Measuring catatonia: a systematic review of rating scales

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.

Case Report: Catatonic Stupor in Behavioral Variant Frontotemporal Dementia

Catatonia is a psychomotor syndrome common to several medical and neuropsychiatric disorders. Here, we report on the case of a 95-year-old woman who underwent a radical change in personality characterized by sexual disinhibition, and physical and verbal aggressiveness. Over several months, she developed verbal stereotypies, gait deterioration, and double incontinence. She eventually developed mutism and an active opposition to all attempts to be fed or cared for. Benzodiazepines, olanzapine and electroconvulsive therapy were of no benefit. Magnetic resonance imaging revealed asymmetric (more severe on the right) frontotemporal, parietal, and upper brainstem atrophy. She died from sepsis without recovering from stupor seven years after the onset of symptoms. We believe that the initial behavioral disinhibition was related to the frontotemporal injury, whereas catatonic stupor reflected the progression of the degenerative process to the parietal cortices. Our case adds to the small number of cases of catatonia as a symptom of degenerative dementia. It also supports the idea that damage to the parietal cortex gives rise to pathological avoidance of which catatonic stupor represents an extreme form.

Measuring catatonia motor behavior with objective instrumentation

OBJECTIVE

Catatonia is a neuropsychiatric syndrome, with important psychomotor features, associated with schizophrenia and other psychiatric disorders. The syndrome comprises multiple symptoms including abnormal motor control, behaviors, volition, and autonomic regulation. Catatonia assessment relies on clinical rating scales and clinicians familiar with the catatonia exam. However, objective instrumentation may aid the detection of catatonia. We aimed to investigate the relationship between movement parameters derived from actigraphy and expert ratings of catatonia symptoms measured by the Bush Francis Catatonia Rating Scale (BFCRS) and the Northoff Catatonia scale (NCS).

METHODS

Eighty-six acutely ill inpatients with schizophrenia spectrum disorders were assessed with the BFCRS, the NCS, and 24 h continuous actigraphy. Non-wear and sleep periods were removed from the actigraphy data prior to analysis. Associations between total catatonia scores, derived from both BFCRS and NCS, and actigraphy parameters as well as between single BFCRS items and actigraphy parameters were calculated using Spearman's rank correlation and non-parametric ANCOVAs (Quade's ANCOVAs), respectively.

RESULTS

Both higher BFCRS total scores (r = 0.369, p = 0.006) and NCS total scores (r = 0.384, p = 0.004) were associated with lower activity levels (AL). Higher scores on single BFCRS items such as immobility/stupor or staring were linked to lower AL (immobility/stupor: F = 17.388, p < 0.001, η² = 0.175; staring: F = 7.849, p = 0.001, η² = 0.162) and lower metabolic equivalents of task (MET).

CONCLUSION

Specific catatonia symptoms such as immobility/stupor and staring can be measured with actigraphy. This may aid the detection, staging, and monitoring of catatonia in clinical settings.

The occurrence of catatonia diagnosis in acute care hospitals in the United States: A national inpatient sample analysis

OBJECTIVE

Catatonia is a neuropsychiatric disorder that can occur in the setting of many illnesses, but the frequency of catatonia diagnosis among hospitalized patients is poorly characterized. This study reports the occurrence of catatonia diagnosis among acute care hospital discharges in the United States and the cooccurring diagnoses of these patients.

METHOD

The National Inpatient Sample, an all-payors database of acute care hospital discharges, was queried for patients older than 18 discharged with a diagnosis of catatonia in 2019.

RESULTS

13,630 encounters among the 30,080,038 adult hospitalizations in the NIS during the study year included a diagnosis of catatonia. Total hospital charges for these admissions were $1.15 billion, with 215,165 cumulative hospital days. In this sample, approximately 60% of admissions had a primary psychiatric discharge diagnosis, while 40% had a primary neurologic or medical discharge diagnosis. Procedures were performed in 36.7% of hospitalizations involving catatonia, of which electroconvulsive therapy was most common.

CONCLUSIONS

Catatonia is a rare but costly discharge diagnosis among patients in acute care hospitals. It occurs across the age spectrum and is associated with a range of medical and psychiatric comorbidities. Further research is needed to better characterize the occurrence of catatonia and its optimal treatment.

Catatonia: Back to the future of the neuropsychiatric syndrome

Catatonia is an undertreated and underdiagnosed neuropsychiatric syndrome whose prognosis is benign if treated early, thus avoiding possible complications and compromising the health of patients. The latest epidemiological studies indicate a prevalence of catatonia of 9.2%, being frequent in medical pathologies (especially neurological ones), as well as in psychiatric pathologies. The use of validated scales is recommended for its diagnosis, to be able to measure the severity and response to treatment. Once catatonia has been identified, it is necessary to perform a protocolized diagnostic study of the underlying aetiology («Catatonia Workup»). Treatment of choice is benzodiazepines and electroconvulsive therapy. In recent years, new therapeutic alternatives such as non-invasive transcranial magnetic stimulation have emerged. In this review we propose several initiatives to promote the dissemination and knowledge of catatonia in the clinical setting.

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.

Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting

OBJECTIVE

Catatonia can be life-threatening unless timely identified and treated. Lorazepam's ubiquitous response has led to its universal acceptance as being the first-line management of catatonia and alludes to catatonia's neurobiological underpinnings. Lorazepam challenge test (LCT) is widely used to either confirm a catatonia diagnosis or determine lorazepam sensitivity. It has a proposed schedule for administering lorazepam. However, efficacy of recommended LCT doses lack systematic evidence, resulting in variable LCT doses used in clinical and research settings contributing to findings that are challenging to generalize or assist with developing standardized lorazepam treatment protocols for catatonia. Given the same, this study aimed to objectively compare the response between two groups receiving different LCT doses and factors influencing the same.

METHODS

The 6-month study in a psychiatric emergency setting at a tertiary neuropsychiatric center in India evaluated 57 catatonia patients, before and after administration of single 2 mg (n = 37; LCT-2) or 4 mg (n = 20; LCT-4) lorazepam dose, applying Bush Francis Catatonia Rating Scale (BFCRS), Mini International Neuropsychiatric Interview (MINI 5.0) and obtaining sociodemographic, clinical data.

RESULTS

No between-group differences (LCT-2 vs LCT-4) for sociodemographic, clinical profiles or BFCRS severity score changes to lorazepam on Mann-Whitney U test were noted. Applying Wilcoxon signed rank test comparing individual sign severity demonstrated response variability, with significant response noted to both doses (stupor, mutism, staring, posturing, withdrawal, ambitendency, automatic obedience) and others selectively to 2 mg (echolalia, rigidity, negativism, mitgehen). Notably, sign resolution (present/absent) only to 2 mg was significant for stupor, mutism, staring, posturing, echolalia, rigidity, negativism and mitgehen.

CONCLUSION

This study suggests 2 mg lorazepam may be an optimal LCT dose, given significant response to most catatonic signs thereby ensuring accurate detection and preventing misinterpretation of response. It offers future studies direction for standardizing lorazepam dosing schedules for catatonia management and exploring neurobiological underpinnings for individual catatonic signs that may be potentially different, given these findings.

Psychiatric Phenotypes of Pediatric Patients With Seropositive Autoimmune Encephalitis

OBJECTIVES

Patients with autoimmune encephalitis (AE) often present with symptoms that are broadly characterized as psychiatric or behavioral, yet little attention is given to the precise symptomatology observed. We sought to more fully define the psychiatric symptoms observed in patients with anti-N-methyl-D-aspartate receptor (NMDAR), anti-glutamic-acid-decarboxylase 65 (GAD65), and anti-voltage-gated-potassium-channel complex (VGKC) antibody-mediated AE using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition nomenclature.

METHODS

We present a case series (n = 25) using a retrospective chart review of 225 patients evaluated for AE in a tertiary care academic medical center between 2014 and 2018. The included patients were ≤18 years old with anti-NMDAR AE (n = 13), anti-GAD65 AE (n = 7), or anti-VGKC AE (n = 5). The frequency of neuropsychiatric symptoms present at the onset of illness and time to diagnosis were compared across groups.

RESULTS

Psychiatric symptoms were seen in 92% of patients in our cohort. Depressive features (72%), personality change (64%), psychosis (48%), and catatonia (32%) were the most common psychiatric symptoms exhibited. On average, patients experienced impairment in ≥4 of 7 symptom domains. No patients had isolated psychiatric symptoms. The average times to diagnosis were 1.7, 15.5, and 12.4 months for anti-NMDAR AE, anti-GAD65 AE, and anti-VGKC AE, respectively (P < .001).

CONCLUSIONS

The psychiatric phenotype of AE in children is highly heterogenous. Involving psychiatry consultation services can be helpful in differentiating features of psychosis and catatonia, which may otherwise be misidentified. Patients presenting with psychiatric symptoms along with impairments in other domains should prompt a workup for AE, including testing for all known antineuronal antibodies.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Time and Body. 2020. [DOI: 10.1017/9781108776660]

Time and Body promotes the application of phenomenological psychopathology and embodied research to a broad spectrum of mental disorders. In a new and practical way, it integrates the latest research on the temporal and intersubjective constitution of the body, self and its mental disorders from phenomenological, embodied and interdisciplinary research perspectives. The authors investigate how temporal processes apply to the contribution of embodiment and selfhood, as well as to their destabilization, such as in eating disorders and borderline personality disorders, schizophrenia, depression, social anxiety or dementia. The chapters demonstrate the applicability of phenomenological psychopathology to a range of illnesses and its relevance to treatment and clinical practice.

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.

Catatonia in elderly psychiatric inpatients is not always associated with intense anxiety: Factor analysis and correlation with psychopathology

OBJECTIVE

Catatonic stupor has been linked to extreme fear. Whether the underlying phenomenology of every catatonic dimension is intense anxiety or fear remains unknown.

METHODS

One hundred and six patients aged ≥64 years were assessed for catatonia and clinical variables during the first 24 hours of admission. Two-sample t test were used to test for group differences. A principal component analysis was developed. Analysis of variance was performed to assess for differences in the diagnostic groups. Correlation coefficients were used to examine the association between catatonic dimensions and psychopathological variables.

RESULTS

There were statistically significant differences between catatonic and non-catatonic patients in the Hamilton and NPI scores. The three factor-model accounted for 52.23% of the variance. Factor 1 loaded on items concerned with "excitement," factor 2 on "inhibition" items, and factor 3 on "parakinetic" items. There was a significant effect for factor 1 (F [5.36] = 2.83, P = .02), and not significant for factor 2 and factor 3. Compared with patients with depression, patients with mania scored significantly higher on factor "excitement" (P < .05). Factor 2 showed a moderate correlation with Hamilton total score (r = .346, P = .031) and Hamilton psychic score (r = .380, P = .017).

CONCLUSIONS

Catatonic patients experienced more anxiety and hyperactivity. A three-factor solution provided best fit for catatonic symptoms. Patients with mania scored highest on Excitement, patients with depression on Inhibition, and patients with schizophrenia on Parakinetic. The main finding in this study was a positive moderate correlation between the Hamilton psychic score and the Inhibition factor score, meaning that not every catatonic dimension is associated to intense anxiety.

Movement disorder and sensorimotor abnormalities in schizophrenia and other psychoses - European consensus on assessment and perspectives

Over the last three decades, movement disorder as well as sensorimotor and psychomotor functioning in schizophrenia (SZ) and other psychoses has gained greater scientific and clinical relevance as an intrinsic component of the disease process of psychotic illness; this extends to early psychosis prediction, early detection of motor side effects of antipsychotic medication, clinical outcome monitoring, treatment of psychomotor syndromes (e.g. catatonia), and identification of new targets for non-invasive brain stimulation. In 2017, a systematic cooperation between working groups interested in movement disorder and sensorimotor/psychomotor functioning in psychoses was initiated across European universities. As a first step, the members of this group would like to introduce and define the theoretical aspects of the sensorimotor domain in SZ and other psychoses. This consensus paper is based on a synthesis of scientific evidence, good clinical practice and expert opinions that were discussed during recent conferences hosted by national and international psychiatric associations. While reviewing and discussing the recent theoretical and experimental work on neural mechanisms and clinical implications of sensorimotor behavior, we here seek to define the key principles and elements of research on movement disorder and sensorimotor/psychomotor functioning in psychotic illness. Finally, the members of this European group anticipate that this consensus paper will stimulate further multimodal and prospective studies on hypo- and hyperkinetic movement disorders and sensorimotor/psychomotor functioning in SZ and other psychotic disorders.

Diagnosing catatonia and its dimensions: Cluster analysis and factor solution using the Bush Francis Catatonia Rating Scale (BFCRS)

Advances in research into catatonia in the preceding two decades has offered increasing clarity and an improved understanding of various aspects of this complex syndrome. Despite the above, there are several aspects that hinder a broader interpretation of these findings, the most common being a lack of consensus on the criteria required for diagnosing catatonia. Whilst being the most frequently used tool for diagnosis, the number of signs from Bush-Francis Catatonia Rating Scale (BFCRS) needed to diagnose catatonia remain unclear. This study aimed to determine the number of signs required to accurately diagnose catatonia using BFCRS and delineate its dimensions in an acute inpatient unit in the Indian setting. A random sample of 300 patients were evaluated for catatonia within 24 h of admission. Cluster Analysis followed by discriminant analysis and receiver operating curve analysis (ROC) provided cut-off values for diagnosing catatonia syndrome. Principle Component Analysis (PCA) with varimax rotation was used to identify factors in those with catatonia. Findings revealed that a cut off of two signs from both Bush-Francis Catatonia Screening Instrument or BFCSI (sensitivity of 100 %, specificity of 96.2 % as well as a positive predictive value [PPV] of 79.6 % and negative predictive value [NPV] 100 % with ROC AUC value of 0.98) and complete BFCRS (sensitivity of 100 % and specificity of 90.7 %, PPV of 80.7 and NPV of 100 % with ROC AUC for at least two items cut-off being 0.95) accurately detected catatonia. However, the prevalence of catatonia in the same population increased by 4% from 16.3% to 20.3% using the BFCRS rather than the BFCSI. The BFCRS generated a 3-factor model accounting for 65.48 % variance offering the best fit, indicating three discrete dimensions to catatonia, namely retarded, excited and what we named as "aberrant volitional". Interestingly, the aberrant volitional dimension comprises of signs that need to be elicited rather than passively observed and excluding one, none of them are part of the BFCSI. Findings of this study suggest that the BFCRS more accurately detects catatonia rather than the BFCSI. Additionally, three dimensions of catatonia more coherently explain the catatonic syndrome given that 55.7 % of the sample had signs from more than one factor concurrently. We propose that the BFCRS rather than BFCSI be routinely administered for evaluating all suspected cases of catatonia to ensure more accurate detection as well as identifying the aberrant volitional dimensional signs more consistently. The three-dimensional model also offers great opportunities to further unravel the pathophysiological basis of catatonic signs more systematically.

Catatonia revived: a unique syndrome updated

Catatonia was buried within the confines of schizophrenia for over a century- deterring study, appropriate diagnosis and treatment for many years. With revised changes in the classification of this distinct neuropsychiatric syndrome, it is becoming more recognized clinically and in ongoing research. Catatonia occurs among various psychiatric, metabolic or neurologic conditions. It may present in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy usually produces dramatic and rapid response, although systematic, randomized trials are lacking. The role of antipsychotic agents in treatment is controversial as they may worsen the syndrome. An important unresolved clinical question is the diagnosis and treatment of catatonia in the setting of delirium.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Catatonia in N-methyl-d-aspartate receptor antibody encephalitis: Phenomenological characteristics from a systematic review of case reports

OBJECTIVE

To ascertain the phenomenological characterisation of catatonia in N-methyl-d-aspartate receptor antibody encephalitis (NMDAr-AbE).

METHODS

A systematic review of case reports was undertaken in accordance with PRISMA guidelines. Case reports of NMDAr-AbE containing sufficient information on the cases' clinical presentation and meeting the study's inclusion criteria were selected. Cases were searched for clinical data in keeping with core catatonic signs by applying the screening instrument of the Bush-Francis Catatonia Rating Scale. When two or more core signs were ascertained catatonia was considered to be present.

RESULTS

2645 records were identified through the database search. Following screening and application of eligibility/inclusion criteria 139 articles were selected reporting on 189 individual subjects. Catatonia was present in 60% of these cases. The most prevalent signs were immobility/stupor (70%), mutism (67%), excitement (50%), posturing/catalepsy (34%), stereotypies (31%), and rigidity (30%). Immobility/stupor and excitement co-occurred in the same patient in 33% of cases.

CONCLUSION

The phenomenological profile of catatonia in this sample of cases of NMDAr-AbE was characterised by a preponderance of signs in the hypokinetic spectrum. However, excitement often co-occurred in these patients suggesting that fluctuations in catatonic semiology may be frequent.

Going Back to Kahlbaum's Psychomotor (and GABAergic) Origins: Is Catatonia More Than Just a Motor and Dopaminergic Syndrome?

In 1874, Karl Kahlbaum described catatonia as an independent syndrome characterized by motor, affective, and behavioral anomalies. In the following years, various catatonia concepts were established with all sharing the prime focus on motor and behavioral symptoms while largely neglecting affective changes. In 21st century, catatonia is a well-characterized clinical syndrome. Yet, its neurobiological origin is still not clear because methodological shortcomings of hitherto studies had hampered this challenging effort. To fully capture the clinical picture of catatonia as emphasized by Karl Kahlbaum, 2 decades ago a new catatonia scale was developed (Northoff Catatonia Rating Scale [NCRS]). Since then, studies have used NCRS to allow for a more mechanistic insight of catatonia. Here, we undertook a systematic review searching for neuroimaging studies using motor/behavioral catatonia rating scales/criteria and NCRS published up to March 31, 2019. We included 19 neuroimaging studies. Studies using motor/behavioral catatonia rating scales/criteria depict cortical and subcortical motor regions mediated by dopamine as neuronal and biochemical substrates of catatonia. In contrast, studies relying on NCRS found rather aberrant higher-order frontoparietal networks which, biochemically, are insufficiently modulated by gamma-aminobutyric acid (GABA)-ergic and glutamatergic transmission. This is further supported by the high therapeutic efficacy of GABAergic agents in acute catatonia. In sum, this systematic review points out the difference between motor/behavioral and NCRS-based classification of catatonia on both neuronal and biochemical grounds. That highlights the importance of Kahlbaum's original truly psychomotor concept of catatonia for guiding both research and clinical diagnosis and therapy.

Catatonia-Like Syndrome Treated With Low-Dose Ketamine

BACKGROUND

Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments.

CASE REPORT

A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

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.

Comparative study of symptom profile of catatonia in patients with psychotic disorders, affective disorders and organic disorders

AIM

To compare the symptom profile of catatonia among patients with affective, psychotic and organic disorders.

METHODOLOGY

A 46 item catatonia rating scale prepared by combining items from 3 catatonia rating scales, i.e., Bush Francis Catatonia Rating Scale(BFCRS), North off catatonia rating scale and Catatonia rating scale was used.

RESULTS

Study included 53, 45 and 42 patients with psychotic disorders, affective disorders and organic catatonia respectively. No significant difference was seen in the prevalence and severity of various catatonic symptoms between patients with psychotic and affective disorders. Compared to participants in the organicity group, participants in the psychotic group had significantly higher prevalence and severity of posturing. There was no difference in the affective and organicity group in terms of frequency and severity of catatonic symptoms.

CONCLUSIONS

Patients with organic catatonia do not differ from those with catatonia due to affective and psychotic disorders in terms of prevalence and severity of signs and symptoms of catatonia except for posturing. The present study suggests that catatonic symptoms in patients with various disorders are not just limited to BFCRS and extend beyond the same.

Electroconvulsive Treatment for Catatonia in Autism Spectrum Disorders

Catatonia has been increasingly recognized in people with autism spectrum disorders (ASD). Assessment, diagnosis, and treatments are reviewed and illustrated with 2 new case vignettes. The use of electroconvulsive treatment (ECT) is recommended in patients who fail to respond to medical treatments, including a trial of lorazepam or another benzodiazepine. The importance of maintenance ECT is discussed. There is an urgent need for prospective studies of catatonia in ASD and for controlled treatment trials.

The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia

Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.

Schizophrenia with prominent catatonic features: A selective review

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

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

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

[German version of the Northoff catatonia rating scale (NCRS-dv) : A validated instrument for measuring catatonic symptoms]

The clinical picture of catatonia includes impressive motor phenomena, such as rigidity, dyskinesia, festination, negativism, posturing, catalepsy, stereotypies and mannerisms, along with affective (e. g. aggression, anxiety, anhedonism or emotional lability) and behavioral symptoms (e.g. mutism, autism, excitement, echolalia or echopraxia). In English speaking countries seven catatonia rating scales have been introduced, which are widely used in clinical and scientific practice. In contrast, only one validated catatonia rating scale is available in Germany so far. In this paper, we introduce the German version of the Northoff catatonia rating scale (NCRS-dv). The original English version of the NCRS consists of 40 items describing motor (13 items), affective (12 items) and behavioral (15 items) catatonic symptoms. The NCRS shows high internal reliability (Crombachs alpha = 0.87), high interrater (r = 0.80-0.96) and high intrarater (r = 0.80-0.95) reliability. Factor analysis of the NCRS revealed four domains: affective, hyperactive or excited, hypoactive or retarded and behavior with individual eigenvalues of 8.98, 3.61, 2.98 and 2.82, respectively, which explained 21.5 %, 9.3 %, 7.6 % and 7.2 % of variance, respectively. In conclusion, the NCRS-dv represents a second validated instrument which can be used by German clinicians and scientists for the assessment of catatonic symptoms.

Periodic Catatonia Marked by Hypercortisolemia and Exacerbated by the Menses: A Case Report and Literature Review

Kahlbaum first described catatonia; later Kraepelin, Gjessing, and Leonhard each defined periodic catatonia differently. A 48-year-old female with catatonia, whose grandmother probably died from it, was prospectively followed for >4 years in a US psychiatric state hospital. Through 4 catatonic episodes (one lasting 17 months) there were menstrual exacerbations of catatonia and increases in 4 biological variables: (1) creatine kinase (CK) up to 4,920 U/L, (2) lactate dehydrogenase (LDH) up to 424 U/L, (3) late afternoon cortisol levels up to 28.0 mcg/dL, and (4) white blood cell (WBC) counts up to 24,200/mm3 with neutrophilia without infections. Records from 17 prior admissions documented elevations of WBC and LDH and included an abnormal dexamethasone suppression test (DST) which normalized with electroconvulsive therapy. Two later admissions showed CK and WBC elevations. We propose that these abnormalities reflect different aspects of catatonic biology: (1) the serum CK, the severity of muscle damage probably exacerbated by the menses; (2) the hypercortisolemia, the associated fear; (3) the leukocytosis with neutrophilia, the hypercortisolemia; and (4) the LDH elevations, which appear to be influenced by other biological abnormalities. Twentieth-century literature was reviewed for (1) menstrual exacerbations of catatonia, (2) biological abnormalities related to periodic catatonia, and (3) familial periodic catatonia.

Recognizing Catatonia in Medically Hospitalized Older Adults: Why It Matters

Catatonia is a neuropsychiatric syndrome characterized by a variety of motor, behavioral, emotional, and autonomic abnormalities caused by general medical, neurological, and psychiatric disorders, as well as by medications and drugs of abuse. Although there has been a plethora of research on catatonia over the last twenty years, it is still underdiagnosed. Studies of catatonia involving older adults have been sparse, despite its apparent high prevalence, higher risk of serious complications, and of association with non-psychiatric causes. This paper aims to provide an introduction to catatonia as a syndrome, as well as an account of its specificities in older adults, especially those in general hospitals, with the aim to raise awareness of catatonia amongst clinicians working with this age group in acute medical settings, so improvements in its diagnostic rates, treatment, and outcomes can be achieved.

Management of Emergency Electroconvulsive Therapy in the Intensive Care Unit for Life-Threatening Psychiatric Conditions: A Case Series

Catatonia can lead to severe complications and may be lethal but is often underdiagnosed. The clinical presentation can be similar to coma. In these situations, electroconvulsive therapy (ECT) can be used as first-line treatment to enable extubation, recovery of autonomy, and rapid discharge from intensive care. We report 4 cases of patients hospitalized in the intensive care unit with comatose clinical presentation and life-threatening condition caused by catatonia. All patients received ECT sessions, after which the catatonic symptoms partially or fully remitted. We discuss the clinical identification, general considerations, ECT feasibility, and parameters in the intensive care unit, as well as the differential diagnosis, drug precautions, and prevention concerns.

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.

Catatonia in an inpatient gerontopsychiatric population

There are limited data on the prevalence of catatonia in the elderly. The aim of this study was to determine the prevalence of catatonia in elderly patients (=/> 65 years) acutely admitted to the psychiatric unit of a general hospital. All patients aged 65 years and above admitted to a general hospital psychiatric unit over a 4-month period were screened for catatonia with the 14-item Bush-Francis Catatonia Screening Instrument (BFCSI). Patients with a minimum of 2 symptoms on the BFCSI were rated with the 23-item Bush-Francis Catatonia Rating Scale (BFCRS). Catatonia was simultaneously evaluated according to DSM-5 criteria. Clinical diagnoses were established using the validated Hungarian versions of the Structured Clinical Interview for DSM-IV Disorders, the Mini Mental State Examination and the Clock Drawing Test. Ninety-eight (28.1%) of the 342 patients admitted to the psychiatric unit during the study period were above 65 years of age; 11 (11.22%) and 6 (6.12%) patients were classified as having catatonia according to the BFCRS and DSM-5 criteria, respectively. The majority of the patients had catatonia due to a medical condition. A significant minority of gerontopsychiatric inpatients present with catatonia. Dementia was not a risk factor for catatonia.

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.

The nature and prevalence of catatonic symptoms in young people with autism

BACKGROUND

A proportion of young people with autism are reported to show catatonic-like symptoms in adolescence. The aetiology and prevalence of such presentations is unknown but include a set of behaviours that can best be described as attenuated.

METHOD

The current study empirically investigated the presence and nature of such attenuated behaviours in children and adolescents with autism using a newly developed 34-item third party report measure, the Attenuated Behaviour Questionnaire. Caregivers or parents of young people with autism reported on the presentation of symptoms via the online completion of the Attenuated Behaviour Questionnaire and two established clinical measures of repetitive behaviour and depression.

RESULTS

Initial results indicate that the Attenuated Behaviour Questionnaire is a workable clinical measure in this population with a degree of discriminant validity with regard to catatonia. Attenuated behaviour indicative of catatonia was relatively common in young people with autism with up to 20.2% having an existing diagnosis of catatonia and evidence of a relationship between attenuated behaviours and measures of depression and repetitive and restricted behaviours.

CONCLUSION

Catatonic symptoms are more prevalent in young people with autism than previously thought, and the Attenuated Behaviour Questionnaire has potential as a clinical and research tool.

The Phenomenology and Treatment Response in Catatonia: A Hospital Based Descriptive Study

BACKGROUND

Literatures regarding clinical symptomatology and treatment response of catatonia are very few.

OBJECTIVE

To assess onset, clinical profile, diagnostic break up, treatment response and outcome in patients diagnosed as Catatonia, reported to a tertiary care hospital.

METHODS

The present study was a cross-sectional descriptive study conducted in indoor of Mental Health Institute (Centre of Excellence), S.C.B. Medical College, between March 2015 to March 2016. A total of 34 patients were included in the study who reported at outdoor department of Mental Health Institute with catatonic symptoms. All patients admitted in inpatient department were routinely assessed through a detailed semi-structured interview. The diagnosis of catatonia was made if the patients present with three or more symptoms out of twelve symptoms fulfilling the criteria of DSM-5. All the patients were assessed through Bush-Francis Catatonia Rating Scale. They were initially given parental lorazepam at the doses ranging from 4-12 mg per day as per requirement. Patients who did not respond to lorazepam trial were given ECT.

RESULTS

The patients were predominantly presented with retarded symptoms of catatonia such as staring, mutism, withdrawal, posturing and negativism. Schizophrenia and other psychotic spectrum disorders were more commonly presented as catatonia as compared to mood disorders. Younger age group patients were mainly responded to lorazepam only, whereas older age group patients responded to both ECT and lorazepam.

CONCLUSION

This study has came out with very important insights in the age of incidence, phenomenology, clinical profile, source of referral, diagnostic break up and treatment response with lorazepam and ECT in catatonic patients following mental disorder.

Adverse Childhood Experiences Among Inpatient Youths with Severe and Early-Onset Psychiatric Disorders: Prevalence and Clinical Correlates

This study aimed to determine the prevalence and the clinical correlates of Adverse Childhood Experiences (ACEs) among 158 inpatient youths with two types of severe psychiatric disorders. ACEs were retrospectively collected with the ACEs scale and the List of Threatening Experiences Questionnaire in 77 patients hospitalized for a catatonic syndrome (average age 15.2 years) and 81 for a manic or mixed episode (average age 15.7 years). ACEs were frequent in youths suffering from bipolar disorder type I (BD-I) (58 %) and from catatonia (57 %), with around one quarter exposed to severe abuse (i.e., physical/sexual/emotional abuse or physical/emotional neglect). Youths with BD-I were more likely to be exposed to family violence compared to those with catatonia. Youths who had been exposed to ACEs did not exhibit a more severe presentation or a poorer response to treatment compared to others, either in the bipolar group or in the catatonic group.

Development and validation of the Bush-Francis Catatonia Rating Scale - Brazilian version

Objective:

This article aims to describe the adaptation and translation process of the Bush-Francis Catatonia Rating Scale (BFCRS) and its reduced version, the Bush-Francis Catatonia Screening Instrument (BFCSI) for Brazilian Portuguese, as well as its validation.

Methods:

Semantic equivalence processes included four steps: translation, back translation, evaluation of semantic equivalence and a pilot-study. Validation consisted of simultaneous applications of the instrument in Portuguese by two examiners in 30 catatonic and 30 non-catatonic patients.

Results:

Total scores averaged 20.07 for the complete scale and 7.80 for its reduced version among catatonic patients, compared with 0.47 and 0.20 among non-catatonic patients, respectively. Overall values of inter-rater reliability of the instruments were 0.97 for the BFCSI and 0.96 for the BFCRS.

Conclusion:

The scale's version in Portuguese proved to be valid and was able to distinguish between catatonic and non-catatonic patients. It was also reliable, with inter-evaluator reliability indexes as high as those of the original instrument.

Validation of the Pediatric Catatonia Rating Scale (PCRS)

INTRODUCTION

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

METHOD

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

RESULTS

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

DISCUSSION

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

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.