Catatonic schizophrenia: an international comparative study

Catatonia: “Fluctuat nec mergitur”

In the beginning of the 1900s, the prevalence of catatonia in inpatient samples was reported to be between 19.5% and 50%. From the mid-1900s, most clinicians thought that catatonia was disappearing. Advances in medical sciences, particularly in the field of neurology, may have reduced the incidence of neurological diseases that present with catatonic features or mitigated their severity. More active pharmacological and psychosocial treatment methods may have either eliminated or moderated catatonic phenomena. Moreover, the relatively narrow descriptive features in modern classifications compared with classical texts and ascribing catatonic signs and symptoms to antipsychotic-induced motor symptoms may have contributed to an apparent decline in the incidence of catatonia. The application of catatonia rating scales introduced in the 1990s revealed significantly more symptoms than routine clinical interviews, and within a few years, the notion of the disappearance of catatonia gave way to its un-expected resurgence. Several systematic investigations have found that, on average, 10% of acute psychotic patients present with catatonic features. In this editorial, the changes in the incidence of catatonia and the possible underlying causes are reviewed.

Catatonia: demographic, clinical and laboratory associations

BACKGROUND

Catatonia, a severe neuropsychiatric syndrome, has few studies of sufficient scale to clarify its epidemiology or pathophysiology. We aimed to characterise demographic associations, peripheral inflammatory markers and outcome of catatonia.

METHODS

Electronic healthcare records were searched for validated clinical diagnoses of catatonia. In a case-control study, demographics and inflammatory markers were compared in psychiatric inpatients with and without catatonia. In a cohort study, the two groups were compared in terms of their duration of admission and mortality.

RESULTS

We identified 1456 patients with catatonia (of whom 25.1% had two or more episodes) and 24 956 psychiatric inpatients without catatonia. Incidence was 10.6 episodes of catatonia per 100 000 person-years. Patients with and without catatonia were similar in sex, younger and more likely to be of Black ethnicity. Serum iron was reduced in patients with catatonia [11.6 v. 14.2 μmol/L, odds ratio (OR) 0.65 (95% confidence interval (CI) 0.45-0.95), p = 0.03] and creatine kinase was raised [2545 v. 459 IU/L, OR 1.53 (95% CI 1.29-1.81), p < 0.001], but there was no difference in C-reactive protein or white cell count. N-Methyl-d-aspartate receptor antibodies were significantly associated with catatonia, but there were small numbers of positive results. Duration of hospitalisation was greater in the catatonia group (median: 43 v. 25 days), but there was no difference in mortality after adjustment.

CONCLUSIONS

In the largest clinical study of catatonia, we found catatonia occurred in approximately 1 per 10 000 person-years. Evidence for a proinflammatory state was mixed. Catatonia was associated with prolonged inpatient admission but not with increased mortality.

Stem cell-based models and therapies: a key approach into schizophrenia treatment

Psychiatric disorders such as schizophrenia can generate distress and disability along with heavy costs on individuals and health care systems. Different genetic and environmental factors play a pivotal role in the appearance of the mentioned disorders. Since the conventional treatment options for psychiatric disorders are suboptimal, investigators are trying to find novel strategies. Herein, stem cell therapies have been recommended as novel choices. In this context, the preclinical examination of stem cell-based therapies specifically using appropriate models can facilitate passing strong filters and serious examination to ensure proper quality and safety of them as a novel treatment approach. Animal models cannot be adequately helpful to follow pathophysiological features. Nowadays, stem cell-based models, particularly induced pluripotent stem cells reflected as suitable alternative models in this field. Accordingly, the importance of stem cell-based models, especially to experiment with the regenerative medicine outcomes for schizophrenia as one of the severe typing of psychiatric disorders, is addressed here.

The catatonia conundrum: evidence of psychomotor phenomena as a symptom dimension in psychotic disorders

To provide a rational basis for reconceptualizing catatonia in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), we briefly review historical sources, the psychopathology of catatonia, and the relevance of catatonic schizophrenia in contemporary practice and research. In contrast to Kahlbaum, Kraepelin and others (Jaspers, Kleist, and Schneider) recognized the prevalence of motor symptoms in diverse psychiatric disorders but concluded that the unique pattern and persistence of certain psychomotor phenomena defined a "catatonic" subtype of schizophrenia, based on intensive long-term studies. The enduring controversy and confusion that ensued underscores the fact that the main problem with catatonia is not just its place in Diagnostic and Statistical Manual of Mental Disorders but rather its lack of conceptual clarity. There still are no accepted principles on what makes a symptom catatonic and no consensus on which signs and symptoms constitute a catatonic syndrome. The resulting heterogeneity is reflected in treatment studies that show that stuporous catatonia in any acute disorder responds to benzodiazepines or electroconvulsive therapy, whereas catatonia in the context of chronic schizophrenia is phenomenologically different and less responsive to either modality. Although psychomotor phenomena are an intrinsic feature of acute and especially chronic schizophrenia, they are insufficiently recognized in practice and research but may have significant implications for treatment outcome and neurobiological studies. While devising a separate category of catatonia as a nonspecific syndrome has heuristic value, it may be equally if not more important to re-examine the psychopathological basis for defining psychomotor symptoms as catatonic and to re-establish psychomotor phenomena as a fundamental symptom dimension or criterion for both psychotic and mood disorders.

Malignant catatonia in a patient with bipolar disorder, B12 deficiency, and neuroleptic malignant syndrome: one cause or three?

A Case is presented of a 23-year-old woman with progressive onset of paranoid psychosis and catatonia, who was ultimately found to have both vitamin B12 deficiency and a family history of bipolar disorder. The patient was initially diagnosed with schizophrenia and treated with the antipsychotic medication ziprasidone. Her condition rapidly worsened to a state consistent with either neuroleptic malignant syndrome or malignant catatonia. Work-up then revealed vitamin B12 deficiency and a family history of bipolar disorder. Her symptoms improved rapidly but partially with benzodiazepines and electrocon-vulsive therapy, and completely with addition of valproic acid, vitamin B12 replacement, and re-introduction of antipsychotic medication in the form of olanzapine. The authors discuss the differential diagnosis of catatonia as reflecting a high likelihood of underlying mood disorder; the evaluation and management of malignant catatonia and malignant neuroleptic syndrome; and the role of vitamin B12 deficiency in precipitating psychotic symptoms. The case also illustrates the problems of diagnosing and managing a multifactorial disorder with psychiatric, general medical, and perhaps iatrogenic components.

Catatonia is frequent in black immigrants admitted to Psychiatry in Canada

Objective. To assess the prevalence of catatonia in a sample of patients of African ancestry admitted to Psychiatry in Canada. Methods. Retrospective chart review of 20 consecutive black francophone inpatients assessed by the same psychiatrist. Results. The sample consisted of 12 men and eight women aged 17-59 years. Catatonic symptoms were prominent in 30% of this small sample (n=6), more frequent than the 9% reported in a Canadian general psychiatry population of 140 inpatients (P=0.0126). Conclusions. This finding is limited by the small sample size and the provenance from troubled countries for most of the patients. It is consistent with earlier reports of a higher prevalence of catatonia in nonwhite subjects and among immigrants coming from developing countries, and stresses the importance of systematically assessing catatonia in clinical settings. Further research is warranted to distinguish between the effects of ethnic origin and immigrant status and to determine if the increased prevalence of catatonia is related to neurobiological causes such as maternal gestational infections or to socio-cultural factors.

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.

The catatonic dilemma expanded

Catatonia is a common syndrome that was first described in the literature by Karl Kahlbaum in 1874. The literature is still developing and remains unclear on many issues, especially classification, diagnosis, and pathophysiology. Clinicians caring for psychiatric patients with catatonic syndromes continue to face many dilemmas in diagnosis and treatment. We discuss many of the common problems encountered in the care of a catatonic patient, and discuss each problem with a review of the literature. Focus is on practical aspects of classification, epidemiology, differential diagnosis, treatment, medical comorbidity, cognition, emotion, prognosis, and areas for future research in catatonic syndromes.

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.

One-year outcome after response to ECT in middle-aged and elderly patients with intractable catatonic schizophrenia

BACKGROUND AND OBJECTIVE

ECT is one of the most efficacious treatments for catatonic schizophrenia. However, there has been no study on the efficacy of ECT in elderly patients with catatonic schizophrenia. Thus, we conducted prospective studies on the short-term (phase 1 study) and long-term (phase 2 study) effects of acute ECT on intractable catatonic schizophrenia in middle-aged and elderly patients.

SUBJECTS AND METHODS

The phase 1 study included 11 consecutive patients over 45 years of age who fulfilled the DSM-IV criteria for catatonic schizophrenia and were referred to Tohoku University Hospital for the first time for acute ECT between January 1, 1998, and August 31, 2003, after other treatments had failed. We evaluated the clinical response of these patients to acute ECT by means of the Brief Psychiatric Rating Scale (BPRS). We also evaluated adverse effects of acute ECT. The patient or guardian provided written informed consent. Exclusion criterion was a history of dementia or substance abuse. Patients were considered clinical responders if they had a BPRS score ;ek 25 for 1 week after the final ECT session. The phase 2 study included 11 consecutive patients who responded to acute ECT in the phase 1 study. Patients provided written informed consent. Patients' BPRS scores were evaluated weekly (18 items, rated 0-6) for 48 weeks or until relapse/recurrence, during which time they received pharmacotherapy. Patients were considered clinical "relapsers" if they had a BPRS score of at least 37 for 3 consecutive days. Differences in clinical characteristics between patients with and without recurrence were analyzed statistically by the Mann-Whitney U test.

RESULTS

All 11 patients completed the phase 1 study, and the acute ECT response rate was 100%. No patient experienced a severe adverse cognitive or physical effect during the course of acute ECT. All 11 patients also completed the phase 2 study. The mean dose of continuation neuroleptics in all 11 cases was 296.8 +/- 277.6 mg (range, 0-982 mg) (chlorpromazine [CPZ] equivalent). Relapse occurred in 7 cases, and all occurred within 6 months. The 1-year recurrence rate was 63.6%. The mean (+/-SD) relapse prevention time in the 7 cases was 76.0 +/- 64.7 days (range, 11-163 days). A significant difference in daily neuroleptic dose before acute ECT was found between the patients suffering recurrence and those not suffering recurrence (766.7 +/- 521.8 CPZ-equivalent mg with recurrence versus 101.9 +/- 75.2 CPZ-equivalent mg without recurrence, U = 2.0, P = 0.923). There was a trend toward a lower Global Assessment of Functioning (GAF) score just before ECT (7.3 +/- 4.0 with recurrence versus 16.8 +/- 11.2 without recurrence, U = 4.5, P = 0.073).

CONCLUSIONS

The short-term efficacy of acute ECT for middle-aged and elderly patients with intractable catatonic schizophrenia is excellent. However, the 1-year recurrence rate, especially the 6-month relapse rate, after response to acute ECT is high, despite continuation pharmacotherapy. The need for more effective relapse-prevention strategies, such as continuation ECT, is urgent.

Psychopathology of catatonic speech disorders and the dilemma of catatonia: a selective review

OBJECTIVE

Over the past decade there has been an upsurge of interest in the prevalence, nosological position, treatment response and pathophysiology of catatonia. However, the psychopathology of catatonia has received only scant attention. Once the hallmark of catatonia, speech disorders--particularly logorrhoea, verbigeration and echolalia--seem to have been neglected in modern literature. The aims of the present paper are to outline the conceptual history of catatonic speech disorders and to follow their development in contemporary clinical research.

METHOD

The English-language psychiatric literature for the last 60 years on logorrhoea, verbigeration and echolalia was searched through Medline and cross-referencing. Kahlbaum, Wernicke, Jaspers, Kraepelin, Bleuler, Kleist and Leonhard's oft cited classical texts supplemented the search.

RESULTS

In contrast to classical psychopathological sources, very few recent papers were found on catatonic speech disorders. Current clinical research failed to incorporate the observations of traditional descriptive psychopathology.

CONCLUSIONS

Modern catatonia research operates with simplified versions of psychopathological terms devised and refined by generations of classical writers.

Benzodiazepines in the treatment of catatonic syndrome

During a 5-month period, 18 (8%) of 212 patients admitted to a psychiatric unit affiliated to a teaching hospital were found to have a catatonic syndrome associated with various nonorganic mental disorders. Signs and symptoms of motor retardation predominated the clinical presentations. In the course of a prospective, open study, all 18 patients were challenged by a small dose of oral lorazepam or intramuscular diazepam. Catatonic signs and symptoms in 2 patients showed an immediate, complete, and sustained response to the medication. The remaining 16 patients were maintained on 1 of the 2 benzodiazepines for the next 48 h when their motor status was re-evaluated. Significant clinical improvement was detected in all but 2 patients. However, 9 patients needed electroconvulsive treatment to achieve further improvement. Short-term benzodiazepine administration proved to be a safe and effective treatment of the catatonic syndrome.

Speech-prompt catatonia: a case report and review of the literature

The clinical picture of speech-prompt catatonia, one of the six catatonic subtypes in Leonhard's classification, is demonstrated by a case report. The Leonhardian catatonic subtypes offer a radically different way of approaching the problem of catatonia. The need for a reevaluation of Leonhard's intricate, clinically oriented system, rich in psychopathological details, is emphasized.

An appraisal of the DSM-III system

DSM-III is a major document in the history of psychiatry. The DSM-III system is here seen as an instrument that promotes the scientific development of psychiatry and the clarity of communication among psychiatrists. However a major theme of this review is that reliability does not ensure validity. While making this point it is recognized that the major defects in the DSM-III system result from scientific inadequacies inherent in present day psychiatry. This review also may be taken as an amplification of the statement in DSM-III-R that it is not a textbook. In particular the data required to arrive at diagnoses in the DSM-III system do not provide sufficient information to arrive at a comprehensive biopsychosocial case formulation, a shortcoming that has relevance for teaching and clinical practice.