The study of pediatric catatonia supports a home of its own for catatonia in DSM-5

Catatonia

Catatonia is a neuropsychiatric disorder characterized by motor, affective and cognitive-behavioural signs, which lasts from hours to days. Intensive research over the past two decades has led to catatonia being recognized as an independent diagnosis in the International Classification of Diseases, 11th Revision (ICD-11) since 2022. Catatonia is found in 5-18% of inpatients on psychiatric units and 3.3% of inpatients on medical units. However, in an unknown number of patients, catatonia remains unrecognized and these patients are at risk of life-threatening complications. Hence, recognizing the symptoms of catatonia early is crucial to initiate appropriate treatment to achieve a favourable outcome. Benzodiazepines such as lorazepam and diazepam, electroconvulsive therapy, and N-methyl-D-aspartate antagonists such as amantadine and memantine, are the cornerstones of catatonia therapy. In addition, dopamine-modulating second-generation antipsychotics (for example, clozapine and aripiprazole) are effective in some patient populations. Early and appropriate treatment combined with new screening assessments has the potential to reduce the high morbidity and mortality associated with catatonia in psychiatric and non-psychiatric settings.

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.

Diagnostic overshadowing clouding the efficient recognition of pediatric catatonia: a case series

Catatonia is a neuropsychiatric condition that causes disruption of movement, emotion, and behaviors. Children and adults with underlying psychiatric conditions are particularly susceptible to developing catatonia, which may result in medical and psychiatric complications. Although catatonia research has been growing at a rapid rate in the last 20 years, it continues to be met with inefficiencies in its diagnosis and incertitude in its treatment. In the pediatric population, catatonia is plagued by diagnostic overshadowing, where the catatonia is erroneously attributed to existing pathologies that lead to a prolonged disease state. This paper describes three pediatric patients with catatonia that fell victim to diagnostic overshadowing. More rigorous training and education are imperative to improve the efficient recognition and treatment of children with catatonia.

Catatonia in neurodevelopmental disorders: assessing catatonic deterioration from baseline

Despite the inclusion of catatonia as a specifier of autism spectrum disorder in DSM-5, we-a team of child and adolescent neuropsychiatrists who specialise in paediatric catatonia and neurodevelopmental disorders-have identified a number of issues with the diagnosis and clinical management of catatonia in our patients. In this Personal View, we summarise the literature regarding catatonia in people with neurodevelopmental disorders, including autism spectrum disorder, describe our concerns, and offer a novel approach to addressing important issues with current diagnostic and treatment paradigms. We emphasise the need for a measure to diagnose and monitor people with catatonia and their history of neurodevelopmental disorders. This measure should consider previous complex and underlying motor, medical, functional, and neurobehavioural symptoms. We propose two concepts for understanding catatonia that relate to the baseline status of an individual: the personalised score at baseline, an estimate of premorbid neurobehavioral and motor symptoms, and the catatonic deterioration from baseline, an estimate of current features that are due to catatonia rather than an underlying neurodevelopmental disorder. We hope this measure will provide a practical tool for clinicians and researchers working with this underserved and high-risk population.

Asylum-seeking children with resignation syndrome: catatonia or traumatic withdrawal syndrome?

In the beginning of the 2000s, an increasing number of asylum-seeking children in Sweden fell into a stuporous condition. In the present study, we report 46 consecutive children with the most severe form of this illness where the children were unable to give any response at all, did not react to pain, cold or touching, could not be supported to sit or stand on their feet, could not do anything when requested, and in most cases had enuresis/encopresis. A minority of the children came from war zones (n = 8, 17.4%). A majority belonged to an ethnic or religious minority (n = 32, 69.6%) in their homeland and almost all were persecuted (n = 43, 93.5%). All had either experienced violence themselves or had witnessed or heard about violence against close family members. The age of onset of the first symptom of illness for boys was 11.2 years [CI 9.6-12.8], for girls 11.8 yrs.[CI 10.4-13.2], and the age for falling into stupor for boys was 12.9 years [CI 11.6-14.1] years and was the same for girls, 12.9 years [CI 11.6-14.2] years. Girls tended to have depression before entering the stuporous condition, while the boys tended to have PTSD first (Chi-square = 3.73, p = 0.054). A majority of the children had one (n = 13, 28.3%) or both parents (n = 14, 30.4%) suffering from mental or severe physical disorder. It is discussed whether the presented condition is a separate entity or if the syndrome should be regarded as a variant of catatonia, and whether benzodiazepines should be tried.

Multidisciplinary treatment plan for challenging behaviors in neurodevelopmental disorders

Among symptoms that patients with neurodevelopmental disorders can exhibit, challenging behaviors (CBs) are some of the more complex to face, both for caregivers and the patients themselves. They are more frequent in individuals with severe autism spectrum disorders and intellectual disability, and during the transition period from late childhood to young adulthood. Here, we offer an overview of the therapeutic approaches proven worthy in managing CB. Topics include nonpharmacologic treatments (such as behavioral and family interventions), drug prescriptions, and specific intensive care for life-threatening situations, including inpatient stay in specialized neurobehavioral units. Then, we focus on rare, complex, and resistant clinical presentations, mainly based on the authors' clinical experience. We propose a multimodal intervention framework for these complex presentations, embracing developmental and dimensional approaches. A case presentation illustrates the proposed framework, with the aim of serving readers and health practitioners that are facing such cases.

Catatonia Associated With a SCN2A-Related Disorder in a 4-Year-Old Child

Catatonia is a rare, underdiagnosed syndrome in children. We report the case of a 4-year-old child admitted for recent social withdrawal alternating with psychomotor excitement, verbigeration, and a loss of toilet readiness. He had a history of neonatal seizures, had been stabilized with vigabatrin, and was seizure free without treatment for several months. The pediatric and psychiatric examination revealed motor stereotypes, mannerism, bilateral mydriasis, and visual hallucinations. Laboratory and brain imaging explorations were initially negative. Catatonic symptoms, as measured with the Pediatric Catatonia Rating Scale, significantly decreased after introducing lorazepam, the first-line recommended treatment of this condition. On the basis of the neonatal seizure history, complementary genetic investigations were performed and revealed a mutation in the SCN2A gene, which encodes the voltage-gated sodium channel Nav1.2. Catatonic symptoms progressively disappeared after reintroducing vigabatrin. At the syndromic level, catatonia in young children appears responsive to high-dose lorazepam and is well monitored by using the Pediatric Catatonia Rating Scale. This case reveals the need for wide-ranging explorations in early-onset catatonia because specific targeted treatments might be available.

Catatonia in children and adolescents: New perspectives

INTRODUCTION

Catatonia is a rare and severe psychomotor condition in children and adolescents. In the current report, we aimed to review the recent literature.

METHOD

Using a PRISMA approach, we searched MEDLINE between 1982 and 2017 using the keywords 'CATATONIA' and 'CHILD' or 'ADOLESCENT'. In total, we reviewed 130 reports (controlled study, N=4; clinical chart, N=23; case report, N=54; and editorial/review, N=42).

RESULTS

Several aspects seem to be age specific: (1) although the clinical presentation resembles that in adults, some symptoms are important in children and adolescents (e.g., psychomotor regression). (2) Associated disorders are similar to that found in adults; however, schizophrenia is more frequently observed than mood disorder. Additionally, a history of neurodevelopmental disorders maybe encountered. (3) Morbidity and mortality are among the worst in child psychiatry. (4) Underlying organic conditions are highly prevalent (>20% of the cases), and their search is warranted because some diagnoses may result in specific treatments (e.g., immune-suppressor therapy for autoimmune conditions). (5) Symptomatic approaches - high dose of benzodiazepines and electroconvulsive therapy (ECT) - are as efficient in children or adolescents as they are in adults, but this finding needs to be acknowledged because a resistance against the use of ECT or high-dose medication exists among child psychiatrists.

DISCUSSION

Recent advances in child and adolescent catatonia research have offered major improvements in understanding catatonia and in new therapeutic opportunities. The syndrome is rare, but these advances need to be acknowledged in order to direct patients to centers that have developed a specific expertise.

Catatonia is not schizophrenia and it is treatable

Catatonia is a cluster of motor features that appears in many recognized psychiatric illnesses, that according to the DSM-5 it is not linked as a subtype to schizophrenia anymore. The classic signs are mutism, a rigid posture, fixed staring, stereotypic movements, and stupor, which are all part of a broad psychopathology that may be found in affective, thought, neurological, toxic, metabolic and immunological disorders. Despite the many etiologies, catatonia may be a life-threatening condition with a specific treatment. Benzodiazepines are the first line therapeutic option for catatonia, being lorazepam the first-choice drug. Eighty percent of the patients are relieved by the use of barbiturates or benzodiazepines, while in those who fail, an improvement is achieved by electroconvulsive therapy (ECT). With more than 60years of use in catatonic patients, ECT has proven to be an effective and safe tool for the treatment of this frequent and sometimes forgotten syndrome.

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.

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.

Catatonia in Children Following Systemic Illness

BACKGROUND

The term catatonia was first introduced in 1874 and several etiologies, both organic and psychiatric have been attributed to the clinical phenotype of catatonia. The interesting feature is their response to lorazepam irrespective of their etiology.

PATIENTS AND METHODS

Four patients admitted with verbal and motor unresponsiveness following febrile illness were evaluated for infective and metabolic causes. Those who qualified for catatonia as per Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria and Bush-Francis Catatonia Screening Instrument screening tool and rating scale were evaluated in detail and reported.

OBSERVATIONS

Catatonia occurs in clusters, females are more affected than males. Electroencephalogram can be abnormal based on the precipitating symptom. Minor changes in serum total iron and transferrin saturation and nonspecific elevation of viral antibody titers are seen in some patients. Lorazepam challenge always gives the diagnosis.

RESULT

All patients where females and had preceeding systemic or CNS infection. Three out of the Four patients where independent at the end of one month.

CONCLUSION

Catatonia should be considered as a differential diagnosis in all children with verbal and motor unresponsiveness, which have no other explanation. Early initiation of treatment is very rewarding at least during short term follow-up.

Autism Spectrum Disorder: Defining Dimensions and Subgroups

Autism spectrum disorder (ASD) is a behaviorally defined neurodevelopmental disorder associated with the presence of social-communication deficits and restricted and repetitive behaviors. In the latest conceptualization of ASD, these two behavioral dimensions represent the core defining features of ASD, whereas associated dimensions, such as intellectual and language ability, provide a means for describing the ASD heterogeneity. In addition, the characterization of ASD subgroups, defined by the presence of known medical, genetic, or other psychiatric disorders, furthers our understanding of ASD heterogeneity. This paper reviews the history of autism, describes its core defining features, and provides an overview of the clinically and etiologically relevant subgroups that add to the complexity of this condition.

Prevalence and clinical correlations of catatonia in older adults referred to a liaison psychiatry service in a general hospital

AIM

To determine the frequency and clinical correlations of catatonia in older patients referred to a liaison psychiatry service in a general hospital.

PATIENTS AND METHODS

All patients over 65 years referred to liaison psychiatry were screened for catatonic phenomena with the Bush-Francis Catatonia Screening Instrument (BFCSI) between January and May 2012. Their clinical characteristics and the outcome of treatment were recorded.

RESULTS

One hundred and twelve patients over 65 years were referred. Ten (8.9%) met research diagnostic criteria for catatonia and 7 (6.3%) Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for catatonia. All patients presented with the inhibited variant and 5 to 12 catatonic signs. Three patients presented concomitant delirium. The etiology of catatonia was multifactorial, and complications and death were frequent (40% and 20%, respectively). Lorazepam achieved full resolution of catatonia in 50% of patients.

CONCLUSIONS

Catatonia in older adults referred to liaison psychiatry in a general hospital is not infrequent and has a multifactorial etiology. The BFCSI is a simple and reliable instrument to detect catatonia in this population. Lorazepam seems to be an effective treatment.

Rediscovering catatonia: the biography of a treatable syndrome

OBJECTIVE

Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century.

METHOD

We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia.

RESULTS

Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms.

CONCLUSION

Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.

Medical and developmental risk factors of catatonia in children and adolescents: a prospective case-control study

CONTEXT

Rare diseases have been associated with more and more genetic and non genetic causes and risk factors. But this has not been systematically assessed in catatonia, one of the psychiatric syndromes, that is most frequently associated with medical condition.

OBJECTIVE

We sought to assess the medical and developmental risk factors of catatonia in children and adolescents.

METHODS

From 1993 to 2009, 58 youths aged 10 to 18 years were prospectively admitted for catatonia and were followed up after discharge. A multidisciplinary approach assessed patients' medical condition and developmental history. A causality assessment scored medical risk (maximum score=10; κ=0.91). We compared the prevalence of catatonia in these patients to that of 80 inpatients with bipolar I disorder admitted from 1993 to 2003 who were also followed up.

RESULTS

We found that 13 (22.4%) patients had medical conditions and 18 (31%) had a history of developmental disorder in the catatonia group, whereas 1 (1.3%) and 17 (22.6%) patients had the same conditions in the bipolar group (p<0.001; p=0.17, respectively). Medical conditions associated with catatonia included auto-immune encephalitis (systemic lupus erythematosus [N=3] and anti-NMDA-receptor encephalitis [N=1]), seizures (N=1), ciclosporin encephalitis (N=1), post hypoglycaemic coma encephalitis (N=1), and genetic or metabolic conditions (chorea [N=2], 5HT cerebrospinal fluid deficit [N=1], storage disease [N=1], fatal familial insomnia [FFI; N=1], and PRODH mutations [N=1]). Six patients responded to a specific treatment approach related to their medical condition (e.g., plasma exchange in the case of auto-immune encephalitis).

CONCLUSION

Catatonia in children and adolescents is associated with a high prevalence of medical conditions. This needs to be acknowledged as it may greatly delay the treatment of catatonia and the diagnosis of medically related catatonia. Tragically, this may deny patients treatment opportunities.

The role of deprivation, abuse, and trauma in pediatric catatonia without a clear medical cause

OBJECTIVE

Catatonia is considered a unique syndrome of motor signs, at times life-threatening when aggravated by autonomic dysfunction and fever, but eminently treatable with specific medical treatments, if recognized early. Catatonia commonly occurs in children and adolescents with a wide range of associated disorders. The role of deprivation, abuse, or trauma in the development of pediatric catatonia is examined.

METHOD

Reports considering deprivation, abuse, or trauma as precipitants of catatonia in pediatric cases are culled from the classic writings on catatonia and from a selective review of modern contributions.

RESULTS

Kahlbaum gave trauma a central role in catatonia in many young adult cases. Kanner described children with psychogenic catalepsy. Anaclitic depression, a condition found by Spitz in deprived institutionalized children, strongly resembles stuporous catatonia. Leonhard considered lack of communication with the mother or substitute mother as an important risk factor for childhood catatonia. Children including those with autism who experience emotional and physical trauma sometimes develop catatonia. The clinical descriptions of children with classic catatonic syndromes and those of contemporary refugee children with a syndrome labeled Pervasive Refusal Syndrome are similar.

CONCLUSION

The literature supports the view that deprivation, abuse, and trauma can precipitate catatonia in children and adolescents.

Retrospective chart review of catatonia in child and adolescent psychiatric patients

OBJECTIVE

Identify the frequency of catatonia among at-risk children and adolescents receiving psychiatric treatment.

METHOD

Subjects were children and adolescents (<18 years), who had received psychiatric treatment at a University Hospital during 2004-2009, and were diagnosed with disorders with known risk for catatonia or displayed symptoms suggestive of catatonia. Approval was obtained from the Investigational Review Board (IRB). The first 101 (n = 101) subjects were selected among 570 subjects identified by psychiatric diagnoses: any pervasive developmental disorder, psychosis-NOS (Not Otherwise Specified), intermittent explosive disorder, mental retardation, catatonia and neuroleptic malignant syndrome. Subjects met study-defined criteria for catatonia, if they had three or more of the following symptoms: unexplained agitation/excitement, disturbed or unusual movements, reduced movements, repetitive or stereotyped movements, or reduced or loss of speech.

RESULTS

Eighteen (17.8%) subjects, among a group suspected to be at a higher risk for catatonia, met the study-defined criteria for this syndrome. However, only two subjects had been diagnosed by their treatment providers. Higher rates of intellectual disability and aggression were found among the group that met study-criteria.

CONCLUSION

We concluded that catatonia is under recognized and undertreated among children and adolescents receiving psychiatric treatment.

Measuring catatonia: a systematic review of rating scales

BACKGROUND

Despite a growing scientific and clinical interest in catatonia, its precise definition remains debated.

AIM

The aim of this study was to offer a systematic review of the different rating scales that have been developed to assess catatonia in clinical practice.

METHODS

A Medline-search was performed, up to December 2010.

RESULTS

Seven catatonia rating scales were retrieved: the Modified Rogers Scale, the Rogers Catatonia Scale, the Bush-Francis Catatonia Rating Scale (BFCRS), and its revision, the Northoff Catatonia Rating Scale (NCRS), the Braunig Catatonia Rating Scale (BCRS), and the Kanner Scale.

CONCLUSION

Several catatonia rating scales are proposed to detect the catatonic syndrome and to evaluate treatment response. BFCRS, NCRS and BCRS are reliable for use in variable populations in which catatonia is prevalent. The BFCRS is preferred for routine use, because of its validity and reliability, and its ease of administration.