Catatonia: disappeared or under-diagnosed?

Catatonia in ICD-11

In the International Statistical Classification of Diseases and Related Health Problems Version 11 (ICD-11), the diagnostic criteria for catatonia have been extensively revised. We provide context for these changes beginning with a brief history of how catatonia has been conceptualized and a description of how the criteria for catatonia have changed across ICD versions. We also compare ICD-11 with the criteria in the latest Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5-TR), consider clinical implications of the changes in ICD-11, and highlight conceptual areas in need of further development.Described in 1874 by Karl Kahlbaum, catatonia was subsequently subsumed into the Kraepelinian concept of dementia praecox. This was reflected in versions of ICD up to ICD-9, which considered catatonia exclusively as a form of schizophrenia. ICD-10 introduced the diagnosis of organic catatonic disorder but did not incorporate the growing evidence that catatonia can occur in psychiatric conditions such as mood and autism-spectrum disorders.ICD-11 conceptualizes catatonia as an independent disorder with a common clinical phenotype regardless of associated condition, if present. In ICD-11, catatonia diagnosis requires at least three clinical features from the following categories: decreased, increased or abnormal psychomotor activity. These features may come from any combination of the categories, but only one from the increased psychomotor activity category should be counted. The four catatonia diagnoses in ICD-11 are catatonia associated with another mental disorder, catatonia induced by substances or medications, secondary catatonia syndrome and catatonia, unspecified. This expanded view of catatonia more closely resembles DSM-5-TR, which also recognizes catatonia associated with several psychiatric and general medical conditions. ICD-11 also offers guidance on distinguishing catatonia from similar behavioural features of other conditions, such as psychomotor retardation in depression, delirium, and factitious disorder.This new classification stands to improve recognition of catatonia and our hope is that it may lead to a growing awareness of the wide range of conditions associated with it. Ultimately, a better understanding of catatonia should contribute to improved outcomes as clinicians offer treatments both for catatonia itself as well as tailored treatments for its broad range of associated conditions.

Expanding the phenotype of NEDAMSS with a psychiatric perspective: analysis of a new case, and a systematic review of the literature

Pathogenic variants in the IRF2BPL gene are associated with neurodevelopmental disorders with varying degrees of regression, loss of speech and epilepsy. The phenotype is also known as Neurodevelopmental Disorder with regression, Abnormal Movements, loss of Speech, and Seizures (NEDAMSS). The motor symptoms of this disorder share significant phenotypical characteristics with catatonia, a severe neuropsychiatric psychomotor syndrome. The objective of this article is to expand the knowledge on the presentation of NEDAMSS with a focus on psychiatric symptoms including catatonia. A systematic review of 32 case presentations of NEDAMSS, and a novel case report of a patient with NEDAMSS, exhibiting multiple psychiatric symptoms, including catatonia are presented. Psychiatric symptoms and disorders including affective disorders, psychotic symptoms, catatonia, and developmental disorders are reported in one third of the reviewed cases. Reported effects of pharmacological treatment on motor symptoms of NEDAMSS are very limited. Our case presents improvement in motor symptoms originally attributed to NEDAMSS, after treatment with Lorazepam following diagnosis with catatonia. Patients with NEDAMSS may present with both neurological and psychiatric symptoms. The clinical presentation of NEDAMSS motor symptoms and catatonia have similarities and thus poses significant challenges to the diagnostic process, with risk of incorrect or delayed treatment. The limited experience and the complex phenotype of NEDAMSS complicates pharmacological treatment and encourages caution, especially with the use of antipsychotic drugs in the presence of possible catatonic symptoms.

Psychiatric manifestations of encephalitis

OBJECTIVE

Encephalitis is a serious and potentially life-threatening condition of infectious or autoimmune cause. We aim to characterize the frequency and clinical spectrum of presenting psychiatric symptoms in encephalitis in order to inform earlier recognition and initiation of treatment.

METHODS

This was a retrospective study of adult patients who met the 2013 International Encephalitis Consortium (IEC) and/or 2016 Graus criteria between February 2005 and February 2023. The study included two hospital systems in Houston, Texas, and Baltimore, Maryland and included a total of 642 patients. Psychiatric manifestations were grouped into five high-level categories: behavior, psychosis, mood, sleep disturbances, and catatonia.

RESULTS

In our cohort of 642 patients, 318 (49.6%) had psychiatric symptoms at the time of initial presentation, including 78.2% with autoimmune etiologies and 35.2% with viral etiologies (P < 0.001). Those with psychiatric symptoms were younger (median age 47.5 vs. 51.5; P < 0.001), and more likely to have a history of documented psychiatric disorders, as well as longer lengths of hospital stay, and poorer discharge outcomes. Of patients initially admitted to a psychiatric service (n = 28), most had autoimmune causes, although 3 out of 28 (10.7%) had herpes viral infections; admission to a psychiatric service was associated with substantially longer interval to initiation of antivirals and immunotherapy. Autoimmune and infectious etiologies differed in the spectrum and frequency of psychiatric manifestations.

INTERPRETATION

Psychiatric symptoms are common across etiologies of encephalitis and are associated with longer lengths of hospital stay and worse clinical outcomes. Specific patterns and dimensionality of psychiatric symptoms distinguish autoimmune from infectious causes.

Catatonia-asossicated urinary retention in geriatric patients: a case series report

BACKGROUND

Catatonia is an underdiagnosed neuropsychiatric condition, with only a few studies focusing on medical sequalae among elderly populations. Delayed treatment results in complications with high morbidity and mortality. Among elderly individuals, one such complication is urinary retention. Urinary retention can result in prolonged catheter use. In geriatric populations, prolonged use of catheters become particularly concerning and problematic as it can limit patient mobility, are potential sources for infection, and increase the risk for delirium. Catheter use has been independently associated with increased mortality in nursing home settings. Given the above risks and implications of catheter use, this case series describes clinical cases of catatonia-associated urinary retention specifically in older populations, whereby the use of electroconvulsive therapy (ECT) resulted in resolution of urinary retention concurrent with resolution of depressive and catatonic symptoms using validated scales.

CASE PRESENTATION

This study involved four patients ranging from 66-84 years old who met criteria for major depressive disorder and catatonia. At admission, Montgomery-Asberg Depression Rating Scale (MADRS) scores ranged from 40-56, indicating severe illness in all patients. All patients also met criteria for catatonia as measured by the Bush Francis Catatonia Rating Scale (BFCRS). During the admission, each patient experienced urinary retention as evidenced by post-void residual (PVR) bladder volumes ranging from 569-1400 mL. Medical workup was completed to exclude alternative causes for urinary retention. Each patient completed ECT treatment, ranging from 14-19 sessions which resulted in resolution of catatonia. All four patients were also noted to have PVR volumes ranging from 6-75 mL, thereby suggesting concurrent resolution of urinary retention. Posttreatment, the MADRS scores ranged from 3-16, indicating a mild or subthreshold index of illness. There was no recurrence of elevated post-void residual volumes, and therefore, all patients were discharged from hospital without the requirements of urinary catheter insertion.

CONCLUSIONS

To our knowledge, there are no case reports that describe the concurrent resolution of catatonia, depressive symptoms and urinary retention simultaneously using validated scales throughout the ECT treatment course. Furthermore, there are no prior reports describing catatonia-related urinary retention specifically among a group of geriatric populations. Identifying and treating catatonia in a timely manner can reduce the complications associated with prolonged catheter use. There remains a gap in current research to describe if there exists any overlapping mechanisms and pathways to explain how ECT can treat catatonia, depression, and catatonia-associated urinary retention.

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.

Exploring seasonality in catatonia diagnosis: Evidence from a large-scale population study

Catatonia is a severe psychomotor syndrome mainly associated with psychiatric disorders, such as mood disorders and schizophrenia. Seasonal patterns have been described for these psychiatric disorders, and a previous study conducted in South London showed for the first time a seasonal pattern in the onset of catatonia. In this study, we aim to extend those findings to a larger national sample of patients admitted to French metropolitan hospitals, between 2015 and 2022, and to perform subgroup analyses by the main associated psychiatric disorder. A total of 6225 patients diagnosed with catatonia were included. A seasonal pattern for catatonia diagnosis was described, using cosinor models. Two peaks of diagnoses for catatonic cases were described in March and around September-October. Depending on the associated psychiatric disorder, the seasonality of catatonia diagnosis differed. In patients suffering with mood disorders, peaks of catatonia diagnosis were found in March and July. For patients suffering with schizophrenia, no seasonal pattern was found.

From operational diagnostic to dimensional-continuum concepts of psychotic and non-psychotic illness: Embracing catatonia across psychopathology and intrinsic movement disorder in neural network dysfunction

Psychiatry is currently negotiating several challenges that are typified by (but are not unique to) schizophrenia: do periodic refinements in operational diagnostic algorithms (a) resolve intricacies and subtleties within and between psychotic and non-psychotic disorders that are authentic and impactful, or (b) constitute arbitrary and porous boundaries that should be complemented, or even replaced, by dimensional-continuum concepts of abnormality and dysfunction. Critically, these issues relate not only to apparent boundaries between diagnoses but also to those between 'health' and 'illness'. This article considers catatonia within evolving dimensional-continuum approaches to the description of impairment and dysfunction among psychotic and non-psychotic disorders. It begins by considering the definition and assessment of catatonia vis-à-vis other disorders, followed by its long-standing conjunction with schizophrenia, relationship with antipsychotic drug treatment, transdiagnostic perspectives and relationships, and pathobiological processes. These appear to involve dysfunction across elements in overlapping neural networks that result in a confluence of psychopathology and intrinsic hypo- and hyperkinetic motor dysfunction. It has been argued that while current diagnostic approaches can have utility in defining groups of cases that are closely related, contemporary evidence indicates categorical diagnoses to be arbitrary divisions of what is essentially a continuous landscape. Psychotic and non-psychotic diagnoses, including catatonia, may reflect arbitrary areas around points of intersection between orthogonal dimensions of psychopathology and intrinsic movement disorder in a poly-dimensional space that characterises this continuous landscape of mental health and dysfunction.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSION

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

Catatonia: “Fluctuat nec mergitur”

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

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

Catatonia: demographic, clinical and laboratory associations

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objectives

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

Materials and Methods

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

Results

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

Conclusion

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

Catatonia Secondary to Depolarization Block

Catatonia is a severe psychomotor disorder that is associated with a 60-fold increased risk of premature death. Its occurrence has been associated with multiple psychiatric diagnoses, the most common being type I bipolar disorder. Catatonia can be understood as a disorder of ion dysregulation with reduced clearance of intracellular sodium ions. As the intraneuronal sodium concentration increases, the transmembrane potential is increased, and the resting potential may ultimately depolarize above the cellular threshold potential creating a condition known as depolarization block. Neurons in depolarization block do not respond to stimulation but are constantly releasing neurotransmitter; they mirror the clinical state of catatonia - active but non-responsive. Hyperpolarizing neurons, e.g., with benzodiazepines, is the most effective treatment.

Consultation-Liaison Case Conference: Malignantly Catatonic and Unable to Receive Electroconvulsive Therapy

We present the case of a 65-year-old female with a past psychiatric history of obsessive-compulsive disorder and anxiety who recently underwent diagnostic laparoscopy in the setting of a recent computerized tomography scan revealing a peritoneal mass. Postoperatively, she was delirious and soon found to be malignantly catatonic. This patient's treatment was complicated by an acute stroke, which was a relative contraindication for electroconvulsive therapy. Top experts in the consultation-liaison psychiatry and electroconvulsive therapy fields provide guidance for this clinical scenario based on their experience and a review of the available literature. Key teaching points include a review of diagnosing and treating catatonia, a review of electroconvulsive therapy for the treatment of catatonia, as well as a review of the role of the consultation-liaison psychiatrist in medically complex cases. Specifically, we offer guidance in treating patients that have malignant catatonia when electroconvulsive therapy is unavailable.

Malignant Catatonia: A Review for the Intensivist

Catatonia is a clinical syndrome characterized by psychomotor, neurological and behavioral changes. The clinical picture of catatonia ranges from akinetic stupor to severe motoric excitement. Catatonia can occur in the setting of a primary psychiatric condition such as bipolar disorder or secondary to a general medical illness like autoimmune encephalitis. Importantly, it can co-occur with delirium or coma. Malignant catatonia describes catatonia that presents with clinically significant autonomic abnormalities including change in temperature, blood pressure, heart rate, and respiratory rate. It is a life-threatening form of acute brain dysfunction that has several motoric manifestations and occurs secondary to a primary psychiatric condition or a medical cause. Many of the established predisposing and precipitating factors for catatonia such as exposure to neuroleptic medications or withdrawal states are common in the setting of critical illness. Catatonia typically improves with benzodiazepines and treatment of its underlying psychiatric or medical conditions, with electroconvulsive therapy reserved for catatonia refractory to benzodiazepines or for malignant catatonia. However, some forms of catatonia, such as catatonia secondary to a general medical condition or catatonia comorbid with delirium, may be less responsive to traditional treatments. Prompt recognition and treatment of catatonia are crucial because malignant catatonia may be fatal without treatment. Given the high morbidity and mortality associated with malignant catatonia, intensivists should familiarize themselves with this important and under-recognized condition.

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

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

The State of the Catatonia Literature: Employing Bibliometric Analysis of Articles From 1965-2020 to Identify Current Research Gaps

BACKGROUND

Since Kahlbaum's classic 19th-century description of catatonia, our conceptualization of this syndrome, as well treatment options for it, has advanced considerably. However, little is known about the current state of the catatonia literature since a comprehensive bibliometric analysis of it has not yet been undertaken.

OBJECTIVE

The purpose of this study was to conduct a bibliometric analysis, along with a content analysis of articles reporting new findings, to better understand the catatonia literature and how catatonia research is changing.

METHODS

Using the search term "Title(catatoni∗)" in Web of Science Core Collection for all available years (1965-2020), all available publications (articles, proceeding papers, reviews) pertaining directly to catatonia were identified, and metadata extracted. Semantic and coauthorship network analyses were conducted. A content analysis was also conducted on all available case reports, case series, and research articles written in English.

RESULTS

A total of 1015 articles were identified representing 2861 authors, 346 journals, and 15,639 references. The average number of publications per year over the last 20 years (31.3) more than doubled in comparison to that in the 20 years prior (12.8). The top 3 most common journals were Psychosomatics/Journal of the Academy of Consultation-Liaison Psychiatry, Journal of ECT, and Schizophrenia Research, which represented 12.6% of all publications. Content analysis revealed that catatonia articles are increasingly published in nonpsychiatric journals. There was a notable paucity of clinical trials throughout the study period. Since 2003, articles on catatonia secondary to a general medical condition, as well as articles including child/adolescent patients and patients with autism spectrum disorder or intellectual disability, have made up increasing shares of the literature, with a smaller proportion of articles reporting periodic or recurrent catatonia. We noted a decrease in the proportion of articles detailing animal/in vitro studies, genetic/heredity studies, and clinical trials, along with stagnation in the proportion of neuroimaging studies.

CONCLUSIONS

The catatonia literature is growing through contributions from authors and institutions across multiple countries. However, recent growth has largely been driven by increased case reports, with significant downturns observed in both clinical and basic science research articles. A dearth of clinical trials evaluating potential treatments remain a critical gap in the catatonia literature.

Challenges of treating catatonia in the community setting without access to electroconvulsive therapy

Catatonia is a psychomotor syndrome resulting from an underlying psychiatric or medical disorder commonly observed in inpatient psychiatric units. While benzodiazepines and electroconvulsive therapy (ECT) are effective treatment options, the unavailability of ECT in many community psychiatric hospitals in the United States negatively affects patient outcomes. We present a 25-year-old African American male with a psychiatric diagnosis of schizophrenia complicated by malignant catatonia who was admitted to a community psychiatric hospital. He required intensive medical stabilization with supportive management, and transfer requests to ECT-equipped hospitals were initiated. While awaiting transfer for 148 days, the patient's symptoms did not fully remit with lorazepam (even with 36 mg daily in divided doses) and other psychotropic medication trials, including antipsychotics and mood stabilizers. After nearly 5 months of inpatient stay, he was successfully transferred, received ECT treatment, and experienced rapid resolution of catatonia. After discharge, to obtain three monthly sessions of maintenance ECT, he had 5-h one-way ground transportation arranged to an out-of-county ECT-equipped facility. There was no relapse in catatonia by the 2-year follow-up. This report highlights a significant healthcare disparity when attempting to manage severe catatonia within community hospital settings without access to ECT in the United States. Alternative treatments, including antipsychotics, had minimal impact on symptoms and possibly increased morbidity in this case while awaiting ECT. Treatment at our designated safety net hospital still required referral to 14 ECT-equipped hospitals before successful transfer. This case highlights the urgent need for ECT availability in more community hospitals to treat patients with refractory psychiatric conditions, including catatonia. ECT is an essential psychiatric treatment that, for certain conditions, has no appropriate alternatives. We propose that access to ECT be considered in the determination of safety net hospital systems, with improved ability to transfer patients who are suffering from treatable life-threatening mental health conditions.

Recurrent Catatonia due to Episodic Obsessive-Compulsive Disorder

Background

Catatonia is regarded as a diverse type of motor dysregulation syndrome that includes mutism, immobility, catalepsy, negativism, stereotypies, and echo phenomena. Catatonia is known to coexist with a wide range of physical and mental health conditions, including mood disorders, schizophrenia, autoimmune disorders, and metabolic abnormalities. Albeit, the association between obsessive-compulsive disorder (OCD) and catatonia is underreported, and mechanisms are not well elucidated. Study. In this study, we present a case of a 36-year-old woman who developed episodes of catatonia during the course of her obsessive-compulsive disorder (OCD). Success rates have been recorded with both benzodiazepines and electroconvulsive therapy (ECT). Gauging the severity of her symptoms and poor drug compliance, the patient was opted for and successfully treated with ECT. She was also educated about OCD through a series of therapy sessions and exposure and response prevention (ERP) principles. She was maintained on ERP and adjunctive clonazepam upon discharge. On subsequent follow-ups, the patient seemed to be doing well and was eager to begin her job again.

Conclusion

Our study shows a possible link between OCD and catatonia. Additionally, robust studies are needed in order to determine the pathophysiology of catatonia and the mechanism of ECT so that more beneficial therapeutics can be developed. A combination of ECT and antidepressants with ERP therapy for recurrent catatonia with OCD could be effective as a therapeutic modality.

Clinical Neuroimaging Findings in Catatonia: Neuroradiological Reports of MRI Scans of Psychiatric Inpatients With and Without Catatonia

OBJECTIVE

Catatonia is a debilitating psychomotor disorder. Previous neuroimaging studies have used small samples with inconsistent results. The authors aimed to describe the structural neuroradiological abnormalities in clinical magnetic resonance imaging (MRI) brain scans of patients with catatonia, comparing them with scans of psychiatric inpatients without catatonia. They report the largest study of catatonia neuroimaging to date.

METHODS

In this retrospective case-control study, neuroradiological reports of psychiatric inpatients who had undergone MRI brain scans for clinical reasons were examined. Abnormalities were classified by lateralization, localization, and pathology. The primary analysis was prediction of catatonia by presence of an abnormal MRI scan, adjusted for age, sex, Black race-ethnicity, and psychiatric diagnosis.

RESULTS

Scan reports from 79 patients with catatonia and 711 other psychiatric inpatients were obtained. Mean age was 36.4 (SD=17.3) for the cases and 44.5 (SD=19.9) for the comparison group. Radiological abnormalities were reported in 27 of 79 cases (34.2%) and in 338 of 711 in the comparison group (47.5%) (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.35, 0.93; adjusted OR=1.11, 95% CI=0.58, 2.14). Among the cases, most abnormal scans had bilateral abnormalities (N=23, 29.1%) and involved the forebrain (N=25, 31.6%) and atrophy (N=17, 21.5%).

CONCLUSIONS

Patients with catatonia were commonly reported to have brain MRI abnormalities, which largely consisted of diffuse cerebral atrophy rather than focal lesions. No evidence was found that these abnormalities were more common than in other psychiatric inpatients undergoing neuroimaging, after adjustment for demographic variables. Study limitations included a heterogeneous control group and selection bias in requesting scans.

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

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

Lorazepam challenge test: A unique clinical response in catatonia

Catatonia is a psychomotor behavioral syndrome characterized as a complex syndrome of bizarre motor behavior, impaired volition, and vegetative abnormalities. Catatonia is a medical emergency and if not recognized on time may have potentially fatal outcomes. We present a case series of three patients with catatonia, in whom Injection lorazepam 4 mg administered intravenously (Lorazepam Challenge) produced quick, optimum outcome.

Incidence of schizophrenia and influence of prenatal and infant exposure to viral infectious diseases

OBJECTIVE

There is conflicting evidence in recent literature about whether the incidence of schizophrenia is increasing or decreasing. A role for prenatal and early childhood viral infections in the aetiology of schizophrenia has also been debated. We examined the incidence of schizophrenia and the catatonic subtype of schizophrenia over a 30-year period in Finland. We also investigated whether the incidence rate of the catatonic subtype of schizophrenia was linked to changes in exposure to viral infection (polio and measles) during the prenatal or infant period.

METHODS

Persons with schizophrenia were identified from the Hospital Discharge Register. Cumulative incidence of schizophrenia from 1956 to 1989 in 4 age groups was calculated with follow-up from 1972 to 2014. Annual rates of polio and measles were derived from nationwide registers. The association between log-transformed polio and measles incidence and incidence of schizophrenia, and specifically catatonic schizophrenia, were analysed using linear models.

RESULTS

Cumulative incidence of schizophrenia among individuals born 1956-1989 decreased by 23% (from 13 to 10 cases per 1000 live births). The decline was the most prominent in those with onset of schizophrenia diagnosed 16-25 years of age (-41%). The incidence of catatonic schizophrenia declined by 90% over three decades, and there was a significant association between annual polio incidence during the birth year and incidence of catatonic schizophrenia.

CONCLUSIONS

The results indicate that the incidence of schizophrenia in Finland has declined for individuals born between 1956 and 1989, and that the decline of catatonic schizophrenia may be partially attributable to eradication of polio.

Hungarian Psychiatrists' Recognition, Knowledge, and Treatment of Catatonia

DSM-5 introduced a number of modifications to the catatonic syndrome, which is now closer to Kahlbaum's original concept. The aim of the present study was to assess residents' and qualified psychiatrists' knowledge, experience and views about the treatment of catatonia in acute psychiatric care in Budapest, Hungary. Authors approached all psychiatric units that provide acute psychiatric care (N = 11) in Budapest and invited all psychiatrists and residents, who consented, to participate in the survey, completing a 13 items questionnaire. Ninety-eight fully qualified and trainee psychiatrists completed the questionnaire. Although 84.7% of the participants rated their knowledge of catatonia as moderate or significant, there were a number of obvious mistakes in their answers. Most catatonic signs and symptoms were not identified by almost 50% of the respondents and the frequency of catatonia was also underestimated. The views of the majority of the participants reflected the Kraepelinian concept, in which catatonia is primarily associated with schizophrenia. Although benzodiazepines are widely recommended as a first line treatment for catatonia, only 69.4% of participants chose them as a treatment option. In view of its clinical importance, catatonia deserves more attention in the education and training of medical students and psychiatric residents.

Catatonia secondary to anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis: a review

Anti-N-methyl-D-aspartate receptor (NMDAr) encephalitis is a relatively recent autoimmune entity, as it was first described in 2007. Given that it is a condition with neuropsychiatric symptoms, its initial symptom is frequently psychiatric in nature. Hence, psychiatrists are often the first physicians to assess these patients and, as so, must recognize this type of encephalitis as a possible cause. Catatonia may be inaugural or develop throughout the course of the disease. Management of patients with anti-NMDAr encephalitis is based on etiologic treatment with immunotherapy and removal of the associated tumor, if any. However, these catatonic patients may have variable responses to etiologic treatment, sometimes with refractory catatonic symptoms, which attests to the necessary urgency to know how to manage these patients. In the clinical setting, physicians appear to be using guidelines originally created to the management of catatonia due to primary psychiatric conditions. In this literature review, catatonia was historically contextualized and anti-NMDAr encephalitis overall described. Finally, catatonia secondary to this type of encephalitis was discussed.

Lorazepam-Resistant Catatonia in an Antipsychotic-Naïve 24-Year-Old with Psychotic Symptoms

Catatonia is a complex identifiable clinical syndrome characterized primarily by psychomotor symptoms. In recent decades, some authors have considered that catatonia can be presented as a catatonic syndrome in several pathologies such as bipolar disorder, schizophrenia and other psychotic disorders and not only in schizophrenia. Prior to DSM 5, there were two conceptions of catatonia: one in which clinical characterization seemed to play a determining role (a categorical view) and another in which a dimensional perspective advocated the existence of catatonia as a clinical entity in its own right, detached from the underlying pathology. Although there are no definitive consensus guidelines for the treatment of catatonia, some studies show that in the schizophrenic form of catatonia, benzodiazepines are partially effective, as well as treatment with ECT. We present the case of a 24-year-old man with severe catatonia and psychotic symptoms, resistant to lorazepam treatment, who achieved complete remission with clozapine treatment according to our diagnostic hypothesis of schizophrenia.

Mental, behavioral and neurodevelopmental disorders in the ICD-11: an international perspective on key changes and controversies

An update of the chapter on Mental, Behavioral and Neurodevelopmental Disorders in the International Classification of Diseases and Related Health Problems (ICD) is of great interest around the world. The recent approval of the 11th Revision of the ICD (ICD-11) by the World Health Organization (WHO) raises broad questions about the status of nosology of mental disorders as a whole as well as more focused questions regarding changes to the diagnostic guidelines for specific conditions and the implications of these changes for practice and research. This Forum brings together a broad range of experts to reflect on key changes and controversies in the ICD-11 classification of mental disorders. Taken together, there is consensus that the WHO's focus on global applicability and clinical utility in developing the diagnostic guidelines for this chapter will maximize the likelihood that it will be adopted by mental health professionals and administrators. This focus is also expected to enhance the application of the guidelines in non-specialist settings and their usefulness for scaling up evidence-based interventions. The new mental disorders classification in ICD-11 and its accompanying diagnostic guidelines therefore represent an important, albeit iterative, advance for the field.

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.

Benzodiazepine Withdrawal Catatonia, Delirium, and Seizures in a Patient With Schizoaffective Disorder

Benzodiazepine withdrawal symptoms vary from mild anxiety to life-threatening delirium or seizures. In susceptible individuals, such as those with mood disorders, benzodiazepine withdrawal may also precipitate catatonia. A 26-year-old man with schizoaffective disorder (depressed type with catatonia) ran out of lorazepam and presented with catatonia, delirium, and seizures. He was taking olanzapine, venlafaxine, and trazodone for schizoaffective disorder. Lorazepam 2 mg twice daily kept him free of catatonia for 6 months. Besides catatonia and delirium, lorazepam withdrawal also triggered convulsive seizures and nonconvulsive status epilepticus. He was admitted to the intensive care unit where he underwent continuous video-EEG monitoring. Catatonia resolved with lorazepam on day 2. Seizures stopped with levetiracetam, lacosamide, and propofol on day 4. His mental status was normal when he was discharged on day 6. If not immediately recognized and treated, catatonia and delirium can lead to significant morbidity or mortality. Unfortunately, physicians tend to overlook catatonia and delirium, especially if both syndromes are present. At first, we suspected that our patient had ictal catatonia, but video-EEG showed no clear-cut correlation between catatonia, seizures, and epileptiform activity. As with prior observations, the patient's catatonia was more sensitive to benzodiazepine withdrawal and treatment than his seizures. The efficacy of benzodiazepines in aborting catatonia, seizures, and mixed delirium-catatonia syndromes suggests a key pathogenetic role of abnormal GABA neurotransmission in these brain disorders.

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.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review of Psychiatric Phenotypes and Management Considerations: A Report of the American Neuropsychiatric Association Committee on Research

OBJECTIVE

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is an autoimmune disorder characterized by prominent neuropsychiatric symptoms. Given the nature of its pathophysiology, psychiatrists tend to be one of the first clinicians encountering patients with the disease.

METHODS

In the present review of patients described in the literature with psychiatric symptoms, the authors aimed to characterize the psychiatric symptoms of the disease and its management in adults and adolescents as well as children (≤12 years old). A total of 544 patients fulfilled the inclusion criteria.

RESULTS

The authors found that 77% of patients with NMDAR encephalitis presented initially with psychiatric symptoms. These were mostly agitation (59%) and psychotic symptoms (in 54%, especially disorganized behavior and visual-auditory hallucinations), with agitation even more commonly being the presenting symptom in children (66%). Where psychotic symptoms were detailed, visual (64%) and auditory (59%) hallucinations were the most common, as well as persecutory delusions (73%). However, delusions were not clearly characterized in most cases. Catatonia was described in 42% of adult patients and 35% of children. Of the patients with documented exposure to antipsychotics, 33% were suspected to have an adverse drug reaction (notably, neuroleptic malignant syndrome in 22% of the cases).

CONCLUSIONS

On the basis of these findings, it is important to consider anti-NMDAR encephalitis in the differential diagnosis of patients with an acute onset psychosis, especially in association with agitation, catatonia, or adverse response to antipsychotics. Furthermore, it is important to use antipsychotics with caution in patients with suspected or confirmed anti-NMDAR encephalitis.

Cortical Contributions to Distinct Symptom Dimensions of Catatonia

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

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Structure and neural mechanisms of catatonia

Catatonia is a psychomotor syndrome associated with several psychiatric and medical conditions. Psychomotor signs range from stupor to agitation, and include pathognomonic features such as verbigeration and waxy flexibility. Disturbances of volition led to the classification of catatonia as a subtype of schizophrenia, but changes in nosology now recognise the high prevalence in mood disorders, overlap with delirium, and comorbidity with medical conditions. Initial psychometric studies have revealed three behavioural factors, but the structure of catatonia is still unknown. Evidence from brain imaging studies of patients with psychotic disorders indicates increased neural activity in premotor areas in patients with hypokinetic catatonia. However, whether this localised hyperactivity is due to corticocortical inhibition or excess activity of inhibitory corticobasal ganglia loops is unclear. Current treatment of catatonia relies on benzodiazepines and electroconvulsive therapy-both effective, yet unspecific in their modes of action. Longitudinal research and treatment studies, with neuroimaging and brain stimulation techniques, are needed to advance our understanding of catatonia.

[Catatonia education in France: A cross-sectional study]

OBJECTIVES

Catatonia is a transnosographic syndrome described by K. Kahlbaum in 1874. Catatonia can be life-threatening due to its complications and in case of malignant catatonia. Safe and effective treatments have been identified (benzodiazepines and electro-convulsive-therapy). The prevalence of this syndrome is important and represents about 10% of inpatients in an acute psychiatric ward. However, this syndrome appears to remain under-diagnosed and poorly known. We were, therefore, interested in the current knowledge of French psychiatry residents and young psychiatrists as well as the education they had received about catatonia.

METHODS

A questionnaire was submitted to French psychiatry residents and young psychiatrists with fewer than 5 years of experience. It included questions about knowledge of the symptoms, complications, causes and treatments of catatonia. Participants were also asked about their confidence in the management of a patient with catatonia and about the number of catatonic patients they had already met. The type of lecture and teaching about catatonia was also assessed.

RESULTS

Among the 376 psychiatrists that completed the questionnaire, 37.5% never had received any specific teaching about catatonia. Concerning the 62.5% who benefited from a specific lecture, this was mainly delivered as part of psychiatry DES. Heterogeneity in the education delivery on the French territory had been highlighted. In addition, participants' knowledge of catatonic syndrome seems incomplete. However, knowledge of catatonic symptoms and first intention treatments was significantly better among respondents who were part of the "with education" group. The confidence in catatonia recognition and management, as well as the number of catatonic patients they met, are also significantly higher in the group "with education".

CONCLUSION

Specific education seems to improve the knowledge of young doctors and their ability to diagnose and treat catatonic patients. This education remains poorly provided and heterogeneous on the French territory. Catatonia deserves a place in the teaching program of the psychiatry DES, thus to become systematic.

Why do neurologists miss catatonia in neurology emergency? A case series and brief literature review

Catatonia is a well-described clinical syndrome characterized by features that range from mutism, negativism and stupor to agitation, mannerisms and stereotype. Causes of catatonia may range from organic brain disorders to psychiatric conditions. Despite a characteristic syndrome, catatonia is grossly under diagnosed. The reason for missed diagnosis of catatonia in neurology setting is not clear. Poor awareness is an unlikely cause because catatonia is taught among conditions with deregulated consciousness like vegetative state, locked-in state and akinetic mutism. We determined the proportion of catatonia patients correctly identified by neurology residents in neurology emergency. We also looked at the alternate diagnosis they received to identify catatonia mimics. Twelve patients (age 22-55 years, 7 females) of catatonia were discharged from a single unit of neurology department from 2007 to 2017. In the emergency department, neurology residents diagnosed none of the patients as catatonia. They offered diagnosis of extrapyramidal syndrome in 7, meningitis in 2, and conversion reaction, acute psychosis/encephalopathy and non-convulsive status epilepticus in one each. Their final diagnosis at discharge was catatonia due to general medical condition in 6 (progressive supranuclear palsy in 2, post-status epilepticus, uremic encephalopathy, glioblastoma multiforme and tuberculous meningitis in one each), catatonia due to major depression in 4, schizophrenia and idiopathic catatonia in one each. Extrapyramidal syndrome appeared as common mimic of catatonia. The literature reviewed also revealed the majority of organic catatonia secondary to causes that are usually associated with extrapyramidal features. Therefore, we suggest that neurologists should consider catatonia in patients presenting with extrapyramidal syndromes.

First known case of catatonia due to cyclosporine A-related neurotoxicity in a pediatric patient with steroid-resistant nephrotic syndrome

BACKGROUND

Catatonia is a neuropsychiatric syndrome characterized by diverse psychomotor abnormalities, including motor dysregulation and behavioral and affective disturbances. Once thought to occur primarily in the context of schizophrenia, recent data suggest most cases of catatonia develop in individuals with depressive or bipolar disorders. Moreover, catatonia may ensue in general medical and neurological conditions, as well as due to a variety of pharmaceuticals, drugs of abuse, and toxic agents. At one time considered rare in pediatric patients, evidence now suggests catatonia is both underrecognized and undertreated in this population, where it carries an elevated risk of morbidity and mortality. Here we present the case of a child with steroid-resistant nephrotic syndrome who developed catatonia due to cyclosporine A-related neurotoxicity.

CASE PRESENTATION

A 9-year-old African-American boy with no psychiatric history and a 9-month history of nephrotic syndrome due to focal segmental glomerulosclerosis was admitted to the local children's hospital for management of mutism, posturing, insomnia, gait abnormalities, and somatic delusions. Seven days prior to admission, his cyclosporine plasma concentration was elevated at 1224 ng/mL (therapeutic range: 100-200 ng/mL). Upon admission, cyclosporine was discontinued and psychiatry was consulted, diagnosing catatonia. The patient subsequently received propofol 80 mg IV resulting in a transient lysis of catatonia. Over a lengthy hospitalization, the patient's catatonia was initially treated with lorazepam, quetiapine being added later to target psychosis. All signs and symptoms of catatonia resolved, and the patient was eventually tapered off both lorazepam and quetiapine with no return of symptoms more than 6 months later.

CONCLUSIONS

To our knowledge, this case represents the first reported instance of cyclosporine A-induced catatonia in a patient with steroid-resistant nephrotic syndrome. It illustrates the importance of maintaining vigilance for signs and symptoms of cyclosporine A-related neurotoxicity (including catatonia) in patients with steroid-resistant nephrotic syndrome. In addition, it highlights the challenges faced by clinicians in jurisdictions that prohibit the use of electroconvulsive therapy in pediatric patients.

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.

Clinical and demographic profile of catatonic patients who received electroconvulsive therapy in a South African setting

BACKGROUND

Catatonia is a psychomotor dysregulation syndrome seen in several illnesses. Uncertainties exist regarding its prevalence and causes. While some research shows a strong association with mood disorders, other data show catatonia to be strongly associated with schizophrenia. Data from low- and middle-income countries are required.

AIM

To determine the clinical and demographic profile of patients with catatonia that received electroconvulsive therapy (ECT) between 01 January 2012 and 31 December 2014.

SETTING

The study was conducted at Elizabeth Donkin Psychiatric Hospital in Port Elizabeth, Eastern Cape. The hospital has mostly patients admitted under the Mental Health Care Act 17 of 2002 as Involuntary Mental Health Care Users.

METHOD

A retrospective chart review was conducted. Using the hospital ECT database, all files of patients who received ECT for catatonia were identified. Demographics, psychiatric and medical diagnoses, signs of catatonia and other data were abstracted from these files.

RESULTS

Forty-two patients received ECT for catatonia, of whom 34 (80.95%) were diagnosed with a psychotic illness. Schizophrenia was the most common diagnosis (n = 19; 45.24%), followed by psychotic disorder owing to a general medical condition (n = 8; 19.05). Human immunodeficiency deficiency virus was the cause in 75.00% of the patients whose medical conditions caused catatonia. Seven (16.67%) patients had mood disorders, with bipolar I disorder accounting for 6 (14.29%) of these.

CONCLUSION

Psychotic disorders were more frequent than mood disorders in the sample. Schizophrenia was the most common diagnosis, followed by psychotic disorder owing to a general medical condition.

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.

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.

Systematic review of catatonia treatment

OBJECTIVE

To investigate the evidence-based treatment of catatonia in adults. The secondary aim is to develop a treatment protocol.

MATERIALS AND METHODS

A systematic review of published treatment articles (case series, cohort or randomized controlled studies) which examined the effects of particular interventions for catatonia and/or catatonic symptoms in adult populations and used valid outcome measures was performed. The articles for this review were selected by searching the electronic databases of the Cochrane Library, MEDLINE, EMBASE and PSYCHINFO.

RESULTS

Thirty-one articles met the inclusion criteria. Lorazepam and electroconvulsive therapy (ECT) proved to be the most investigated treatment interventions. The response percentages in Western studies varied between 66% and 100% for studies with lorazepam, while in Asian and Indian studies, they were 0% and 100%. For ECT, the response percentages are 59%-100%. There does not seem to be evidence for the use of antipsychotics in catatonic patients without any underlying psychotic disorder.

CONCLUSION

Lorazepam and ECT are effective treatments for which clinical evidence is found in the literature. It is not possible to develop a treatment protocol because the evidence for catatonia management on the basis of the articles reviewed is limited. Stringent treatment studies on catatonia are warranted.