Prevalence of the catatonic syndrome in an acute inpatient sample

A Rare Case of Arnold Chiari Malformation Type 1 Presenting With Features of Catatonia

The Arnold Chiari malformation is a congenital neurological condition. It occurs due to a defect in the cerebellum. Our patient is a 19-year-old postpartum female who presented to our ER with headaches, crying spells, reduced interaction, poor self-care, and neglect of her newborn for the past five days. Before the onset of her presenting symptoms, the patient had complained of a severe headache in the back of the head and dizziness. Her baseline investigations were normal. On examination, the patient was noticed to have a fixed gaze, ambiguity, mutism, and rigidity. So, she was diagnosed with catatonia, a differential diagnosis of mental and behavioral disorders associated with pregnancy, childbirth, and puerperium, and was treated with medications appropriately. As her headache showed minimal relief with adequate analgesic measures, neuroimaging was done, which showed Arnold Chiari malformation type I with hydrocephalus. A liaison was made with the neurology team, who confirmed the diagnosis and advised her on the decompression procedure. Her family refused to undergo the procedure. Once she showed minimal improvement in her symptoms, her family members requested her discharge. In our case, the Arnold Chiari malformation type I presented with features of catatonia, unlike the usual reported presentation of depression and anxiety. This case highlights the need for a thorough evaluation of any patient presenting with catatonia.

Catatonia associated with pediatric postoperative cerebellar mutism syndrome

OBJECTIVE

To ascertain the presence of catatonia in cases of pediatric postoperative cerebellar mutism syndrome (PPCMS).

METHOD

A systematic review of PPCMS case reports of patients aged 0-17 years with sufficient clinical information to extract catatonic phenomena was undertaken following PRISMA guidelines. Standardized catatonia rating scales were applied to selected cases retrospectively to ascertain whether diagnostic criteria for catatonia were met. A case known to the authors is also presented.

RESULTS

Two hundred twenty-one suitable full-text articles were identified. Following screening and application of inclusion criteria, 51 articles were selected plus seven more from their references, reporting on 119 subjects. All cases met Bush and Francis (BF) diagnostic criteria for catatonia, 92.5% Pediatric Catatonia Rating Scale (PCRS), 52.9% ICD-11, and 44.5% DSM-5. All patients presented with mutism. The next most frequent signs were immobility/stupor (77.3%), withdrawal (35.3%), mannerisms (23.5%), and excitement/agitation (18.5%). Most cases presented with stuporous catatonia (75.6%). Catatonia most frequently occurred following resection of medulloblastoma (64.7%). Preoperative hydrocephalus occurred in 89 patients (74.8%).

CONCLUSION

Catatonia was frequent in this PPCMS sample, with a predominant stuporous variant; it should be considered in patients with PPCMS and assessed with reliable and validated instruments for prompt diagnosis and management.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

Microstructural white matter biomarkers of symptom severity and therapy outcome in catatonia: Rationale, study design and preliminary clinical data of the whiteCAT study

The number of magnetic resonance imaging (MRI) studies on neuronal correlates of catatonia has dramatically increased in the last 10 years, but conclusive findings on white matter (WM) tracts alterations underlying catatonic symptoms are still lacking. Therefore, we conduct an interdisciplinary longitudinal MRI study (whiteCAT) with two main objectives: First, we aim to enroll 100 psychiatric patients with and 50 psychiatric patients without catatonia according to ICD-11 who will undergo a deep phenotyping approach with an extensive battery of demographic, psychopathological, psychometric, neuropsychological, instrumental and diffusion MRI assessments at baseline and 12 weeks follow-up. So far, 28 catatonia patients and 40 patients with schizophrenia or other primary psychotic disorders or mood disorders without catatonia have been studied cross-sectionally. 49 out of 68 patients have completed longitudinal assessment, so far. Second, we seek to develop and implement a new method for semi-automatic fiber tract delineation using active learning. By training supportive machine learning algorithms on the fly that are custom tailored to the respective analysis pipeline used to obtain the tractogram as well as the WM tract of interest, we plan to streamline and speed up this tedious and error-prone task while at the same time increasing reproducibility and robustness of the extraction process. The goal is to develop robust neuroimaging biomarkers of symptom severity and therapy outcome based on WM tracts underlying catatonia. If our MRI study is successful, it will be the largest longitudinal study to date that has investigated WM tracts in catatonia patients.

The origins of catatonia - Systematic review of historical texts between 1800 and 1900

Since January 1st 2022, catatonia is (again) recognized as an independent diagnostic entity in the 11th revision of the International Classification of Diseases (ICD-11). This is a relevant time to systematically review how the concept of catatonia has evolved within the 19th century and how this concept changed under the influence of a wide variety of events in the history of psychiatry. Here, we systematically reviewed historical and modern German and English texts focusing on catatonic phenomena, published from 1800 to 1900. We searched five different electronical databases (https://archive.org, www.hathitrust.org, www.books.google.de, https://link.springer.com and PubMed) and closely reviewed 60 historical texts on catatonic symptoms. Three main findings emerged: First, catatonic phenomena and their underlying mechanisms were studied decades before Karl Ludwig Kahlbaum's catatonia concept of 1874. Second, Kahlbaum not only introduced catatonia, but, more generally, also called for a new classification of psychiatric disorders based on a comprehensive analysis of the entire clinical picture, including the dynamic course and cross-sectional symptomatology. Third, the literature review shows that between 1800 and 1900 catatonic phenomena were viewed to be 'located' right at the interface of motor and psychological symptoms with the respective pathophysiological mechanisms being discussed. In conclusion, catatonia can truly be considered one of the most exciting and controversial entity in both past and present psychiatry and neurology, as it occupies a unique position in the border territory between organic, psychotic and psychogenic illnesses.

Affected cortico-striatal-cerebellar network in schizophrenia with catatonia revealed by magnetic resonance imaging: indications for electroconvulsive therapy and repetitive transcranial magnetic stimulation

Catatonia is a psychomotor syndrome that can occur in a broad spectrum of brain disorders, including schizophrenia. Current findings suggest that the neurobiological process underlying catatonia symptoms in schizophrenia is poorly understood. However, emerging neuroimaging studies in catatonia patients have indicated that a disruption in anatomical connectivity of the cortico-striatal-cerebellar system is part of the neurobiology of catatonia, which could serve as a target of neurostimulation such as electroconvulsive therapy and repetitive transcranial magnetic stimulation.

Unconscious Communications by the Body in Catatonia-A Jungian Perspective

Outside of specific motor conditions, bodily movements are rarely considered in contemporary psychiatry. Stereotypies and mannerisms in clinical cases of catatonia are seen as having no deeper meaning in contemporary psychiatry. Perhaps we are missing something that could be important for us and our patients. The psychiatrist and analyst Carl Jung suggested there was an unconscious communication, and therefore a meaning in psychotic symptoms, including the movements in catatonia. The unconscious is rarely considered in psychotic presentations, yet psychosis is a prevalent condition in clinical settings. In this article Jung's ideas are presented along with case examples that invite the reader to consider them in their own future practice.

A unique presentation of echo phenomena in a patient with catatonia: a case report and literature review

BACKGROUND

Catatonia is a complex syndrome notable for a highly variable presentation. Standardized exam and criteria can enumerate possible presentations, but recognition of novel catatonic phenomenon may facilitate better understanding of catatonia's core features.

CASE PRESENTATION

A 61 year-old divorced pensioner with history of schizoaffective disorder was hospitalized for psychosis in the setting of medication noncompliance. While hospitalized, she developed multiple classic catatonia signs such as staring and grimacing, as well as a bizarre echo phenomenon while reading text that improved alongside other catatonic symptoms with treatment.

CONCLUSION

Echo phenomenon are a component of catatonia often recognized when presenting as echopraxia or echolalia, but other echo phenomenon are well established in the literature. Recognition or novel catatonic symptoms like this can lead to improved recognition and treatment of catatonia.

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.

The retrospective and observational study of catatonia - Diagnosis, course of illness, and the response to lorazepam - in a tertiary health-care center

Objectives

In patients with catatonia, it has been discovered that benzodiazepines (BZD) have a remarkable impact. However, there is not much evidence reflecting the long-term treatment with only BZDs before considering electroconvulsive therapy.

Materials and Methods

One-year retrospective data of patients obtained from the health management information system (HMIS) portal and records of the department of psychiatry with the diagnosis of catatonia. This data was then analyzed for adequate history, presenting complaints, treatment taken, substance use, and was organized into five groups depending on the primary diagnosis as per the Diagnostic and Statistical Manual of Mental. The scores of Bush-Francis Catatonia Rating Scales of day 1 and subsequent follow-ups were secured. Categorical variables were analyzed with the Chi-squared test. The response overtime for all the groups and its correlation with the number of visits was compared using repeated measures analysis of variance.

Results

We found that the lorazepam challenge test versus improvement after 1 week of oral lorazepam had Pearson's correlation of 0.604, this correlation decreased in the following weeks. In the 3 week, the correlation was 0.373, which was statistically significant. This shows that the highest correlation was seen in the 1st week. Hence, our study suggested that lorazepam challenge test is a good predictor of response in the 1st week alone. We observe negative correlation which is significant in the 3rd week (P = 0.048) and not in the 1st and 2nd week.

Conclusion

Our study analyzed the patients with catatonia in psychiatric diagnostic categories, history, and the outcome after treating them with lorazepam at every visit over 3 weeks. The correlation in the level of improvement of symptoms at subsequent visits was noteworthy and had a strong association with the lorazepam challenge test. When dose of lorazepam was tapered, on an average dose was reduced in the 2nd week. Suggesting that at least 3 week treatment would be ideal.

[Catatonia Through the Ages - from Kahlbaum to the ICD-11]

For decades, the psychomotor syndrome of catatonia was considered exclusively a subtype of schizophrenia. The use of antipsychotics and changes in the teaching content in the further training of psychiatrists led to the fact that catatonia was hardly recognized anymore. Yet catatonia is in principle well treatable. The new status in ICD-11 will probably allow to better teach, recognize, and treat catatonia in the future.

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

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

Resting state functional connectivity and structural abnormalities of the brain in acute retarded catatonia: an exploratory MRI study

In this first cross-sectional MRI study in acute catatonia, we compared the resting state whole-brain, within-network and seed (left precentral gyrus)-to-voxel connectivity, as well as cortical surface complexity between a sample of patients in acute retarded catatonic state (n = 15) diagnosed as per DSM-5 criteria and a demographically matched healthy control sample (n = 15). The patients had comorbid Axis-I psychiatric disorders including schizophrenia spectrum disorders and psychotic mood disorders, but did not have diagnosable neurological disorders. Acute retarded catatonia was characterized by reduced resting state functional connectivity, most robustly within the sensorimotor network; diffuse region of interest (ROI)-ROI hyperconnectivity; and seed-to-voxel hyperconnectivity in the frontoparietal and cerebellar regions. The seed (left precentral gyrus)-to-voxel connectivity was positively correlated to the catatonia motor ratings. The ROI-ROI as well as seed-to-voxel functional hyperconnectivity were noted to be higher in lorazepam responders (n = 9) in comparison to the non-responders (n = 6). The overall Hedges' g effect sizes for these analyses ranged between 0.82 and 3.53, indicating robustness of these results, while the average Dice coefficients from jackknife reliability analyses ranged between 0.6 and 1, indicating fair (inter-regional ROI-ROI connectivity) to perfect (within-sensorimotor network connectivity) reliability of the results. The catatonia sample showed reduced vertex-wise cortical complexity in the right insular cortex and contiguous areas. Thus, we have identified neuroimaging markers of the acute retarded catatonic state that may show an association with treatment response to benzodiazepines. We discuss how these novel findings have important translational implications for understanding the pathophysiology of catatonia as well as for the mechanistic understanding and prediction of treatment response to benzodiazepines.

COVID-19 and first manic episodes: a systematic review

Sars-CoV-2 is a respiratory virus that can access the central nervous system, as indicated by the presence of the virus in patients' cerebrospinal fluid and the occurrence of several neurological syndromes during and after COVID-19. Growing evidence indicates that Sars-CoV-2 can also trigger the acute onset of mood disorders or psychotic symptoms. COVID-19-related first episodes of mania, in subjects with no known history of bipolar disorder, have never been systematically analyzed. Thus, the present study assesses a potential link between the two conditions. This systematic review analyzes cases of first appearance of manic episodes associated with COVID-19. Clinical features, pharmacological therapies, and relationships with pre-existing medical conditions are also appraised. Medical records of twenty-three patients fulfilling the current DSM-5 criteria for manic episode were included. Manic episodes started, on average, after 12.71±6.65 days from the infection onset. Psychotic symptoms were frequently reported. 82.61% of patients exhibited delusions, whereas 39.13% of patients presented hallucinations. A large discrepancy in the diagnostic workups was observed. Mania represents an underestimated clinical presentation of COVID-19. Further studies should focus on the pathophysiological substrates of COVID-19-related mania and pursue appropriate and specific diagnostic and therapeutic workups.

Management and outcomes of catatonia: A prospective study in urban South Africa

Objectives

Rapid intervention for catatonia with benzodiazepines and electroconvulsive therapy can prevent fatal complications. We describe the management and treatment response of 44 patients with catatonia in a psychiatric unit in urban South Africa. The objective was to screen admissions for catatonia and investigate management, treatment response, and treatment outcomes.

Method

We used a prospective, descriptive, observational study design and collected data using a data collection sheet, the Bush Francis Catatonia Screening Instrument, the Bush Francis Catatonia Rating Scale, and the Diagnostic Statistical Manual-5 to assess catatonia in new admissions from September 2020 to August 2021.

Results

Of the 241 participants screened on admission, 44 (18.3% of 241) screened positive for catatonia on the Bush Francis Catatonia Screening Instrument, while 197 (81.7% of 241) did not. Thirty-eight (86.4% of 44) received lorazepam, seven (15.9%) received clonazepam, and two (4.6%) received diazepam, implying that three (6.8%) of the 44 participants with catatonia received more than one benzodiazepine sequentially. Ten (22.7% of 44) patients received electroconvulsive therapy. Seven of those treated with electroconvulsive therapy (15.9% of 44 and 70% of 10) responded well and were discharged, whereas 22 (50% of 44 and 64.7% of 34) of those given lorazepam were discharged. Patients treated with electroconvulsive therapy had a higher initial Bush Francis Catatonia Rating Scale score. One patient (2.3%) relapsed within 4 weeks of discharge. Twenty (45.5%) of the 44 patients with catatonia had low average iron levels, 14 (31.8%) had low vitamin B12, and 24 (54.6%) had high creatinine kinase.

Conclusion

Both lorazepam and electroconvulsive therapy were found to be effective treatments for catatonia with good response and outcomes. The length of hospital stay of patients with catatonia was similar to that of patients without catatonia. Treatment guidelines for catatonia need to include the role and timing of electroconvulsive therapy to augment current treatment protocols for the use of lorazepam.

Catatonia Psychopathology and Phenomenology in a Large Dataset

Background

The external clinical manifestations (psychopathology) and internal subjective experience (phenomenology) of catatonia are of clinical importance but have received little attention. This study aimed to use a large dataset to describe the clinical signs of catatonia; to assess whether these signs are associated with underlying diagnosis and prognosis; and to describe the phenomenology of catatonia, particularly with reference to fear.

Methods

A retrospective descriptive cross-sectional study was conducted using the electronic healthcare records of a large secondary mental health trust in London, United Kingdom. Patients with catatonia were identified in a previous study by screening records using natural language processing followed by manual validation. The presence of items of the Bush-Francis Catatonia Screening Instrument was coded by the investigators. The presence of psychomotor alternation was assessed by examining the frequency of stupor and excitement in the same episode. A cluster analysis and principal component analysis were conducted on catatonic signs. Principal components were tested for their associations with demographic and clinical variables. Where text was available on the phenomenology of catatonia, this was coded by two authors in an iterative process to develop a classification of the subjective experience of catatonia.

Results

Searching healthcare records provided 1,456 validated diagnoses of catatonia across a wide range of demographic groups, diagnoses and treatment settings. The median number of catatonic signs was 3 (IQR 2-5) and the most commonly reported signs were mutism, immobility/stupor and withdrawal. Stupor was present in 925 patients, of whom 105 (11.4%) also exhibited excitement. Out of 196 patients with excitement, 105 (53.6%) also had immobility/stupor. Cluster analysis produced two clusters consisting of negative and positive clinical features. From principal component analysis, three components were derived, which may be termed parakinetic, hypokinetic and withdrawal. The parakinetic component was associated with women, neurodevelopmental disorders and longer admission duration; the hypokinetic component was associated with catatonia relapse; the withdrawal component was associated with men and mood disorders. 68 patients had phenomenological data, including 49 contemporaneous and 24 retrospective accounts. 35% of these expressed fear, but a majority (72%) gave a meaningful narrative explanation for the catatonia, which consisted of hallucinations, delusions of several different types and apparently non-psychotic rationales.

Conclusion

The clinical signs of catatonia can be considered as parakinetic, hypokinetic and withdrawal components. These components are associated with diagnostic and prognostic variables. Fear appears in a large minority of patients with catatonia, but narrative explanations are varied and possibly more common.

A prospective descriptive study on prevalence of catatonia and correlates in an acute mental health unit in Nelson Mandela Bay, South Africa

Catatonia is a psychomotor abnormality caused by neurological, medical or severe psychiatric disorders and substances. Its prevalence ranges from less than 10% to just above 60%. Diagnosis may be influenced by the screening tools used. Screening of new admissions to a mental health unit for catatonia was undertaken using three instruments to determine prevalence of catatonia. Participants ranged from age 16 years and over. Recruitment took place from September 2020 to August 2021. The setting was a mental health unit within a general hospital in Nelson Mandela Metro, South Africa. Five assessors were trained by the principal investigator to apply the Bush Francis Screening Instrument (BFCSI), the Bush Francis Catatonia Rating Scale (BFCRS), and the Diagnostic and Statistical Manual 5 (DSM-5), to assess participants. Clinical and demographic data were collected using a specially designed datasheet. Data analysis was performed to identify significant associations between presence or absence of catatonia and clinical and demographic data. Up to 241 participants were screened and 44 (18.3%) had catatonia. All 44 cases were identified through the BFCSI while the DSM-5 identified only 16 (6.6%%) of the 44 cases even though the remaining 28 (63.6%) participants still required treatment for catatonic symptoms. The DSM-5 diagnostic criteria excluded staring, which was the commonest sign of catatonia identified through the BFCSI [n = 33 (75%)]. Close to half (21; 47.7%) of those with catatonia on the BFCSI had schizophrenia. The rest had bipolar disorder (12; 27.3%), substance-induced psychotic disorder (7; 15.9%) and no specified diagnosis in one (1; 2.6%). The BFCSI was very effective at identifying catatonia while the DSM-5 was inadequate, missing close to 64% (28 of 44) of cases. Predictors of catatonia in this sample were a younger age and being male. A prevalence of 18.3%, indicates that assessment for catatonia should be routinely conducted in this and similar settings.

Evaluating the Effectiveness of an Educational Module for the Bush-Francis Catatonia Rating Scale

OBJECTIVE

Catatonia is widely underdiagnosed, in large part due to inaccurate recognition of its specific features. This study aimed to evaluate the effectiveness of an online educational module to improve theoretical and practical knowledge of the Bush-Francis Catatonia Rating Scale (BFCRS) across a broad range of clinicians and medical students.

METHOD

A 1-h online module, including a training manual and videos, was disseminated to medical students, psychiatry residents and fellows, and psychiatrists through national Listservs and through the Academy of Consultation-Liaison Psychiatry. Participants completed pre- and post-module testing consisting of a 50-question multiple-choice test and a 3-min standardized patient video scored using the 23-item BFCRS. Participants accessed the module from October 1, 2020, to April 4, 2021. Immediate improvement and 3-month knowledge retention were assessed using quantitative and qualitative analyses.

RESULTS

Study enrollment was high with moderate dropout (pre-testing: n = 482; post-testing: n = 236; 3-month testing: n = 105). Adjusting for demographics, large pre-post improvements were found in performance (multiple-choice: 11.3 points; standardized patient scoring: 4.2 points; both p < 0.001) and for nearly all individual BFCRS items. Knowledge attrition was modest, and improvements persisted at 3 months.

CONCLUSIONS

This educational resource provides descriptive and demonstrative reference standards of the items on the BFCRS. This curriculum improved identification of catatonia's features on both multiple choice and standardized patient scoring across all ages and training levels with good overall knowledge retention.

Catatonia in older adults: A systematic review

BACKGROUND

Catatonia is a complex psychomotor syndrome that often goes unrecognized and untreated, even though its classification has evolved in recent years. Prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications. The underrecognition of catatonia in older patients is also frequent, and research in this population is scarce.

AIM

To conduct a systematic review of the literature on catatonia in older people to ascertain its clinical characteristics across settings.

METHODS

Following the PRISMA guidelines, MEDLINE, EMBASE, and PsycINFO databases were searched from inception to December 2021, with a strategy aimed at identifying all articles published on catatonia in older adults. Titles and abstracts were scanned and selected independently by two authors. Papers investigating issues related to catatonia and/or catatonic symptoms in older people, with English abstracts available, were included. References of selected articles were revised to identify other relevant studies.

RESULTS

In total, 1355 articles were retrieved. After removing duplicates, 879 remained. Of the 879 identified abstracts, 669 were excluded because they did not meet the inclusion criteria. A total of 210 articles underwent full text review, and 51 were eliminated for various reasons. Fourteen more articles were selected from the references. Overall, 173 articles were reviewed: 108 case reports, 35 case series, 11 prospective cohort studies, 6 case-control studies, 3 retrospective cohort studies and 10 reviews. We found several particular aspects of catatonia in this population. Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. Older patients, compared to younger patients, have a higher risk of developing catatonia with benzodiazepine (BZD) withdrawal, in bipolar disorder, and in the general hospital. Age, together with other risk factors, was significantly associated with the incidence of deep venous thrombosis, neuroleptic malignant syndrome poor outcome, other complications and mortality. Treatment with BZDs and electroconvulsive therapy is safe and effective. Prompt treatment of its cause is essential to ensure a good prognosis.

CONCLUSION

Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. The risk of developing catatonia in some settings and conditions, as well as of developing complications, is high in this population. Symptomatic treatment is safe and effective, and timely etiologic treatment is fundamental.

Malignant catatonia: Severity, treatment and outcome - a systematic case series analysis

Objectives: Malignant catatonia (MC) is a rare, yet potentially life-threatening neuropsychiatric condition. Evidence on its therapy is weak, treatment recommendations are scarce and predominantly unprecise. The aim of this study was to compare the effectiveness of different MC treatment approaches regarding outcome and severity of MC.Methods: We conducted systematic searches for MC case reports in biomedical databases and the psychiatric archive of University Hospital Ulm. Treatments were compared considering MC severity and temporal aspects.Results: A total of 117 cases were included. Treatment had a significant influence on outcome: treatment with both benzodiazepines and electroconvulsive therapy (ECT) entailed the most favourable, purely supportive therapy the least favourable outcome. Earlier application of benzodiazepines was significantly associated with a favourable outcome. A classification of MC severity was developed. Patients with severe MC were significantly more often subject to intensive care treatment and had a 78% higher risk of dying than in moderate MC.Conclusions: This is the first study to introduce a severity classification for MC, and the largest to compare outcomes of MC treatments with clear distinction from neuroleptic malignant syndrome (NMS). Preferable MC treatment should include early initiation of benzodiazepines and ECT. MC severity could serve as a prognostic instrument.

Assessment of catatonia and inter-rater reliability of three instruments: a descriptive study

BACKGROUND

Clinical assessment of catatonia includes the use of diagnostic systems, such as the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) and the International Classification of Disease, Tenth Revision (ICD-10), or screening tools such as the Bush Francis Catatonia Screening Instrument (BFCSI)/Bush Francis Catatonia Rating Scale (BFCRS) and the Braunig Catatonia Rating Scale. In this study, we describe the inter-rater reliability (IRR), utilizing the BFCSI, BFCRS, and DSM-5 to screen for catatonia.

METHODS

Data from 10 participants recruited as part of a larger prevalence study (of 135 participants) were used to determine the IRR by five assessors after they were trained in the application of the 14-item BFCSI, 23-item BFCRS, and DSM-5 to assess catatonia in new admissions. Krippendorff's α was used to compute the IRR, and Spearman's correlation was used to determine the concordance between screening tools. The study site was a 35-bed acute mental health unit in Dora Nginza Hospital, Nelson Mandela Bay Metro. Participants were mostly involuntary admissions under the Mental Health Care Act of 2002 and between the ages of 13 and 65 years.

RESULTS

Of the 135 participants, 16 (11.9%) had catatonia. The majority (92 [68.1%]) were between 16 and 35 years old, with 126 (93.3%) of them being Black and 89 (66.4%) being male. The BFCRS (complete 23-item scale) had the greatest level of inter-rater agreement with α = 0.798, while the DSM-5 had the lowest level of inter-rater agreement with α = 0.565. The highest correlation coefficients were observed between the BFCRS and the BFCSI.

CONCLUSION

The prevalence rate of catatonia was 11.9%, with the BFCSI and BFCRS showing the highest pick-up rate and a high IRR with high correlation coefficients, while the DSM-5 had deficiencies in screening for catatonia with low IRR and the lowest correlation with the other two tools.

Cannabis-Induced Malignant Catatonia: A Medical Emergency and Review of Prior Case Series

Few case reports of catatonia associated with cannabis use are reported. Here, we describe a case of a 35-year-old African American male who developed malignant catatonia following heavy cannabis use. The patient was brought to the emergency department (ED) for altered mental status, hypertension, and erratic behavior. Before his ED presentation, he was smoking cannabis in heavy amounts, confirmed by positive urine toxicology in ED. Initial lab results showed leukocytosis, elevated creatine phosphokinase (CPK) levels. Head CT scans without contrast, including cerebrospinal fluid (CSF) analysis, were nonsignificant. In ED, the patient was agitated, combative, mute, and rigid. He was sedated using 2 mg of intramuscular (IM) midazolam. Psychiatric consultation services suspected catatonia, and the patient scored 12 points on Bush-Francis Catatonia Rating Scale (BFCRS). Although the patient’s symptoms responded to 2 mg of IM lorazepam, the patient later relapsed, became tachycardic with blood pressure fluctuations, and his repeat BFCRS score was 18. At this point, the patient was diagnosed as having malignant catatonia, and his lorazepam dosage was increased up to 6 mg IM per day. After a few days of waxing and waning of his symptoms, he finally started to show constant improvement and gradually reduced his symptoms. Our case highlights the first-ever reported case of malignant catatonia associated with cannabis use.

Factors associated with post-electroconvulsive therapy delirium: A retrospective chart review study

Although electroconvulsive therapy (ECT) is generally a safe therapeutic method, unexpected adverse effects, such as post-ECT delirium, may occur. Despite its harmful consequences, there has been little discussion about the predictors of post-ECT delirium. Thus, the current study aimed to clarify the factors associated with post-ECT delirium by reviewing electronic medical records of 268 bitemporal ECT sessions from December 2006 to July 2018 in a university hospital.Demographic and clinical characteristics of sessions involving patients with or without post-ECT delirium were compared. Multiple logistic regression analysis was applied to analyze the correlation between variables and post-ECT delirium.Post-ECT delirium developed in 23 sessions (8.6%). Of all the demographic and clinical variables measured, only etomidate use was significantly different between delirium-positive and delirium-negative groups after Bonferroni correction. The regression model also indicated that etomidate use to be significantly associated with post-ECT delirium.In this study, etomidate was associated with a higher risk of developing post-ECT delirium, an association that appeared unrelated to other possible measured variables. Practitioners should take into account the risk of post-ECT delirium while choosing anesthetics, so as to prevent early discontinuation before sufficient therapeutic gain is achieved.

Protocol for a prospective descriptive prevalence study of catatonia in an acute mental health unit in urban South Africa

INTRODUCTION

Catatonia arises from serious mental, medical, neurological or toxic conditions. The prevalence range depends on the setting and the range is anything from 7% to 63% in other countries. South African prevalence rates are currently unknown. The proposed study is a quantitative descriptive study using the Bush Francis Catatonia Screening Instrument as a screening tool with a data capturing information sheet to extract clinical information from patient folders. The study will investigate: (1) prevalence of catatonia, (2) clinical and demographic correlates associated with catatonia, (3) predictors of catatonia, (4) response to treatment and (5) subjective experience of catatonia.

METHODS AND ANALYSIS

The setting is an acute mental health unit (MHU) within a regional, general medical hospital in Nelson Mandela Bay, South Africa, which accepts referrals from within the hospital and from outlying clinics. Participants will be recruited from inpatients in the MHU from beginning of September 2020 to end of August 2021. Most admissions are involuntarily, under the Mental Health Care Act of 2002 with an age range of 13 to over 65 years. Participants who screen positive for catatonia will be followed up after discharge for 3 months to measure outcomes. Primary outcomes will include the 12-month prevalence rate of catatonia, descriptive and other data on presentation and assessment of catatonia in the MHU. Secondary outcomes will include data on treatment response, participants' report of their subjective experience of catatonia and predictors of catatonia. Descriptive statistics, multivariate binomial logistic regression and univariate analyses will be conducted to evaluate associations between catatonia and clinical or demographic data which could be predictors of catatonia. Survival analysis will be used to examine the time to recovery after diagnosis and initiation of treatment. The 95% CI will be used to demonstrate the precision of estimates. The level of significance will be p≤0.05.

ETHICS AND DISSEMINATION

The study has received ethical approval from the Research and Ethics Committees of the Eastern Cape Department of Health, Walter Sisulu University and Nelson Mandela University. The results will be disseminated as follows: at various presentations and feedback sessions; as part of a PhD thesis in Psychology at Nelson Mandela University; and in a manuscript that will be submitted to a peer-reviewed journal.

Cognitive motor impairments and brain structure in schizophrenia spectrum disorder patients with a history of catatonia

There is growing interest in understanding the behavioral and neural mechanisms of catatonia. Here, we examine cognition and brain structure in schizophrenia spectrum disorder (SSD) patients with a history of catatonia. A total of 172 subjects were selected from a data repository; these included SSD patients with (n = 43) and without (n = 43) a history of catatonia and healthy control subjects (n = 86). Cognitive functioning was assessed using the Screen for Cognitive Impairment in Psychiatry (SCIP) and brain structure was assessed using voxel-based morphometry (VBM) in the CAT12 toolbox. SSD patients with a history of catatonia showed worse performance on tests of verbal fluency and processing speed compared to SSD patients without such a history, even after controlling for current antipsychotic and benzodiazepine use. No differences were found between patients with and without a history of catatonia in terms of brain structure. Both patient groups combined showed significantly smaller grey matter volumes compared to healthy control subjects in brain regions consistent with prior studies, including the anterior cingulate, insular, temporal, and medial frontal cortices. The results highlight a cognitive-motor impairment in SSD patients with a history of catatonia. Challenges and limitations of examining brain structure in patients with a history of catatonia are discussed.

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.

Psychiatric Symptoms of Patients With Anti-NMDA Receptor Encephalitis

Objective: We conducted this study to analyze the clinical characteristics of the psychiatric symptoms of patients with anti-NMDAR encephalitis. Methods: A retrospective study of anti-NMDAR encephalitis in China was performed. The clinical characteristics of the psychiatric symptoms, the relationship between the antibodies titers and clinical characteristics of patients with anti-NMDAR encephalitis were determined. Results: A total of 108 patients with a definitive diagnosis of anti-NMDAR encephalitis were included in this study. 103 patients (95%) developed one or several psychiatric symptoms. The comparison of the high titer group and the low titer group showed that more patients presented psychiatric symptoms as the initial symptom in the high titer group (P = 0.020), the prevalence of the symptoms such as depressive, catatonic, and central hypoventilation were also higher in the high titer group than the low titer group (P = 0.033, 0.031 and 0.006, respectively). Meanwhile, more patients received a combination treatment of IVIg and corticosteroids in the high titer group than the low titer group and patients in high titer group were prescript with anti-psychiatric drugs more often than the patients in low titer group (P = 0.026 and 0.003, respectively). Conclusions: Psychiatric symptoms are the most common clinical characteristics of patients with anti-NMDAR encephalitis. Patients with higher antibodies titers more often presented with psychiatric symptoms as the initial symptom, and showed a more severe clinical feature. Screening for the anti-NMDAR antibodies is essentially important in patients who present psychiatric symptoms with or without other neurological symptoms.

Multimodal Magnetic Resonance Imaging Data Fusion Reveals Distinct Patterns of Abnormal Brain Structure and Function in Catatonia

Catatonia is a nosologically unspecific syndrome, which subsumes a plethora of mostly complex affective, motor, and behavioral phenomena. Although catatonia frequently occurs in schizophrenia spectrum disorders (SSD), specific patterns of abnormal brain structure and function underlying catatonia are unclear at present. Here, we used a multivariate data fusion technique for multimodal magnetic resonance imaging (MRI) data to investigate patterns of aberrant intrinsic neural activity (INA) and gray matter volume (GMV) in SSD patients with and without catatonia. Resting-state functional MRI and structural MRI data were collected from 87 right-handed SSD patients. Catatonic symptoms were examined on the Northoff Catatonia Rating Scale (NCRS). A multivariate analysis approach was used to examine co-altered patterns of INA and GMV. Following a categorical approach, we found predominantly frontothalamic and corticostriatal abnormalities in SSD patients with catatonia (NCRS total score ≥ 3; n = 24) when compared to SSD patients without catatonia (NCRS total score = 0; n = 22) matched for age, gender, education, and medication. Corticostriatal network was associated with NCRS affective scores. Following a dimensional approach, 33 SSD patients with catatonia according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision were identified. NCRS behavioral scores were associated with a joint structural and functional system that predominantly included cerebellar and prefrontal/cortical motor regions. NCRS affective scores were associated with frontoparietal INA. This study provides novel neuromechanistic insights into catatonia in SSD suggesting co-altered structure/function-interactions in neural systems subserving coordinated visuospatial functions and motor behavior.

[Catatonia in clinical reality: underdiagnosed and forgotten]

BACKGROUND

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

METHOD

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

RESULTS AND CONCLUSIONS

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

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.

Prevalence of catatonic signs and symptoms in an acute psychiatric unit from a tertiary psychiatric center in India

BACKGROUND

The prevalence of catatonia varies with the setting and type of rating scale used to measure catatonia. Catatonia, initially subsumed under schizophrenia, now is increasingly recognized in association with affective disorders.

AIM

We aimed to examine the prevalence of catatonia in an acute psychiatric inpatient unit in a tertiary center in India.

METHODS

Study subjects (n = 300) were randomly selected from amongst the inpatients over one year and evaluated within 24 h of admission using BFCRS and NCS, besides a sociodemographic and clinical proforma. During the inpatient stay MINI PLUS 5.0 was applied.

RESULTS

Among 300 inpatients recruited, 88 (29.3%) demonstrated at least one catatonic sign in either of the rating scales. As per the diagnostic cut-offs defined by BFCRS and NCS, the prevalence of catatonia syndrome was 49 (16.3%) and 32 (10.6%) respectively. The prevalence rates as per ICD-10 criteria and DSM-5 criteria were 19% and 5.3% respectively. The two most frequently noted signs - staring and withdrawal, were not listed as signs in either the ICD-10 or DSM V. The prevalence of catatonic symptoms was different in psychotic disorders in contrast to affective disorders. Severity of catatonia was associated with younger age, lesser duration of primary illness and prior episodes of catatonia.

CONCLUSIONS

The prevalence of catatonia varies from 5.3% to 19% based on the criteria used. Identification warrants use of structured instruments. Catatonia is more severe in the initial years of illness, those with prior episodes of catatonia and in the younger age group.

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.

The utility of an RDoC motor domain to understand psychomotor symptoms in depression

Despite the clinical impact of motor symptoms such as agitation or retardation on the course of depression, these symptoms are poorly understood. Novel developments in the field of instrumentation and mobile devices allow for dimensional and continuous recording of motor behavior in various settings, particularly outside the laboratory. Likewise, the use of novel assessments enables to combine multimodal neuroimaging with behavioral measures in order to investigate the neural correlates of motor dysfunction in depression. The research domain criteria (RDoC) framework will soon include a motor domain that will provide a framework for studying motor dysfunction in mood disorders. In addition, new studies within this framework will allow investigators to study motor symptoms across different stages of depression as well as other psychiatric diagnoses. Finally, the introduction of the RDoC motor domain will help test how motor symptoms integrate with the original five RDoC domains (negative valence, positive valence, cognitive, social processes, and arousal/regulation).

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.

Severe clinical events in 100 patients with schizophrenia: a retrospective clinical description using a system-specific psychopathological approach

Catatonic states and numerous other severe clinical events can complicate the course of schizophrenia. Whether these severe courses are associated with particular system-specific symptom dimensions remain unclear. Aim is to assess the frequency of severe clinical events in a clinical population and to investigate the association of these events with sociodemographic data and system-specific psychopathology, combining qualitative and quantitative data. We performed a comprehensive retrospective description of a well-described and geographically stable sample of 100 patients with schizophrenia or schizoaffective disorder and linked severe clinical events with sociodemographic data at inclusion into the study (as indicators of social functioning) and symptoms at first admission, classified with the Bern Psychopathology Scale (BPS). We found 12 mentions of catatonic stupor or excitement, 45 of suicide attempts, 26 of suicidality, 18 of deliberate self-harm, 18 of self-threatening behaviour other than deliberate self-harm, 34 of violence against other persons, 18 of violence against objects and six of sexual harassment. Disinhibited language on first admission seemed to be a protective factor against suicidality and disinhibited motor behaviour seemed to predict self-threatening and violent behaviour. Catatonia and violence in particular seemed to be socially disabling. This exploratory study showed that the BPS is a promising instrument and might represent a system-specific approach in identifying patients at risk for severe sequelae of schizophrenia. This will have to be tested in future prospective studies.

Distinct Associations of Motor Domains in Relatives of Schizophrenia Patients-Different Pathways to Motor Abnormalities in Schizophrenia?

INTRODUCTION

Aberrant motor function is an integral part of schizophrenia. In fact, abnormalities are frequently found in patients, in populations at risk, and in unaffected relatives. Motor abnormalities are suspected to be relevant for the clinical outcome and could probably predict the conversion from at-risk individuals to schizophrenia. Furthermore, motor function has been argued as endophenotype of the disorder. Yet, which particular motor domain may classify as a potential endophenotype is unknown. We aimed to compare schizophrenia patients, unaffected first-degree relatives and healthy controls for different motor domains. We expected impairments in all domains in patients and in some domains in relatives.

METHOD

We included 43 schizophrenia patients, 34 unaffected first-degree relatives of schizophrenia patients, and 29 healthy control subjects, matched for age, gender, and education level. We compared motor function of four motor domains between the groups. The domains comprise neurological soft signs (NSS), abnormal involuntary movements (dyskinesia), Parkinsonism, and fine motor function including simple [finger tapping (FT)] and complex fine motor function, (i.e., dexterity as measured with the coin rotation test). Furthermore, we tested the association of motor function of the four domains with working memory, frontal lobe function, and nonverbal intelligence for each group separately using within-group bivariate correlations.

RESULTS

Schizophrenia patients showed poorer motor function in all tested domains compared to healthy controls. First-degree relatives had intermediate ratings with aberrant function in two motor domains. In detail, relatives had significantly more NSS and performed poorer in the FT task than controls. In contrast, complex fine motor function was intact in relatives. Relatives did not differ from controls in dyskinesia or Parkinsonism severity.

DISCUSSION

Taken together, schizophrenia patients have motor abnormalities in all tested domains. Thus, motor abnormalities are a key element of the disorder. Likewise, first-degree relatives presented motor deficits in two domains. A clear difference between relatives and healthy controls was found for NSS and FT. Thus, NSS and FT may be potential markers of vulnerability for schizophrenia. The lack of association between genetic risk and dyskinesia or Parkinsonism suggests distinct pathobiological mechanisms in the various motor abnormalities in schizophrenia.

Catatonia as a putative nosological entity: A historical sketch

Kahlbaum was the first to propose catatonia as a separate disease following the example of general paresis of the insane, which served as a model for establishing a nosological entity. However, Kahlbaum was uncertain about the nosological position of catatonia and considered it a syndrome, or “a temporary stage or a part of a complex picture of various disease forms”. Until recently, the issue of catatonia as a separate diagnostic category was not entertained, mainly due to a misinterpretation of Kraepelin’s influential views on catatonia as a subtype of schizophrenia. Kraepelin concluded that patients presenting with persistent catatonic symptoms, which he called “genuine catatonic morbid symptoms”, particularly including negativism, bizarre mannerisms, and stereotypes, had a poor prognosis similar to those of paranoid and hebephrenic presentations. Accordingly, catatonia was classified as a subtype of dementia praecox/schizophrenia. Despite Kraepelin’s influence on psychiatric nosology throughout the 20^th century, there have only been isolated attempts to describe and classify catatonia outside of the Kraepelinian system. For example, the Wernicke-Kleist-Leonhard school attempted to comprehensively elucidate the complexities of psychomotor disturbances associated with major psychoses. However, the Leonhardian categories have never been subjected to the scrutiny of modern investigations. The first three editions of the DSM included the narrow and simplified version of Kraepelin’s catatonia concept. Recent developments in catatonia research are reflected in DSM-5, which includes three diagnostic categories: Catatonic Disorder due to Another Medical Condition, Catatonia Associated with another Mental Disorder (Catatonia Specifier), and Unspecified Catatonia. Additionally, the traditional category of catatonic schizophrenia has been deleted. The Unspecified Catatonia category could encourage research exploring catatonia as an independent diagnostic entity.

Resting-State Hyperperfusion of the Supplementary Motor Area in Catatonia

Catatonia is a psychomotor syndrome that not only frequently occurs in the context of schizophrenia but also in other conditions. The neural correlates of catatonia remain unclear due to small-sized studies. We therefore compared resting-state cerebral blood flow (rCBF) and gray matter (GM) density between schizophrenia patients with current catatonia and without catatonia and healthy controls. We included 42 schizophrenia patients and 41 controls. Catatonia was currently present in 15 patients (scoring >2 items on the Bush Francis Catatonia Rating Scale screening). Patients did not differ in antipsychotic medication or positive symptoms. We acquired whole-brain rCBF using arterial spin labeling and GM density. We compared whole-brain perfusion and GM density over all and between the groups using 1-way ANCOVAs (F and T tests). We found a group effect (F test) of rCBF within bilateral supplementary motor area (SMA), anterior cingulate cortex, dorsolateral prefrontal cortex, left interior parietal lobe, and cerebellum. T tests indicated 1 cluster (SMA) to be specific to catatonia. Moreover, catatonia of excited and retarded types differed in SMA perfusion. Furthermore, increased catatonia severity was associated with higher perfusion in SMA. Finally, catatonia patients had a distinct pattern of GM density reduction compared to controls with prominent GM loss in frontal and insular cortices. SMA resting-state hyperperfusion is a marker of current catatonia in schizophrenia. This is highly compatible with a dysregulated motor system in catatonia, particularly affecting premotor areas. Moreover, SMA perfusion was differentially altered in retarded and excited catatonia subtypes, arguing for distinct pathobiology.

Motor Abnormalities: From Neurodevelopmental to Neurodegenerative Through "Functional" (Neuro)Psychiatric Disorders

Background

Motor abnormalities (MAs) of severe mental disorders have been traditionally neglected both in clinical practice and research, although they are an increasing focus of attention because of their clinical and neurobiological relevance. For historical reasons, most of the literature on MAs has been focused to a great extent on schizophrenia, and as a consequence their prevalence and featural properties in other psychiatric or neuropsychiatric disorders are poorly known. In this article, we evaluated the extent to which catatonic, extrapyramidal and neurological soft signs, and their associated clinical features, are present transdiagnostically.

Methods

We examined motor-related features in neurodevelopmental (schizophrenia, obsessive compulsive disorder, autism spectrum disorders), "functional" (nonschizophrenic nonaffective psychoses, mood disorders) and neurodegenerative (Alzheimer's disease) disorders. Examination of the literature revealed that there have been very few comparisons of motor-related features across diagnoses and we had to rely mainly in disorder-specific studies to compare it transdiagnostically.

Results

One or more motor domains had a substantial prevalence in all the diagnoses examined. In "functional" disorders, MAs, and particularly catatonic signs, appear to be markers of episode severity; in chronic disorders, although with different degree of strength or evidence, all motor domains are indicators of both disorder severity and poor outcome; lastly, in Alzheimer's disease they are also indicators of disorder progression.

Conclusions

MAs appear to represent a true transdiagnostic domain putatively sharing neurobiological mechanisms of neurodevelopmental, functional or neurodegenerative origin.

Prevalence and characteristics of catatonia on admission to an acute geriatric psychiatry ward

BACKGROUND

This study aims to describe the prevalence of catatonia in a population of older acute psychiatric inpatients according to different diagnostic criteria. Secondary objectives are: to compare the catatonic symptom profile, prevalence, and severity, in respect to the underlying aetiology, and to evaluate the association between catatonic and somatic comorbidity.

METHODS

The study included 106 patients admitted to an acute geriatric psychiatry ward. Catatonia was assessed using the Bush Francis Catatonia Rating Scale (BFCRS).

RESULTS

Catatonia was highly prevalent (n=42; 39.6%), even when using restrictive diagnostic criteria: Fink and Taylor (n=19; 17.9%) and DSM 5 (n=22; 20.8%). Depression was the most frequent psychiatric syndrome among catatonic patients (n=18; 42.8%). Catatonia was more frequent in depression (48.6%) and delirium (66.7%). Affective disorders showed a higher risk than psychotic disorders to develop catatonia (OR=2.68; 95% CI 1.09-6.61). This association was not statistically significant when controlling for dementia and geriatric syndromes. The most prevalent catatonic signs were excitement (64.3%), verbigeration (61.9%), negativism (59.5%), immobility/stupor (57.1%), and staring (52.4%).

CONCLUSIONS

Catatonia in older psychiatric inpatients was highly prevalent. Depression was the most common psychiatric syndrome among catatonic patients, and catatonia was more frequent in depression and mania, as well as in delirium. Affective disorders were associated with a higher risk of developing catatonia compared to psychotic disorders. Somatic and cognitive comorbidity played a crucial aetiological role in catatonia in this series.

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.

Catatonic syndrome: From detection to therapy

INTRODUCTION

Catatonia is a psychomotor syndrome which can include motor, mental, behavioral and vegetative symptoms. Exclusively associated with schizophrenia until the 1970s, catatonia still remains an under-diagnosed syndrome with significant morbidity and mortality.

LITERATURE FINDINGS

As a result of its different forms and developments, catatonic syndrome can be associated with many organic and psychiatric etiologies and confused with a variety of diagnoses. In addition to its organic complications, malignant catatonia can also be extremely severe. Several diagnostic scales are described, those of Bush and Peralta being the most widely used. Despite the recent development of the DSM-5, we can regret the lack of progress in the international classifications concerning both the recognition of the etiological diversity of this syndrome and in the clinical and therapeutic approaches to it. The diagnosis is based solely on clinical data, and needs to be completed by information from paraclinical settings, particularly with respect to detecting organic etiology. The first-line treatment is still based on the use of certain benzodiazepines or benzodiazepine-like agents such as lorazepam, diazepam and zolpidem. If the first or second line fails, or in case of malignant catatonia, electroconvulsive therapy is recommended. For the periodic form, no large-sample study has been performed on long-term treatment. A few case reports suggest the use of lithium in periodic catatonia, specifically to prevent recurrent episodes or at least to extend the inter-episode intervals. Other studies are in favor of the use of benzodiazepines, with disagreement between gradual discontinuation and long-term treatment. Concerning the management of catatonia in patients with schizophrenia, for whom first-line benzodiazepines are often insufficient, certain atypical antipsychotics such as clozapine or quetiapine appear efficient. These data are also applicable to children and adolescents.

CONCLUSION

Often neglected by practitioners, catatonic syndrome remains a common entity of which it is important to be aware, especially in case of rapid installation of the symptoms. Diagnostic scales should be used and a lorazepam test should be performed to avoid delaying the diagnosis. Second-line therapy requires further study. This concerns in particular diazepam, anti-NMDA (N-methyl-D-aspartate) and rTMS (repetitive transcranial magnetic stimulation). Some specificities of catatonia, such as the periodic form and cases in patients with schizophrenia, also require further evaluations.

Prevalence and symptomatology of catatonia in elderly patients referred to a consultation-liaison psychiatry service

OBJECTIVES

To determine the prevalence and clinical correlations of catatonia in patients aged over 65 years who are referred to a consultation-liaison service within a regional area of Australia. Additionally, to examine if the use of standardised screening tools is likely to change the rate of diagnosis of catatonia within the consultation-liaison service.

METHODS

One hundred and eight referrals from general hospital wards were assessed using the Bush-Francis Catatonia Screening Instrument (BFCSI) and associated examination; each consented patient was screened for catatonic symptoms. If two or more signs were present on the BFCSI, then severity was rated using the Bush-Francis Catatonia Rating Scale. These clinical characteristics were compared with their socio-demographic and medical data.

RESULTS

Prevalence of catatonia was 5.5%. The most common symptoms appeared to be rigidity, posturing and immobility (67% of cases), and were elicited through routine psychiatric examination.

CONCLUSIONS

Routine psychiatric history and examination are likely sufficient to elicit catatonic signs in a consultation-liaison setting. Standardised screening examination may be more suited for conducting research or for use when examining for catatonia in psychiatric inpatient settings.