Negative symptoms and neuroleptics in catatonic schizophrenia

Treatment of schizophrenia with catatonic symptoms: A narrative review

Catatonia is a neuropsychiatric syndrome consisting of psychomotor abnormalities caused by a broad range of disorders affecting brain function. While the nosological status of catatonia is no longer restricted to a subtype of schizophrenia in standardized diagnostic systems, the character, course, and clinical significance of catatonia in people with schizophrenia remain unclear. Evidence suggests that catatonia could be a nonspecific state-related phenomenon, a fundamental core symptom dimension of schizophrenia, or a subcortical variant of schizophrenia. Either way, the validity of catatonia in schizophrenia is clinically significant only insofar as it predicts prognosis and response to treatment. Most contemporary clinical trials of antipsychotics have targeted schizophrenia as an overly broad unitary psychosis neglecting any differential response defined by phenomenology or course. However, early naturalistic studies showed that catatonia predicted poor response to first-generation antipsychotics in chronic schizophrenia and case reports cautioned against the risk of triggering neuroleptic malignant syndrome. More recent studies suggest that second-generation antipsychotics, particularly clozapine, may be effective in schizophrenia with catatonic symptoms, while small randomized controlled trials have found that the short-term response to ECT may be faster and more significant. Based on available data, conclusions are limited as to whether antipsychotics are as effective and safe in acute and chronic schizophrenia with catatonic symptoms compared to other treatments and compared to schizophrenia without catatonia. Further studies of the pathophysiology, phenomenology, course and predictive value of catatonia in schizophrenia are worthwhile.

Subtyping chronic catatonia: Clinical and neuropsychological characteristics of progressive periodic catatonia and chronic system catatonias vs. non-catatonic schizophrenia

Catatonia has been defined by ICD-11 as a nosologically unspecific syndrome. Previous neuropsychiatric conceptions of catatonia such as Wernicke-Kleist-Leonhard's (WKL) one, have isolated chronic catatonic entities, such as progressive periodic catatonia (PPC) and chronic system catatonias (CSC). This study aimed at comparing the clinical and neuropsychological features of PPC, CSC and non-catatonic patients, all diagnosed with a schizophrenia spectrum disorder (SSD). The clinical and cognitive measures were compared among 53 SSD patients, first by separating catatonic (C-SSD, n = 27) and non-catatonic patients (NC-SSD, n = 26), and second, by separating PPC (n = 20), CSC (n = 6) and NC-SSD patients. Bayes factors were used to compare the model with 1 or 2 catatonic groups. We found that PPC had a more frequent schizo-affective presentation, higher levels of depression and less positive psychotic symptoms than both CSC and NC-SSD. CSC patients had an earlier illness onset, a poorer cognitive functioning, and higher antipsychotics doses than both PPC and NC-SSD. Most differences between C- and NC-SSD were accounted by characteristics of either PPC or CSC. The model with 2 catatonic groups clearly outperformed that with 1 catatonic group. Our results point to a substantial clinical heterogeneity of 'catatonia' within the SSD population and suggest that distinguishing (at least) 2 chronic catatonic phenotypes (PPC and CSC) may represent a relevant step to apprehend this heterogeneity. It is also a more parsimonious attempt than considering the around 32.000 distinct catatonic presentations resulting from the combinations of 3 out of 15 polythetic criteria for ICD-11 catatonia.

Clozapine responsive catatonia: A series of five cases

The main objective of presenting the case series is that despite dramatic symptomatic response by intra venous lorazepam or electro convulsive therapy irrespective of primary diagnosis in catatonia cases some cases remain difficult to treat by conventional treatment. Here, we present five catatonia cases who did not respond to conventional treatment even when treated for primary psychiatric diagnosis along with treatment for catatonia. They ultimately responded partially or completely to clozapine only, which explains the multi-factorial causation of catatonia syndrome as postulated by different scientific research.

DSM-IV catatonia signs and criteria in first-episode, drug-naive, psychotic patients: psychometric validity and response to antipsychotic medication

OBJECTIVE

To examine the prevalence, psychometric validity and response to antipsychotic drugs of DSM-IV catatonia signs and criteria in patients with a first-episode psychotic disorder.

METHODS

Two-hundred antipsychotic-naive patients with a DSM-IV nonaffective psychosis were assessed for catatonia signs and criteria using the Modified Rogers Scale, and the psychometric validity of the 12 DSM-IV catatonia signs and diagnostic criteria was examined. Treatment response of catatonia was assessed in 173 patients who completed one-month trial with haloperidol (n=23), risperidone (n=93) or olanzapine (n=57).

RESULTS

Sixty-two patients (31%) endorsed at least one catatonia sign and 24 (12%) met DSM-IV criteria for catatonia. DSM-IV catatonia signs showed an excellent convergent validity (r>0.8) with other rating scales, and DSM-IV criteria showed moderate to fair concordance with other criteria (kappa from 0.57 to 0.77). The total number of signs reflected catatonia severity and demonstrated excellent diagnostic performance against alternative diagnostic criteria. The presence of at least any three signs accurately identified patients with catatonia. Three catatonia domains were identified (hyperkinesia, volitional and hypokinesia), which showed a different association pattern with external variables. Overall, catatonia ratings were particularly related to both dyskinesia and disorganization symptoms and lacked diagnostic specificity for schizophrenia. Patients with catatonia responded well to antipsychotic medication irrespective of the type of antipsychotic drug used, although treatment response was dependent upon the remission of psychotic symptoms.

CONCLUSIONS

These results may inform the DSM-V development on diagnosis and classification of catatonia, and indicate that catatonia signs and syndromes are highly responsive to antipsychotic drugs.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia') III. Latent class analysis of the catatonic syndrome

No reports have yet been published on catatonia using latent class analysis (LCA). This study applied LCA to a large, diagnostically homogenous sample of patients with chronic schizophrenia who also presented with catatonic symptoms. A random sample of 225 Chinese inpatients with DSM-IV schizophrenia was selected from the long-stay wards of a psychiatric hospital. Their psychopathology, extrapyramidal motor status and level of functioning were evaluated with standardized rating scales. Catatonia was rated using a modified version of the Bush-Francis Catatonia Rating Scale. LCA was then applied to the 178 patients who presented with at least one catatonic sign. In LCA a four-class solution was found to fit best the statistical model. Classes 1, 2, 3 and 4 constituted 18%, 39.4%, 20.1% and 22.5% of the whole catatonic sample, respectively. Class 1 included patients with symptoms of 'automatic' phenomena (automatic obedience, Mitgehen, waxy flexibility). Class 2 comprised patients with 'repetitive/echo' phenomena (perseveration, stereotypy, verbigeration, mannerisms and grimacing). Class 3 contained patients with symptoms of 'withdrawal' (immobility, mutism, posturing, staring and withdrawal). Class 4 consisted of 'agitated/resistive' patients, who displayed symptoms of excitement, impulsivity, negativism and combativeness. The symptom composition of these 4 classes was nearly identical with that of the four factors identified by factor analysis in the same cohort of subjects in an earlier study. In multivariate regression analysis, the 'withdrawn' class was associated with higher scores on the Scale of Assessment of Negative Symptoms and lower and higher scores for negative and positive items respectively on the Nurses' Observation Scale for Inpatient Evaluation's (NOSIE). The 'automatic' class was associated with lower values on the Simpson-Angus Extrapyramidal Side Effects Scale, and the 'repetitive/echo' class with higher scores on the NOSIE positive items. These results provide preliminary support for the notion that chronic schizophrenia patients with catatonic features can be classified into 4 distinct syndromal groups on the basis of their motor symptoms. Identifying distinct catatonic syndromes would help to find their biological substrates and to develop specific therapeutic measures.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'). II. Factor analysis of the catatonic syndrome

Previous factor analyses of catatonia have yielded conflicting results for several reasons including small and/or diagnostically heterogeneous samples and incomparability or lack of standardized assessment. This study examined the factor structure of catatonia in a large, diagnostically homogenous sample of patients with chronic schizophrenia using standardized rating instruments. A random sample of 225 Chinese inpatients diagnosed with schizophrenia according to DSM-IV criteria were selected from the long-stay wards of a psychiatric hospital. They were assessed with a battery of rating scales measuring psychopathology, extrapyramidal motor status, and level of functioning. Catatonia was rated using the Bush-Francis Catatonia Rating Scale. Factor analysis using principal component analysis and Varimax rotation with Kaiser normalization was performed. Four factors were identified with Eigenvalues of 3.27, 2.58, 2.28 and 1.88. The percentage of variance explained by each of the four factors was 15.9%, 12.0%, 11.8% and 10.2% respectively, and together they explained 49.9% of the total variance. Factor 1 loaded on "negative/withdrawn" phenomena, Factor 2 on "automatic" phenomena, Factor 3 on "repetitive/echo" phenomena and Factor 4 on "agitated/resistive" phenomena. In multivariate linear regression analysis negative symptoms and akinesia were associated with 'negative' catatonic symptoms, antipsychotic doses and atypical antipsychotics with 'automatic' symptoms, length of current admission, severity of psychopathology and younger age at onset with 'repetitive' symptoms and age, poor functioning and severity of psychopathology with 'agitated' catatonic symptom scores. The results support recent findings that four main factors underlie catatonic signs/symptoms in chronic schizophrenia.

Discontinuation of citalopram medication and striatal dopamine activity

A 35-year-old caucasian woman who suffered from major depression with marked psychomotor symptoms was treated with a selective serotonin re-uptake inhibitor (SSRI), citalopram. After 16 months successful treatment, the medication was gradually discontinued. One week after stopping citalopram, she experienced lowered mood and unnatural slowness in her movements. These symptoms were associated with low striatal dopamine (DA) activity as measured with baseline and follow-up [(18)F]DOPA PET scans. We suggest that stimulation of serotonergic system in the brain increases dopaminergic activity in the striatum. After cessation of this stimulation, striatal dopaminergic activity may decrease considerably in vulnerable patients and cause transient emotional and psychomotor discontinuation symptoms that disappear spontaneously in a few weeks.

Schizophrenia with prominent catatonic features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase

This study set out to determine the frequency of catatonic syndrome in chronic schizophrenia and its association with sociodemographic, clinical, and treatment variables. A cross-sectional assessment of a randomly selected cohort of patients (n=225; mean age=42+/-7 years; mean length of illness=20.4+/-7.5 years) with DSM-IV schizophrenia was employed using standard rating instruments for catatonia, drug-induced extrapyramidal symptoms (EPS), and psychotic, depressive, and obsessive-compulsive symptoms. Using a rather narrow definition of catatonia [the presence of four or more signs/symptoms with at least one having a score '2' or above on the Bush-Francis Catatonia Rating Scale (BFCRS)], 72 subjects (32%) met the criteria for the catatonia group (mean number of catatonic signs/symptoms=5.9+/-2.0; mean sum score of 8.7+/-3.4 on the BFCRS). The frequency distribution of catatonic signs/symptoms in the catatonic group and in the whole sample was very similar, with mannerisms, grimacing, stereotypes, posturing, and mutism being the most frequent. In the logistic regression analysis, catatonic subjects had a significantly earlier age of onset, more negative symptoms, and were more likely to receive benzodiazepines than their noncatatonic counterparts. In multiple regression analysis, the severity of catatonia as indicated by the sum score of BFCRS was predicted only by earlier age of onset and negative symptoms. Using relatively narrow criteria, this study confirmed that, if methodically assessed, catatonic signs and symptoms are prevalent in patients with chronic schizophrenia. Catatonia can be differentiated from EPS. Catatonic features indicate a generally poor prognosis in the chronic phase of schizophrenia.

Catatonia: disappeared or under-diagnosed?

BACKGROUND

Over the last century, especially during the latter half, the prevalence of the diagnosis of catatonic schizophrenia decreased considerably. Several explanations for this phenomenon have been put forward.

SAMPLING AND METHODS

The present study investigated the frequency of the diagnosis of catatonic schizophrenia in a large sample of admitted psychiatric patients (n = 19,309). In addition, the presence of catatonic symptoms was studied in a sample of patients with schizophrenia (n = 701) and in a group of consecutively admitted psychotic patients (n = 139). In these two groups the effect of the diagnostic procedures on the recognition of catatonia was examined.

RESULTS

The diagnosis of catatonic schizophrenia dropped from 7.8% in 1980-1989 to 1.3% in 1990-2001 (p < 0.001). In addition, a possible under-diagnosis of catatonic schizophrenia was found in an independent sample of patients with schizophrenia. Application of a systematic catatonia rating scale in patients admitted with acute psychosis identified a bimodally distributed catatonic dimension. At least 18% of these patients fulfilled the criteria for catatonia. Interestingly, the catatonic subgroup used atypical antipsychotic compounds more frequently (p < 0.05).

CONCLUSIONS

The results suggest that changes in diagnostic criteria and the diagnostic procedure itself are responsible for the under-recognition of catatonia.