Catatonic schizophrenia: a cohort prospective study

Catatonia is associated with higher rates of negative affect amongst patients with schizophrenia and schizoaffective disorder

Catatonia is a complex syndrome encompassing motor, behavioral, and affective symptoms seen in a significant proportion of patients with schizophrenia. There is growing evidence to suggest affective dysregulation is a salient feature of both catatonia and schizophrenia. To test the hypothesis of a linkage between affective dysregulation and catatonia in schizophrenia, we searched electronic medical records from 36,839 patients with schizophrenia, using anxiety and depression diagnoses as proxies for affective dysregulation. Catatonia was found in 4.7 % of the cohort. Analyses indicated that catatonia was significantly associated with both anxiety and depression co-morbidities: schizophrenia patients with catatonia were 1.71 times more likely to have anxiety and 1.80 times more likely to have depression than those without catatonia. Benzodiazepine usage was also 7.73 times more common in schizophrenia patients with a catatonia diagnosis than without that diagnosis. Taken together, the findings could be related to GABAergic dysfunction underlying schizophrenia, catatonia, and affective dysregulation.

Exploring genetic risk for catatonia in a genome wide association study and polygenic risk score analysis

BACKGROUND

Catatonia is an under-recognized disorder characterized by psychomotor (increased, decreased, or abnormal) changes, affective symptoms, and disturbance of volition, which may arise in the setting of decompensated psychiatric or non-psychiatric medical disorders. Genetic studies of catatonia are limited, and to the best of our knowledge no prior genome wide association studies of catatonia have been performed to date.

METHODS

First we performed a genome wide association study of catatonia regardless of etiology (psychiatric or non-psychiatric). Secondarily we evaluated whether there was an elevated genetic risk profile for predisposing psychiatric disorders (schizophrenia spectrum disorder, bipolar affective disorder, etc.) in patients with catatonia. We used a matched case control design and applied polygenic risk scores to evaluate for a shared polygenetic contribution to catatonia from common psychiatric phenotypes that show a high prevalence of catatonia in their decompensated states.

RESULTS

Anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorder polygenic risk scores were significantly associated with catatonia case status in both unadjusted and adjusted logistic regression models for the European Ancestry set even after correcting for multiple comparisons. Depression, Alzheimer's, Autism Spectrum Disorder and Obsessive Disorder polygenic risk scores were not significantly associated with catatonia status in participants of European Ancestry. In the African Ancestry set, no psychiatric polygenic risk scores were significantly associated with catatonia status in either the unadjusted or adjusted regression models.

CONCLUSIONS

Even after controlling for relevant covariates, anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorders were significantly associated with catatonia status suggesting that there might be a shared genetic risk for those disorders amongst patients with catatonia.

The validity of atypical psychosis diagnostic criteria to detect anti-NMDA receptor encephalitis with psychiatric symptoms

Anti-NMDAR encephalitis has a psychotic presentation that is difficult to distinguish from primary psychosis. An atypical psychosis that is similar to schizophrenia, mood disorder, and epilepsy is unique, and the original diagnostic criteria exist only in Japan. The clinical symptoms and courses of anti-NMDAR encephalitis and atypical psychosis are very similar. We investigated whether the diagnostic criteria of atypical psychosis are useful to increase the detection rate of anti-NMDAR encephalitis with psychiatric symptoms. The presence of anti-NR1/NR2B IgG antibodies in the cerebrospinal fluid of 218 newly admitted inpatients initially diagnosed with schizophrenia (n = 151), mood disorder (n = 47), or epilepsy with psychiatric symptoms (n = 20) was assessed by cell-based assay. Of 218 patients, 123 (36.3 years ± SD 17.2, 69.9 % females) fulfilled the diagnostic criteria of category B for atypical psychosis. All 12 patients (9.8 %, 12/123) with anti-NR1/NR2B IgG antibodies fulfilled category B of atypical psychosis statistically better than the patients without anti-NR1/NR2B IgG antibodies (P = 0.0009). Of the 12 patients with anti-NMDAR antibodies, two did not fulfill either criteria of catatonia (DSM-5) or Graus' diagnostic criteria of anti-NMDAR encephalitis during the time course, and 11 patients showed good prognosis with early immunotherapies. In ROC analysis, abnormal electroencephalogram findings showed the highest sensitivity (0.833) for detection of anti-NR1/NR2B IgG antibodies, and 31.3 % of patients with category B atypical psychosis and abnormal electroencephalogram findings had anti-NMDAR antibodies. Lumbar puncture and detection of anti-NMDAR antibodies should be considered for patients who fulfill atypical psychosis diagnosis criteria with an abnormal electroencephalogram.

Effect of advanced parental age on pregnancy outcome and offspring health

PURPOSE

Fertility at advanced age has become increasingly common, but the aging of parents may adversely affect the maturation of gametes and the development of embryos, and therefore the effects of aging are likely to be transmitted to the next generation. This article reviewed the studies in this field in recent years.

METHODS

We searched the relevant literature in recent years with the keywords of "advanced maternal/paternal age" combined with "adverse pregnancy outcome" or "birth defect" in the PubMed database and classified the effects of parental advanced age on pregnancy outcomes and birth defects. Related studies on the effect of advanced age on birth defects were classified as chromosomal abnormalities, neurological and psychiatric disorders, and other systemic diseases. The effect of assisted reproduction technology (ART) on fertility in advanced age was also discussed.

RESULTS

Differences in the definition of the range of advanced age and other confounding factors among studies were excluded, most studies believed that advanced parental age would affect pregnancy outcomes and birth defects in offspring.

CONCLUSION

To some extent, advanced parental age caused adverse pregnancy outcomes and birth defects. The occurrence of these results was related to the molecular genetic changes caused by aging, such as gene mutations, epigenetic variations, etc. Any etiology of adverse pregnancy outcomes and birth defects related to aging might be more than one. The detrimental effect of advanced age can be corrected to some extent by ART.

A possible anti-anxiety effect of appetitive aggression and a possible link to the work of Donald Winnicott

Various pleasant sensations that give a particularly intense pleasure are able to improve anxiety. In the present study I consider the possibility that their anti-anxiety action depends on the strong pleasure they provide, and I propose a possible mechanism of this action. According to some studies, also appetitive aggression (an aggression that provokes a strong pleasure and that is performed only for the pleasure it provides) can improve anxiety, and in this article I consider the possibility that the pleasure of appetitive aggression is able to reduce anxiety by the same mechanism I have proposed for other intense pleasurable sensations.

The aggression performed by a child against the mother or against a substitute for the mother in the first period of life (a period in which this aggression is not dangerous) is a recurring theme throughout the work of of Donald Winnicott. Winnicott stresses that this aggression is necessary for the normal development of the child, and that the child must be free to practise it. According to Winnicott, this aggression is highly pleasurable and is not a response to unpleasant or hostile external situations. For these characteristics it seems to correspond to appetitive aggression in the adult that has been found to be able to reduce anxiety. Consequently, aggression performed by the child in the first period of life may also relieve anxiety, in the same way that appetitive aggression helps against anxiety in the adult.

In his writings, Winnicott returns several times to an unthinkable or archaic anxiety that children experience when they feel abandoned by their mother for a period that is too long for them, and all children, according to Winnicott, live on the brink of this anxiety. In this study I propose the hypothesis that aggression in the early period of life may be necessary for children because the intense pleasure it provides may help them against this continuously impending anxiety.

Catatonia associated with late-life psychosis successfully treated with lithium: a case report

BACKGROUND

Catatonia is a psychomotor syndrome that presents various symptoms ranging from stupor to agitation, with prominent disturbances of volition. Its pathogenesis is poorly understood. Benzodiazepines and electroconvulsive therapy (ECT) are safe and effective standard treatments for catatonia; however, alternative treatment strategies have not been established in cases where these treatments are either ineffective or unavailable. Here, we report a case of catatonia associated with late-life psychosis, which was successfully treated with lithium.

CASE PRESENTATION

A 66-year-old single man with hearing impairment developed hallucination and delusions and presented with catatonic stupor after a fall. He initially responded to benzodiazepine therapy; however, his psychotic symptoms became clinically evident and benzodiazepine provided limited efficacy. Blonanserin was ineffective, and ECT was unavailable. His catatonic and psychotic symptoms were finally relieved by lithium monotherapy.

CONCLUSIONS

Catatonic symptoms are common in patients with mood disorders, suggesting that lithium may be effective in these cases. Moreover, lithium may be effective for both catatonic and psychotic symptoms, as it normalizes imbalances of excitatory and inhibitory systems in the brain, which underlies major psychosis. Cumulative evidence from further cases is needed to validate our findings.

Brainstem alterations contribute to catatonia in schizophrenia spectrum disorders

Catatonia is a severe psychomotor syndrome that frequently occurs in patients with schizophrenia spectrum disorders (SSD). Accumulating neuroimaging evidence suggests orbitofrontal, frontoparietal and cerebellar network dysfunction in catatonia. Very little is known about contributions of brainstem regions (as part of the dopaminergic-based subcortical-cortical motor circuit) to catatonia in SSD patients. Here, we used structural magnetic resonance imaging (MRI) at 3 T to examine volumes of brainstem regions in catatonic SSD patients compared to non-catatonic SSD patients. Catatonia severity was measured with the Northoff Catatonia Rating Scale (NCRS). The segmentation of the brainstem in order to investigate the volumes of medulla oblongata, pons, superior cerebellar pedunculus, and midbrain was carried out using FreeSurfer vers. 6.0. Catatonic patients (NCRS total score ≥ 3; at least 1 point in the three different symptom categories; i.e., motor, behavioral, and affective; n = 30) had significantly smaller midbrain volumes (p = 0.004, Bonferroni corr.) when compared to non-catatonic patients (NCRS total score = 0; n = 29). In catatonic patients, significant correlations were detected between NCRS motor scores and whole brainstem (p = 0.015, Bonferroni corr.) volumes. These results support a neuromechanistically important role of brainstem structures in catatonia in SSD, particularly in motor symptom expression.

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.

Cortical Contributions to Distinct Symptom Dimensions of Catatonia

Catatonia is a central aspect of schizophrenia spectrum disorders (SSD) and most likely associated with abnormalities in affective, motor, and sensorimotor brain regions. However, contributions of different cortical features to the pathophysiology of catatonia in SSD are poorly understood. Here, T1-weighted structural magnetic resonance imaging data at 3 T were obtained from 56 right-handed patients with SSD. Using FreeSurfer version 6.0, we calculated cortical thickness, area, and local gyrification index (LGI). Catatonic symptoms were examined on the Northoff catatonia rating scale (NCRS). Patients with catatonia (NCRS total score ≥3; n = 25) showed reduced surface area in the parietal and medial orbitofrontal gyrus and LGI in the temporal gyrus (P < .05, corrected for cluster-wise probability [CWP]) as well as hypergyrification in rostral cingulate and medial orbitofrontal gyrus when compared with patients without catatonia (n = 22; P < .05, corrected for CWP). Following a dimensional approach, a negative association between NCRS motor and behavior scores and cortical thickness in superior frontal, insular, and precentral cortex was found (34 patients with at least 1 motor and at least 1 other affective or behavioral symptom; P < .05, corrected for CWP). Positive associations were found between NCRS motor and behavior scores and surface area and LGI in superior frontal, posterior cingulate, precentral, and pericalcarine gyrus (P < .05, corrected for CWP). The data support the notion that cortical features of distinct evolutionary and genetic origin differently contribute to catatonia in SSD. Catatonia in SSD may be essentially driven by cortex variations in frontoparietal regions including regions implicated in the coordination and goal-orientation of behavior.

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.

Schizophrenia with prominent catatonic features: A selective review

A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.

Prevalence of Catatonia and Its Moderators in Clinical Samples: Results from a Meta-analysis and Meta-regression Analysis

Catatonia is an independent syndrome that co-occurs with several mental and medical conditions. We performed a systematic literature review in PubMed/Scopus until February 2017 and meta-analyzed studies reporting catatonia prevalence. Across 74 studies (cross-sectional = 32, longitudinal = 26, retrospective = 16) providing data collected from 1935 to 2017 across all continents, mean catatonia prevalence was 9.0% (k = 80, n = 110764; 95% CI = 6.9-11.7, I2 = 98%, publication bias P < .01), decreasing to 7.8% (k = 19, n = 7612, 95% CI = 7-8.7, I2 = 38.9%) in a subgroup with low heterogeneity. Catatonia prevalence was 23.9% (k = 8, n = 1168, 95% CI = 10-46.9, I2 = 96%) in patients undergoing ECT/having elevated creatinine phosphokinase. Excluding ECT samples, the catatonia prevalence was 8.1% (k = 72, n = 109606, 95% CI = 6.1-10.5, I2 = 98%, publication bias P < .01), with sensitivity analyses demonstrating that country of study origin (P < .001), treatment setting (P = .003), main underlying condition (P < .001), and sample size (P < .001)moderated catatonia prevalence, being highest in Uganda (48.5%, k = 1) and lowest in Mexico (1.9%, 95% CI = 0.4-8.8, I2 = 67%, k = 2), highest in nonpsychiatric out- or inpatient services (15.8%, 95% CI = 8.1-28.4, I2 = 97%, k = 15)and lowest in psychiatric outpatients services (3.2%, 95% CI = 1.7-6.1, I2 = 50%, k = 3), highest in presence of medical or neurological illness with no comorbid psychiatric condition (20.6%, 95% CI = 11.5-34.2, I2 = 95%, k = 10)and lowest in mixed psychiatric samples (5.7%, 95% CI = 4.2-7.7, I2 =98%, k = 43), highest in studies with sample sizes <100 (20.7%, 95% CI = 12.8-31.6, I2 = 90%, k = 17) and lowest in studies with sample sizes >1000 (2.3%, 95% CI = 1.3-3.9, I2 = 99%, k = 16). Meta-regression showed that smaller sample size (P < .01) and less major depressive disorder (P = .02) moderated higher catatonia prevalence. Year of data collection did not significantly moderate the results. Results from this first meta-analysis of catatonia frequencies across time and disorders suggest that catatonia is an epidemiologically and clinically relevant condition that occurs throughout several mental and medical conditions, whose prevalence has not decreased over time and does not seem to depend on different rating scales/criteria. However, results were highly heterogeneous, calling for a cautious interpretation.

Using a systematic approach to assess an acutely unwell patient with catatonia: a case study

Patients in acute settings may present with a variety of signs and symptoms; however, the principles of assessment are applicable to all acutely unwell patients. This article details a case study of a patient who presented to the author's medical ward in a catatonic state, and was assessed using the ABCDE (airway, breathing, circulation, disability, exposure) approach. Catatonia is a disturbed mental state in which a patient exhibits abnormal behaviour, such as the inability to speak and non-responsiveness to stimuli, alongside immobility. Although catatonia is a rare condition, it is important that nurses can identify its signs and symptoms, because it can be fatal if not treated appropriately and rapidly. Thus, it is crucial for nurses to be able to systematically assess acutely unwell patients, including those with catatonia, using the ABCDE approach.

A Possible Link between Anxiety and Schizophrenia and a Possible Role of Anhedonia

In the prodromal phase of schizophrenia, severe alterations of the visual appearance of the environment have been found, accompanied by a state of intense anxiety. The present study considers the possibility that these alterations really exist in the appearance of objects, but that healthy people do not see them. The image of the world that we see is continuously deformed and fragmented by foreshortenings, partial overlapping, and so on and must be constantly reassembled and interpreted; otherwise, it could change so much that we would hardly recognize it. Since pleasure has been found to be involved in visual and cognitive information processing, the possibility is considered that anhedonia (the reduction of the ability to feel pleasure) might interfere with the correct reconstruction and interpretation of the image of the environment and alter its appearance. The possibility is also considered that these alterations might make the environment hostile, might at times evoke the sensation of being trapped by a predator, and might be the cause of the anxiety that accompanies them. According to some authors, they might also induce delusional ideas, in an attempt to restore meaning in a world that has become chaotic and frightening.

The Lorazepam and Diazepam Protocol for Catatonia Due to General Medical Condition and Substance in Liaison Psychiatry

OBJECTIVE

The lorazepam-diazepam protocol had been proved to rapidly and effectively relieve catatonia in patients with schizophrenia or mood disorder. This study aims to investigate the efficacy of lorazepam-diazepam protocol in catatonia due to general medical conditions (GMC) and substance.

METHOD

Patients with catatonia that required psychiatric intervention in various settings of a medical center were included. The lorazepam-diazepam protocol had been used to treat the catatonia due to GMC or substance according to DSM-IV criteria. The treatment response had been assessed by two psychiatrists.

RESULTS

Eighteen (85.7%) of 21 catatonic patients due to GMC or substance became free of catatonia after the lorazepam-diazepam protocol. Five (23.8%) of the 21 patients had passed away with various causes of death and wide range of time periods after catatonia.

CONCLUSION

Our results showed that the lorazepam-diazepam protocol could rapidly and effectively relieve catatonia due to GMC and substance.

Catatonia

One of the most exciting psychiatric conditions is the bizarre psychomotor syndrome called catatonia, which may present with a large number of different motor signs and even vegetative instability. Catatonia is potentially life threatening. The use of benzodiazepines and electroconvulsive therapy (ECT) has been efficient in the majority of patients. The rich clinical literature of the past has attempted to capture the nature of catatonia. But the lack of diagnostic clarity and operationalization has hampered research on catatonia for a long time. Within the last decades, it became clear that catatonia had to be separated from schizophrenia, which was finally accomplished in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In DSM-5, catatonia syndrome may be diagnosed as a specifier to major mood disorders, psychotic disorders, general medical conditions, and as catatonia not otherwise specified. This allows diagnosing the syndrome in a large variety of psychiatric disorders. Currently, the pathobiology remains widely unknown. Suspected neurotransmitter systems include gamma-aminobutyric acid (GABA) and glutamate. Neuroimaging reports pointed to reduced resting state activity and reduced task activation in motor areas of the frontal and parietal cortex. The new classification of catatonia will foster more clinical research and neuroscientific approaches by testing catatonia in various populations and applying stringent criteria. The scarce number of prospective trials will hopefully increase, as more trials will be encouraged within a more precise concept of catatonia.

The Syndrome of Catatonia

Catatonia is a psychomotor syndrome which has historically been associated with schizophrenia. Many clinicians have thought that the prevalence of this condition has been decreasing over the past few decades. This review reminds clinicians that catatonia is not exclusively associated with schizophrenia, and is still common in clinical practice. Many cases are related to affective disorders or are of an idiopathic nature. The illusion of reduced prevalence has been due to evolving diagnostic systems that failed to capture catatonic syndromes. This systemic error has remained unchallenged, and potentiated by the failure to perform adequate neurological evaluations and catatonia screening exams on psychiatric patients. We find that current data supports catatonic syndromes are still common, often severe and of modern clinical importance. Effective treatment is relatively easy and can greatly reduce organ failure associated with prolonged psychomotor symptoms. Prompt identification and treatment can produce a robust improvement in most cases. The ongoing prevalence of this syndrome requires that psychiatrists recognize catatonia and its presentations, the range of associated etiologies, and the import of timely treatment.

Schizophrenia Patient or Spiritually Advanced Personality? A Qualitative Case Analysis

Many aspects of spiritual experience are similar in form and content to symptoms of psychosis. Both spiritually advanced people and patients suffering from psychopathology experience alterations in their sense of 'self.' Psychotic experiences originate from derangement of the personality, whereas spiritual experiences involve systematic thinning out of the selfish ego, allowing individual consciousness to merge into universal consciousness. Documented instances and case studies suggest possible confusion between the spiritually advanced and schizophrenia patients. Clinical practice contains no clear guidelines on how to distinguish them. Here we use a case presentation to help tabulate clinically useful points distinguishing spiritually advanced persons from schizophrenia patients. A 34-year-old unmarried male reported to our clinic with four main complaints: lack of sense of self since childhood; repeated thoughts questioning whether he existed or not; social withdrawal; and inability to continue in any occupation. Qualitative case analysis and discussions using descriptions from ancient texts and modern psychology led to the diagnosis of schizophrenia rather than spiritual advancement.

Risk factors for suicide in schizophrenia: systematic review and clinical recommendations

OBJECTIVE

To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence.

METHOD

A task force formed of experts and clinicians iteratively developed consensus through serial revisions using the Delphi method. Initial survey items were based on systematic literature review published up to June 2013.

RESULTS

Various risk factors were reported to be implicated in suicide in schizophrenia. Our findings indicate that suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and number of psychiatric admissions. Other risk factors identified are given by younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or following psychiatric discharge. Integrating the evidence and the experience of the task force members, a consensus was reached on 14 clinical recommendations.

CONCLUSION

Identification of risk factors for suicide in individuals diagnosed with schizophrenia is imperative to improve clinical management and develop strategies to reduce the incidence of suicide in this population. This study provides the critical overview of available data and clinical recommendations on recognition and management of the above-mentioned risk factors.

The catatonia conundrum: controversies and contradictions

Although catatonia is known to psychiatrists for more than a century, it is still poorly understood, often under recognized, have inspired debate and criticism about nosological status of the catatonic syndrome in recent times without reaching its conclusion. It can present with a number of psychiatric and medical illnesses and is easily treatable, though treatment response varies depending upon the underlying condition and can lead on to a multitude of complications, if not treated. Some issues are more than forty catatonic signs are available to scientific audience for diagnosis; threshold number for labelling varies according to the nosological system followed and the underlying condition; and mood stabilizers like carbamazepine and lithium are helpful in some cases of idiopathic periodic catatonia. Researchers have been asking for a separate diagnostic category for catatonia since long and the debate has gained pace over the last few years, with new editions of both DSM and ICD coming up. Therefore, this paper looks at the controversies associated with the diagnosis and classification of catatonia, the arguments and counter-arguments and future directions, in crisp.

Prevalence of the catatonic syndrome in an acute inpatient sample

OBJECTIVE

In this exploratory open label study, we investigated the prevalence of catatonia in an acute psychiatric inpatient population. In addition, differences in symptom presentation of catatonia depending on the underlying psychiatric illness were investigated.

METHODS

One hundred thirty patients were assessed with the Bush-Francis Catatonia Rating Scale (BFCRS), the Positive and Negative Syndrome Scale, the Young Mania Rating Scale, and the Simpson-Angus Scale. A factor analysis was conducted in order to generate six catatonic symptom clusters. Composite scores based on this principal component analysis were calculated.

RESULTS

When focusing on the first 14 items of the BFCRS, 101 patients (77.7%) had at least 1 symptom scoring 1 or higher, whereas, 66 patients (50.8%) had at least 2 symptoms. Interestingly, when focusing on the DSM-5 criteria of catatonia, 22 patients (16.9%) could be considered for this diagnosis. Furthermore, different symptom profiles were found, depending on the underlying psychopathology. Psychotic symptomatology correlated strongly with excitement symptomatology (r = 0.528, p < 0.001) and to a lesser degree with the stereotypy/mannerisms symptom cluster (r = 0.289; p = 0.001) and the echo/perseveration symptom cluster (r = 0.185; p = 0.035). Similarly, manic symptomatology correlated strongly with the excitement symptom cluster (r = 0.596; p < 0.001) and to a lesser extent with the stereotypy/mannerisms symptom cluster (r = 0.277; p = 0.001).

CONCLUSION

There was a high prevalence of catatonic symptomatology. Depending on the criteria being used, we noticed an important difference in exact prevalence, which makes it clear that we need clear-cut criteria. Another important finding is the fact that the catatonic presentation may vary depending on the underlying pathology, although an unambiguous delineation between these catatonic presentations cannot be made. Future research is needed to determine diagnostical criteria of catatonia, which are clinically relevant.

Duration of untreated illness (DUI) and schizophrenia sub-types: a collaborative study between the universities of Milan and Moscow

BACKGROUND

Several studies show an association between a long duration of untreated illness (DUI) and poor outcome in schizophrenic patients. DUI, in turn, may be influenced by different variables including specific illness-related factors as well as access to local psychiatric services.

AIMS

The purposes of the present study were to detect differences in terms of DUI among schizophrenics coming from different geographic areas and to evaluate differences in DUI across diagnostic sub-types.

METHOD

One hundred and twenty-five (125) schizophrenic patients of the Psychiatric Clinic of Milan (n = 51) and Moscow (n = 74) were enrolled. SCID-I was administered to all patients and information about DUI was obtained by consulting clinical charts and health system databases, and by means of clinical interviews with patients and their relatives. DUI was defined as the time between the onset of illness and the administration of the first antipsychotic drug. One-way analyses of variance (ANOVAs) were performed to find eventual differences in terms of DUI across diagnostic sub-types.

RESULTS

Italian patients showed a longer DUI (M = 4.14 years, SD = 4.95) than Russians (M = 1.16 years, SD = 1.43) (F = 24.03, p < .001). DUI was found to be longer in paranoid schizophrenics (M = 3.47 years, SD = 4.19) compared to catatonic patients (M = 0.96 years, SD = 0.94) (F = 3.56, p = .016).

CONCLUSIONS

The results of the present study suggest that the different schizophrenic sub-types may differ in terms of DUI, likely due to different clinical severity and social functioning. Studies with larger samples are needed to confirm the data of the present study.

Catatonia in DSM-5

Although catatonia has historically been associated with schizophrenia and is listed as a subtype of the disorder, it can occur in patients with a primary mood disorder and in association with neurological diseases and other general medical conditions. Consequently, catatonia secondary to a general medical condition was included as a new condition and catatonia was added as an episode specifier of major mood disorders in DSM-IV. Different sets of criteria are utilized to diagnose catatonia in schizophrenia and primary mood disorders versus neurological/medical conditions in DSM-IV, however, and catatonia is a codable subtype of schizophrenia but a specifier for major mood disorders without coding. In part because of this discrepant treatment across the DSM-IV manual, catatonia is frequently not recognized by clinicians. Additionally, catatonia is known to occur in several conditions other than schizophrenia, major mood disorders, or secondary to a general medical condition. Four changes are therefore made in the treatment of catatonia in DSM-5. A single set of criteria will be utilized to diagnose catatonia across the diagnostic manual and catatonia will be a specifier for both schizophrenia and major mood disorders. Additionally, catatonia will also be a specifier for other psychotic disorders, including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. A new residual category of catatonia not otherwise specified will be added to allow for the rapid diagnosis and specific treatment of catatonia in severely ill patients for whom the underlying diagnosis is not immediately available. These changes should improve the consistent recognition of catatonia across the range of psychiatric disorders and facilitate its specific treatment.