first screened by title and then independently screened by title and abstract by two authors. A total of 77 original papers were selected for full-text review. Data were extracted from 30 papers on JIA and JIA-associated uveitis, and the quality of the evidence was evaluated using National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) tools. Studies on biochemical and radiologic biomarkers were also reviewed and summarized.

RESULTS

Most studies investigating treatment withdrawal in JIA have been observational and of poor or fair quality; interpretations of these studies have been limited by differences in study populations, disease and remission durations, the medications withdrawn, approaches to withdrawal, and definitions of disease outcomes. Overall the data suggest that flares are common after stopping JIA medications, particularly biologic medications. Clinical characteristics associated with increased risks of flare have not been consistently identified. Biochemical biomarkers and ultrasound findings have been shown to predict outcomes after stopping medications, but to date, no such predictor has been consistently validated across JIA populations. Studies have also not identified optimal strategies for withdrawing medication for well-controlled JIA. Promising withdrawal strategies include discontinuing methotrexate before biologic medications in children receiving combination therapy, dose reduction for children on biologics, and treat-to-target approaches to withdrawal. These and other strategies require further investigation in larger, high-quality studies.

CONCLUSIONS

The published literature on treatment withdrawal in JIA has varied in design and quality, yielding little conclusive evidence thus far on the management of JIA in remission. Given the importance of this question, international collaborative efforts are underway to study clinical and biologic predictors of successful medication withdrawal in JIA. These efforts may ultimately support the development of personalized approaches to withdrawing medication in children with JIA in remission.

Catatonia in Down syndrome: systematic approach to diagnosis, treatment and outcome assessment based on a case series of seven patients

OBJECTIVE

The goal is to expand our knowledge of catatonia occurring in adolescents and young adults with Down syndrome (DS) by describing the first prospective, consecutive, well-characterized cohort of seven young people with DS diagnosed with catatonia and treated between 2013 and 2018, and to assess each patient's treatment responses. Longitudinal assessment of each patient's response to treatment is intended to provide clinicians and psychiatrists a firm foundation from which assess treatment efficacy.

STUDY DESIGN

Young adults with Down syndrome were consecutively enrolled in the study as they were diagnosed with catatonia. A comprehensive data set included medical, laboratory, developmental, demographic, family, social and genetic data, including query into disorders for which individuals with DS are at risk. Catatonia was diagnosed based on an unequivocal history of regression, positive Bush-Francis Catatonia Rating Scale and positive response to intravenous lorazepam. Patients' longitudinal progress was monitored using the Catatonia Impact Scale (CIS) developed for this purpose.

RESULTS

Seven consecutive DS patients, who presented with unequivocal regression were diagnosed with catatonia and treated for 2.7-6 years using standard-of-care therapies; primarily GABA agonist, lorazepam, electroconvulsive therapy (ECT) and glutamate antagonists (dextromethorphan/quinidine, memantine, minocycline). Responses to each treatment modality were assessed at clinic visits and through weekly electronic CIS reports.

CONCLUSION

Seven young adults with DS were diagnosed with catatonia; all responded to Lorazepam and/or ECT therapy with good to very good results. Though ECT most dramatically returned patients to baseline, symptoms often returned requiring additional ECT. Dextromethorphan/quinidine, not used until mid-2017, appeared to reduce the reoccurrence of symptoms following ECT. Though all seven patients improved significantly, each continues to require some form of treatment to maintain a good level of functioning. Findings of a significant number of autoimmune disorders and laboratory markers of immune activation in this population may guide new diagnostic and treatment opportunities.

A causality algorithm to guide diagnosis and treatment of catatonia due to autoimmune conditions in children and adolescents

OBJECTIVES

Pediatric catatonia is a rare and life-threatening syndrome. Around 20% of juvenile catatonia is associated with organic condition (Consoli et al., 2012). Autoimmune conditions represent a diagnostic and therapeutic challenge since specific antibodies can be missed. To facilitate decision making, we recently formulated a causality assessment score (CAUS) using a stepwise approach and an immunosuppressive therapeutic challenge (Ferrafiat et al., 2016). Our objectives were to validate retrospectively CAUS and to define its threshold for an accurate distinction between organic catatonia and non-organic catatonia, and specifically between autoimmune catatonia and non-organic catatonia.

METHOD

To obtain a sufficient number of cases with organic catatonia, we pooled two samples (N=104) - one from a child psychiatry center, the other from neuro-pediatrics center - expert in catatonia and autoimmune conditions. Organic conditions were diagnosed using a multidisciplinary approach and numerous paraclinical investigations. Given the binary classification needs, we used receiver operating characteristic (ROC) analysis (Peacock and Peacock, 2010) to calculate the best classification threshold.

RESULTS

The cohort included 67 cases of non-organic catatonia and 37 cases of organic catatonia. ROC analysis showed that the CAUS performance in discriminating both organic catatonia vs. non-organic catatonia, and autoimmune catatonia vs. non-organic catatonia was excellent (Area Under the Curve=0.99). In both analyses, for a CAUS threshold≥5, accuracy equaled to 0.96.

CONCLUSION

Regarding juvenile catatonia, the use of the CAUS score algorithm combining a therapeutic challenge and a threshold≥5 may help to diagnose and treat autoimmune conditions even without formal identification of auto-antibodies.

Catatonia in children and adolescents: New perspectives

INTRODUCTION

Catatonia is a rare and severe psychomotor condition in children and adolescents. In the current report, we aimed to review the recent literature.

METHOD

Using a PRISMA approach, we searched MEDLINE between 1982 and 2017 using the keywords 'CATATONIA' and 'CHILD' or 'ADOLESCENT'. In total, we reviewed 130 reports (controlled study, N=4; clinical chart, N=23; case report, N=54; and editorial/review, N=42).

RESULTS

Several aspects seem to be age specific: (1) although the clinical presentation resembles that in adults, some symptoms are important in children and adolescents (e.g., psychomotor regression). (2) Associated disorders are similar to that found in adults; however, schizophrenia is more frequently observed than mood disorder. Additionally, a history of neurodevelopmental disorders maybe encountered. (3) Morbidity and mortality are among the worst in child psychiatry. (4) Underlying organic conditions are highly prevalent (>20% of the cases), and their search is warranted because some diagnoses may result in specific treatments (e.g., immune-suppressor therapy for autoimmune conditions). (5) Symptomatic approaches - high dose of benzodiazepines and electroconvulsive therapy (ECT) - are as efficient in children or adolescents as they are in adults, but this finding needs to be acknowledged because a resistance against the use of ECT or high-dose medication exists among child psychiatrists.

DISCUSSION

Recent advances in child and adolescent catatonia research have offered major improvements in understanding catatonia and in new therapeutic opportunities. The syndrome is rare, but these advances need to be acknowledged in order to direct patients to centers that have developed a specific expertise.

The Probability That Catatonia in the Hospital has a Medical Cause and the Relative Proportions of Its Causes: A Systematic Review

OBJECTIVE

The objective of this review is to determine the probability that catatonia in the hospital has a secondary cause ("medical catatonia") and to calculate the relative proportions of these causes stratified by hospital setting.

METHODS

PRISMA systematic review of PubMed.

RESULTS

Eleven studies were included. Hospital-wide, 20% of catatonia was medical. In acute medical and surgical settings, medical catatonia comprised more than half of cases. At least 80% of older adults seen by consult psychiatry and critically ill patients had a medical cause. Two thirds of medical catatonia involved CNS-specific disease including encephalitis, neural injury, developmental disorders, structural brain pathology, or seizures.

CONCLUSIONS

Patients in acute medical and surgical settings with catatonia deserve a medical workup that prioritizes CNS etiologies.

The Differential Diagnosis and Treatment of Catatonia in Children and Adolescents

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations.

METHODS

Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar.

RESULTS

Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized.

CONCLUSION

Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.

[Organic troubles with psychiatric symptoms: What is the appropriate childhood and adolescence psychiatric care? Reflections on disimmune encephalitis cases]

Organic mental disorders are different and further revealed by increasingly advanced research. They are nevertheless misunderstood, without consensus, and raise clinical, diagnostic, and therapeutic questions. These disorders require effective collaboration between practitioners such as pediatricians and child psychiatrists. The subject should not disappear behind the complexity related to the clinical expression of these symptoms. Based on three cases of autoimmune encephalitis, we offer a reflection on the management and assessment of these diseases by a multidisciplinary team with the intention of providing optimal management. The aim of this paper is to override an initial divide posed by a particular clinical presentation. We would like to shed light on the place and legitimacy of child psychiatrists and their clinical expertise. This does not exclude the need for care of the symptoms, considering each subject and her experience. Follow-up is necessary because of the possible, often traumatic, functional and psychological consequences. Finally, the presence of each professional should be specified when the psychiatric symptoms appear to be the result of an organic disease in order to better support the subject in his suffering body.

Catatonia and Autoimmune Conditions in Children and Adolescents: Should We Consider a Therapeutic Challenge?

OBJECTIVE

Catatonia as a result of autoimmune conditions offers new therapeutic opportunities for patients that child and adolescent psychiatrists should consider. However, the diagnosis is sometimes challenging when an autoimmune signature is not identified.

METHODS

In this study, we aim to summarize seven cases from a 20-year series of 84 youths with catatonia, including three cases that represented a diagnostic challenge because of the absence of positive autoimmune testing.

RESULTS

Immunosuppressive/modulatory treatment improved catatonic and psychotic features in all cases.

CONCLUSION

To facilitate treatment decision-making, we propose a causality assessment score and a treatment algorithm, which may help clinicians consider whether an autoimmune condition is associated with catatonia.

Validation of the Pediatric Catatonia Rating Scale (PCRS)

INTRODUCTION

Despite the increased recognition of catatonia in children and adolescents, no specific assessment instrument has been validated in this population.

METHOD

Within the context of a prospective study on catatonia, we developed the Pediatric Catatonia Rating Scale (PCRS, maximum score=60), adapted from the Bush and Francis Catatonia Rating Scale for its use in child and adolescent inpatients. We assessed the psychometric properties of the PCRS by measuring its internal consistency, construct validity, and factor structure. Bivariate analyses were performed to compare the different diagnostic patient groups across the extracted factors.

RESULTS

Internal consistency was moderate (Cronbach's α for total score=0.67) suggesting multidimensionality. Multiple factors underlie the PCRS items, as revealed by factor analysis. Four distinct dimensions of catatonic symptoms were identified and accounted for 44% of total variance: a "negative withdrawal" factor (with mutism, negativism, and social withdrawal), a "catalepsy" factor (with posturing and waxy flexibility), an "abnormal movements" factor (with mannerisms and stereotypes) and an "echo phenomenon" factor (with echolalia and echopraxia). Receiver operating characteristic (ROC) analysis showed that the PCRS performance in discriminating individuals with catatonia vs. those without catatonia was excellent for a threshold≥9 (Area Under the Curve=0.983) in this sample.

DISCUSSION

These results support the validity of the PCRS among children and adolescent inpatients. With regard to such analyses, the internal structure of catatonic syndrome in children and adolescents is roughly comparable with the adult form, except the lack of a "hyperactive/excitement" dimension.

Attempted infanticide and suicide inaugurating catatonia associated with Hashimoto's encephalopathy: a case report

BACKGROUND

Catatonia is a neuropsychiatric syndrome with motor and behavioural symptoms. Though usually occurring in patients with schizophrenia and mood disorders, this syndrome may also be associated with neurological diseases or general medical conditions. Few cases of catatonia associated with autoimmune disorders have been described.

CASE PRESENTATION

Here, we report the case of a 27-year-old woman diagnosed with Hashimoto's encephalitis (HE) who attempted suicide and infanticide by defenestration. As she presented risk factors for postpartum psychosis, she was treated principally with antipsychotics. Despite adequate treatment for psychosis, symptoms worsened and she developed catatonia. Complementary investigations showed elevated titres of anti-thyroglobulin and anti-thyroperoxidase antibodies (200 and 10 times, respectively, as compared to normal levels) and electroencephalography were suggestive of encephalopathy. In the presence of an otherwise unexplained neuropsychiatric condition, HE was suspected and oral prednisolone was introduced. Psychiatric symptoms improved dramatically within 72 h and the patient was still free of any symptom 3 years later.

CONCLUSION

Catatonia of organic aetiology should always be considered before a psychiatric aetiology especially in case of clinical worsening in spite of adequate psychotropic treatment. To our knowledge, this is the first description of catatonia associated with HE.

Catatonia vis-à-vis delirium: the significance of recognizing catatonia in altered mental status

BACKGROUND

Catatonia is seldom considered in evaluation of altered mental status (AMS) in medical settings. Furthermore, catatonia often meets delirium criteria due to incoherence, altered awareness and behavioral change. Catatonia may co-occur with or be preferentially diagnosed as delirium.

METHODS

We conducted a systematic literature review of MEDLINE, EMBASE and PsycINFO on the relationship between catatonia and delirium. We also juxtapose clinical features of these syndromes and outline a structured approach to catatonia evaluation and management in acute medical settings.

RESULTS

These syndromes share tremendous overlap: the historical catatonia-related terms "delirious mania" and "delirious depression" bespeak of literal confusion differentiating them. Only recently has evidence on their relationship progressed beyond case series and reports. Neurological conditions account for the majority of medical catatonia cases.

CONCLUSIONS

New-onset catatonia warrants a medical workup, and catatonic features in AMS may guide clinicians to a neurological condition (e.g., encephalitis, seizures or structural central nervous system disease). Lorazepam or electroconvulsive therapy (ECT) should be considered even in medical catatonia, and neuroleptics should be used with caution. Moreover, ECT may prove lifesaving in malignant catatonia. Further studies on the relationship between delirium and catatonia are warranted.

Catatonia in Children Following Systemic Illness

BACKGROUND

The term catatonia was first introduced in 1874 and several etiologies, both organic and psychiatric have been attributed to the clinical phenotype of catatonia. The interesting feature is their response to lorazepam irrespective of their etiology.

PATIENTS AND METHODS

Four patients admitted with verbal and motor unresponsiveness following febrile illness were evaluated for infective and metabolic causes. Those who qualified for catatonia as per Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria and Bush-Francis Catatonia Screening Instrument screening tool and rating scale were evaluated in detail and reported.

OBSERVATIONS

Catatonia occurs in clusters, females are more affected than males. Electroencephalogram can be abnormal based on the precipitating symptom. Minor changes in serum total iron and transferrin saturation and nonspecific elevation of viral antibody titers are seen in some patients. Lorazepam challenge always gives the diagnosis.

RESULT

All patients where females and had preceeding systemic or CNS infection. Three out of the Four patients where independent at the end of one month.

CONCLUSION

Catatonia should be considered as a differential diagnosis in all children with verbal and motor unresponsiveness, which have no other explanation. Early initiation of treatment is very rewarding at least during short term follow-up.

Treatment use in a prospective naturalistic cohort of children and adolescents with catatonia

We aimed to (1) describe the treatment used in a large sample of young inpatients with catatonia, (2) determine which factors were associated with improvement and (3) benzodiazepine (BZD) efficacy. From 1993 to 2011, 66 patients between the ages of 9 and 19 years were consecutively hospitalized for a catatonic syndrome. We prospectively collected sociodemographic, clinical and treatment data. In total, 51 (77%) patients underwent a BZD trial. BZDs were effective in 33 (65%) patients, who were associated with significantly fewer severe adverse events (p = 0.013) and resulted in fewer referrals for electroconvulsive therapy (ECT) (p = 0.037). Other treatments included ECT (N = 12, 18%); antipsychotic medications, mostly in combination; and treatment of an underlying medical condition, when possible. For 10 patients, four different trials were needed to achieve clinical improvement. When all treatments were combined, there was a better clinical response in acute-onset catatonia (p = 0.032). In contrast, the response was lower in boys (p = 0.044) and when posturing (p = 0.04) and mannerisms (p = 0.008) were present as catatonic symptoms. The treatment response was independent of the underlying psychiatric or systemic medical condition. As in adults, BZDs should be the first-line symptomatic treatment for catatonia in young patients, and ECT should be a second option. Additionally, the absence of an association between the response to treatment and the underlying psychiatric condition suggests that catatonia should be considered as a syndrome.

Acute behavioral crises in psychiatric inpatients with autism spectrum disorder (ASD): recognition of concomitant medical or non-ASD psychiatric conditions predicts enhanced improvement

During adolescence, some individuals with autism spectrum disorder (ASD) engage in severe challenging behaviors, such as aggression, self-injury, disruption, agitation and tantrums. We aimed to assess risk factors associated with very acute behavioral crises in adolescents with ASD admitted to a dedicated neurobehavioral unit. We included retrospectively in 2008 and 2009 29 adolescents and young adults with ASD hospitalized for severe challenging behaviors and proposed a guideline (Perisse et al., 2010) that we applied prospectively for 29 patients recruited for the same indications between 2010 and 2012. In total, 58 patients were admitted (n=70 hospitalizations, mean age=15.66 (±4.07) years, 76% male). We systematically collected data describing socio-demographic characteristics, clinical variables (severity, presence of language, cognitive level), comorbid organic conditions, etiologic diagnosis of the episode, and treatments. We explored predictors of Global Assessment Functioning Scale (GAFS) score and duration of hospitalization at discharge. All but 2 patients exhibited severe autistic symptoms and intellectual disability (ID), and two-thirds had no functional verbal language. During the inpatient stay (mean=84.3 (±94.9) days), patients doubled on average their GAFS scores (mean=17.66 (±9.05) at admission vs. mean=31.4 (±9.48) at discharge). Most common etiologies for acute behavioral crises were organic causes [n=20 (28%), including epilepsy: n=10 (14%) and painful medical conditions: n=10 (14%)], environmental causes [n=17 (25%) including lack of treatment: n=11 (16%) and adjustment disorder: n=6 (9%)], and non-ASD psychiatric condition [n=33 (48%) including catatonia: n=5 (7%), major depressive episode: n=6 (9%), bipolar disorder: n=4 (6%), schizophrenia: n=6 (9%), other/unknown diagnosis: n=12 (17%)]. We found no influence of age, gender, socio-economic status, migration, level of ID, or history of seizure on improvement of GAFS score at discharge. Severity of autism at admission was the only negative predictor (p<.001). Painful medical conditions (p=.04), non-ASD psychiatric diagnoses (p=.001), prior usage of specialized ASD care programs (p=.004), functional language (p=.007), as well as a higher number of challenging behaviors upon admission (p=.001) were associated with higher GAFS scores at discharge. Clinical severity at admission, based on the number of challenging behaviors (r=.35, p=.003) and GAFS score (r=-.32, p=.008) was correlated with a longer inpatient stay. Longer hospitalization was however correlated (r=.27, p=.03) with higher GAFS score at discharge even after adjustment for confounding factors. Challenging behaviors among adolescents with ASD may stem from diverse risk factors, including environmental problems, comorbid acute psychiatric conditions, or somatic illness such as epilepsy or acute pain. The management of these behavioral challenges requires a unified, multidisciplinary approach.

Psychiatric manifestations in cerebrotendinous xanthomatosis

Cerebrotendinous xanthomatosis (CTX) is a rare and severe, but treatable, inborn disorder of bile acid biosynthesis and sterol storage with autosomal recessive inheritance and variable clinical presentation. CTX treatment consists of chenodeoxycholic acid and must be started as early as possible to prevent permanent disability. Psychiatric manifestations are rare and non-specific, and often lead to significant diagnostic and treatment delay. Therefore, better recognition of the gamut of psychiatric manifestations in CTX can diminish the risk of misdiagnosis and irreversible neurological deterioration. We hereby describe the psychiatric features in CTX. A complete review of all published cases of CTX in the medical literature was undertaken and the case reports with psychiatric presentation were collected and analyzed. We also describe the psychiatric features in relation to the neurological semeiology in six patients with CTX diagnosed at the La Salpêtrière Hospital. We conclude that psychiatric manifestations in CTX follow a bimodal/bitemporal pattern, appearing early in the disease course in the form of a behavioral/personality disorder associated with learning difficulties or mental retardation, or manifesting in advanced disease in the setting of dementia as rich neuropsychiatric syndromes, such as frontal, orbitofrontal or frontotemporal syndromes of cortico-subcortical dementia encompassing behavioral/personality disturbance, affective/mood disorders or psychotic disorders. Behavioral/personality disturbance in childhood or adolescence, especially when accompanied by learning difficulties, should therefore lead to further investigation to exclude CTX, as early diagnosis and treatment is critical for prognosis.

Medical and developmental risk factors of catatonia in children and adolescents: a prospective case-control study

CONTEXT

Rare diseases have been associated with more and more genetic and non genetic causes and risk factors. But this has not been systematically assessed in catatonia, one of the psychiatric syndromes, that is most frequently associated with medical condition.

OBJECTIVE

We sought to assess the medical and developmental risk factors of catatonia in children and adolescents.

METHODS

From 1993 to 2009, 58 youths aged 10 to 18 years were prospectively admitted for catatonia and were followed up after discharge. A multidisciplinary approach assessed patients' medical condition and developmental history. A causality assessment scored medical risk (maximum score=10; κ=0.91). We compared the prevalence of catatonia in these patients to that of 80 inpatients with bipolar I disorder admitted from 1993 to 2003 who were also followed up.

RESULTS

We found that 13 (22.4%) patients had medical conditions and 18 (31%) had a history of developmental disorder in the catatonia group, whereas 1 (1.3%) and 17 (22.6%) patients had the same conditions in the bipolar group (p<0.001; p=0.17, respectively). Medical conditions associated with catatonia included auto-immune encephalitis (systemic lupus erythematosus [N=3] and anti-NMDA-receptor encephalitis [N=1]), seizures (N=1), ciclosporin encephalitis (N=1), post hypoglycaemic coma encephalitis (N=1), and genetic or metabolic conditions (chorea [N=2], 5HT cerebrospinal fluid deficit [N=1], storage disease [N=1], fatal familial insomnia [FFI; N=1], and PRODH mutations [N=1]). Six patients responded to a specific treatment approach related to their medical condition (e.g., plasma exchange in the case of auto-immune encephalitis).

CONCLUSION

Catatonia in children and adolescents is associated with a high prevalence of medical conditions. This needs to be acknowledged as it may greatly delay the treatment of catatonia and the diagnosis of medically related catatonia. Tragically, this may deny patients treatment opportunities.

Malignant catatonia due to anti-NMDA-receptor encephalitis in a 17-year-old girl: case report

Anti-NMDA-Receptor encephalitis is a severe form of encephalitis that was recently identified in the context of acute neuropsychiatric presentation. Here, we describe the case of a 17-year-old girl referred for an acute mania with psychotic features and a clinical picture deteriorated to a catatonic state. Positive diagnosis of anti-NMDA-receptor encephalitis suggested specific treatment. She improved after plasma exchange and immunosuppressive therapy. Post-cognitive sequelae (memory impairment) disappeared within 2-year follow-up and intensive cognitive rehabilitation.

Catatonia is hidden in plain sight among different pediatric disorders: a review article

Over the past two decades, catatonia has been better demarcated in adult psychiatry as a unique syndrome that consists of specific motor signs with a characteristic response to benzodiazepines and electroconvulsive therapy. Pediatric catatonia is considered rare, but may be underdiagnosed, and hence undertreated. Discussed here are the current diagnostic criteria of catatonia in individual cases of children and adolescents diagnosed with childhood disintegrative disorder, Kleine-Levin syndrome, Prader-Willi syndrome, tic disorder, and autoimmune encephalitis, and the effects of benzodiazepines and electroconvulsive therapy. In these cases, catatonia resolved safely once it was recognized and treated properly. Children and adolescents presenting with these disorders should be systematically assessed for catatonia; when the presence of catatonia is confirmed, the use of benzodiazepines and electroconvulsive therapy should be considered. The occurrence of catatonia in such a wide range of child and adolescent disorders supports the view that pediatric catatonia is not so rare, that there are shared elements in the etiology, psychopathology, and pathophysiology of these disorders, and that catatonia is best classified as a unique neurobiologic syndrome.

Electroconvulsive therapy for catatonia in a boy with hydrocephalus and an arachnoid cyst

We report on the successful use of electroconvulsive therapy in a 13-year-old boy with congenital hydrocephalus, a history of multiple shunt revisions, and a stable prepontine arachnoid cyst, who experienced profound catatonic deterioration. After initial shunt placement at age 20 months, the patient had followed normal motor, cognitive, and social developmental trajectories. Two uncomplicated shunt revisions were performed at ages 10 and 13 years. Three months after the last revision, the patient demonstrated multiple psychomotor signs, culminating in hospital admission for rigidity, posturing, waxy flexibility, stupor, mutism, and cessation of all oral intake. An extensive neurologic workup related to his preexisting conditions produced negative results, and a course of electroconvulsive therapy for acute catatonia was pursued, with outstanding improvement.

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

Association of adolescent catatonia with increased mortality and morbidity: evidence from a prospective follow-up study

This paper examined outcomes among youth with catatonic syndrome and determined whether the characteristics suggesting the relevance of chronic catatonic schizophrenia (CCS) at index episode remained stable at follow-up. From 1993 to 2004, 35 individuals aged 12 to 18 years were prospectively admitted for management of catatonic syndrome and followed up after discharge. Mean duration from discharge to follow-up was 3.9 years (range 1-10). Four patients were lost to follow-up. Among the remaining 31 subjects (mean age=19.5 years, range 15-26), life-time diagnosis using the Diagnostic Interview for Genetic Studies was unchanged in 28 patients, and included schizophrenia (all subtypes; N=20), major depressive episode (N=5), bipolar disorder type I (N=4) and brief psychotic episode (N=2). Mortality (all-cause Standardized Mortality Ratio=6266; 95% CI=1181-18,547) and morbidity were severe, with 3 deaths (including 2 suicides), 6 patients presenting with a causal organic condition and 14 subjects needing continuous psychiatric care. All males in the study (N=8) who had chronic catatonic schizophrenia at the index episode still had chronic catatonic signs at follow-up. Catatonia is one of the most severe psychiatric syndromes in adolescents. It is associated with a 60-fold increased risk of premature death, including suicide, when compared to the general population of same sex and age. This increased risk of premature death remains higher than the one measured in former adolescent psychiatric patients (all-cause SMR=221; 95% CI=156-303; Engqvist and Rydelius, 2006), or in schizophrenia irrespective to age and subtype (all-cause SMR=157; 95% CI=153-160; Harris and Barraclough, 1998).

The successful use of right unilateral ultra-brief pulse electroconvulsive therapy in an adolescent with catatonia

Right unilateral ultra-brief electroconvulsive therapy (RUL UB ECT) has been shown to be efficacious with minimal cognitive adverse effects in adult patients with major depression. We present the case of a 14-year-old girl with major depressive disorder with catatonic and psychotic features whose symptoms remitted after 12 treatments of RUL UB ECT.

[Catatonia in a 14 year-old girl: treatment with clorazepam and carbamazepine, a 10-year follow-up]

INTRODUCTION

Child and adolescent catatonia has been poorly investigated. Moreover, diagnosis criteria only exist for adult psychiatry, and there are no therapeutic guidelines. The aim of this paper is to describe the case of a 14-year-old girl presenting an overlap between psychogenic and neuroleptic induced catatonia, acute treatment and ten year's follow-up.

CASE REPORT

A 14-year-old Caucasian French girl, Elsa, was admitted in February 1998 to a University adolescent mental health center with an acute psychotic disorder. She showed agitation, impulsivity (sudden engagement in inappropriate behaviour), paranoid delusions, visual and auditory hallucinations, diurnal and nocturnal urinary incontinence, lack of self-care, inadequate food intake because of fear of poisoning, and vomiting after meals leading to rapid weight loss of 5 kg. Clinical examination, laboratory tests, EEG and RMI were normal. Toxicological tests were negative. Her IQ, assessed six months before admission, was in the dull average range (70-75). Elsa was treated with loxapine 150 mg per day for one week without improvement and this was then replaced by haloperidol 30 mg per day. One week after the start of haloperidol her agitation, impulsivity, and hallucinatory symptoms decreased. Twenty four days after loxapine introduction and 17 days after the haloperidol, her condition deteriorated rapidly over less than 48 hours. She exhibited immobility, minimal response to stimuli, staring and catalepsy with waxy flexibility. The diagnosis of catatonia was established. Examination revealed tremulous extremities, tachychardia (110 pm) and apyrexia. Creatine phosphokinase levels were 106 UI/l (normal range 0-250). Human immunodeficiency virus, hepatitis, listeria and Lyme serology were negative. Cerebrospinal fluid analysis was normal. Haloperidol was stopped and intravenous clonazepam 5mg/kg was begun. It was not possible to obtain signed consent from the two parents for Electroconvulsive therapy. The patient was transferred to a pediatric intensive care unit. The treatment was standard parenteral nutrition, nursing, intravenous clonazepam 0.05 mg/kg, with regular attendance by a child psychiatrist. Elsa stayed three weeks in this condition. She then began to notice the child psychiatrist, and a few days later she was able to carry out simple requests. Elsa was transferred to an adolescent psychiatric unit. As soon as she could eat by herself again, carbamazepine 400mg per day was begun. Her agitation reduced at a carbamazepine level of 7 mg/l. One month later her condition was stable. However, language difficulties persisted for a further six months. One year after the episode she scored 66 on a repeat IQ test and her RMI was normal. She exhibited no significant residual symptoms except some cognitive impairment. She integrated into a special education facility. These attempts to stop the carbamazepine were followed by depressed mood, aggressiveness and impulsivity; carbamazepine was finally stopped successfully after seven years. Ten years later, Elsa is the mother of two young children and is able to take care of them. She has never had a relapse of her psychotic disorder or catatonic state.

DISCUSSION

The etiopathogenic diagnosis is problematic. Some indices in the familial history may suggest a traumatic event. But one to the total residual amnesia it was never confirmed, and traumatic catatonia are extremely rare. Normal CPK levels, with autonomic disturbance limited to tachycardia and the lack of resolution after discontinuance of medication, argues against a diagnosis of neuroleptic malignant syndrome (NMS). But CPK levels are non specific, and NMS without pyrexia has been described. The occurrence of the catatonic syndrome 21 days after the first dose of a neuroleptic could be diagnostic. This case involved a non organic catatonic psychosis followed by neuroleptic induced catatonia. Catatonia is described as a risk factor for the development of NMS and some consider NMS to be a variant of malignant catatonia. The interest of this report is (1) it reinforces the need to be cautious before prescribing neuroleptics in adolescents presenting with symptoms of catatonia; (2) the complete recovery from catatonia after treatment with intensive care and more than three weeks of intravenous clonazepam without the use of ECT and (3) the effectiveness of carbamazepine over a long period of follow-up. Although trials on carbamazepine in catatonia are published, there are no data available for the control of residual symptoms or the long term prognosis, especially in child and adolescent psychiatry.