1 catatonia james robert brašić, md, mph. 2 acknowledgements this research is sponsored by the...

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Catatonia

James Robert Brašić, MD, MPH

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AcknowledgementsThis research is sponsored by The Essel Foundation, the

National Alliance for Research on Schizophrenia and Depression (NARSAD), the Rett Syndrome Research

Foundation (RSRF), the Tourette Syndrome Association (TSA), the National Institutes of Health (NIH), and the

Department of Psychiatry of Bellevue Hospital Center and the New York University School of Medicine in New York, New

York. The cooperation of the Health and Hospitals Corporation of the City of New York is gratefully

acknowledged. Dr. Brašić is a member of the Medical Advisory Board of the Tourette Syndrome Association of

Greater Washington in Silver Spring, Maryland.

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Syndrome

A constellation of symptoms, signs, and laboratory findings associated with a family history and a natural history

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Symptoms

The subjective complaints of the patient

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Signs

The objective findings of the examiner

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Family History

The traits and conditions of other members of the genetic family of the proband

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Proband

The identified patient

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Natural History

The course of the proband without treatment An indication of the prognosis

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Neuropsychiatric syndromes

Delirium DementiaParkinsonismTardive dyskinesia

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Parkinsonism

Pillrolling Tremor Rigidity Bradykinesia

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Parkinsonism Parkinson Disease Following infections, eg, encephalitis Following toxic exposures Secondary to administration of dopamine receptor blocking drugs

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Catatonia

a state of apparent unresponsiveness to external stimuli in a person who is apparently awake difficult to differentiate from diffuse encephalopathy and nonconvulsive status epilepticus

Brasic JR. Catatonia www.emedicine.com

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Catatonia

occurrence in children, adolescents, and adultsassociation with a heterogeneous group of comorbid conditions symptoms and signs of impairment of the expression of voluntary thoughts and movementsBrasic JR. Catatonia www.emedicine.com

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Catatonia

typically episodic

usually periods of remission

morbidity and mortality of comorbid conditionsBrasic JR. Catatonia www.emedicine.com

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Neuroleptic Malignant Syndrome

Elevated temperatureRigidityDeliriumDysregulation of the autonomic nervous systemBrasic JR. Catatonia www.emedicine.com

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Neuroleptic Malignant Syndrome

Exposure to antipsychotic medications, including typical and atypical antipsychotic medications


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Vulnerability for Catatonia

Mental retardationPervasive developmental disordersOther developmental disabilitiesBrasic JR. Catatonia www.emedicine.com

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Catatonia

Vaslav Nijinsky, the dancer and choreographer (Ostwald, 1994)


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Frequency of Catatonia in the US

Decrease in the past century overallDecrease in Iowa from 1920-1966 (Morrison, 1974)7% of psychiatric inpatients in a university hospital in New York (Fink and Bush, 1994)


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Frequency of Catatonia outside the US

Vastly different ratesGreat difference in various regionsVarying degrees of ascertainmentDiffering diagnostic categoriesUndiagnosed cases


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Various Measures of Frequency of Catatonia of inpatients at psychiatric

hospitals

0.5% in Great Britain in the 1950s (Johnson, 1993)7% in Stony Brook, New York (Fink and Bush, 1994)10% in Canada (Rosebush and Gaind, 1993)11% in Finland in 1953-1955 (Rogers, 1991) 11.4% in Colombia (Escobar, 2000)16.9% in Spain (Peralta, 1997)Brasic JR. Catatonia www.emedicine.com

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Decrements in Varying Measures of the Frequency of Catatonia Outside the US

6% in the 1850s to 0.5% in the 1950s in Great Britain (Johnson, 1993)37% in 1933-1935 to 11% in 1953-1933 in Finland (Rogers, 1991)


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Age-adjusted Relative Risk for Death in Catatonic Schizophrenia in Monroe

County, New York, in 1960-1969 (Guggenhein, 1974)

Thrice the relative risk of the general county population Same as other forms of schizophrenia and mental illness


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Frequency of Catatonia in Different

Races

Unknown


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Female-to-male Ratios

1.1:1 for schizophrenia in Monroe County, New York, in 1960-1969 (Guggenheim, 1974)1.3:1 for catatonic schizophrenia in Monroe County, New York, in 1960-1969 (Guggenheim, 1974)1.3:1 for catatonia in psychiatric inpatients in a municipal hospital of New York City (Abrams, 1976)


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Ages of Patients with Catatonia

AdultsAdolescentsRare in Children


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History of Patients with Catatonia

Unobtainable from patientsObtainable from collateral sourcesBrasic JR. Catatonia www.emedicine.com

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Primary Features of Catatonia

ImmobilityStuporPosturingRigidityStaringGrimacingWithdrawal


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Behavioral Responses to Others of People with Catatonia

MutismNegativismEchopraxiaEcholaliaWaxy flexibility


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Historical Features of People with Catatonia

StereotypiesMannerismsVerbigeration


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Historical Features of People with Excited State of Catatonia

ImpulsivityCombativenessAutonomic instabilityShort-livedPrecipitate collapse from exhaustion


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Possible Precipitating Events of People with Catatonia

InfectionTraumaToxinsSubstances


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History of Similar Episodes of Catatonia

Precipitating events for prior and current episodesInterventions to relieve prior episodes


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Treatable Causes of Catatonia

Neuroleptic malignant syndromeEncephalitisNonconvulsive status epilepticusAcute psychosis


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Behaviors Suggesting Catatonia Only When Examiner is Present

Inconsistent with catatoniaSomatoform disordersFactitious disordersMalingeringPsychogenic movement disordersBrasic JR. Catatonia www.emedicine.com

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Somatoform disorders

Conversion disorderSomatization disorder

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric Association, Washington, DC, 2000

Brašić JR. Conversion disorder in childhood. German Journal of Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf

http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf

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Conversion disorderSomatization disorder




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Somatization disorder

Conversion disorder

Psychogenic movement disorders

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Sincere Reports of Individual Perceptions of Experiences

Catatonia Somatoform disordersNeurological disordersSchizophrenia American Psychiatric Association. Diagnostic and statistical manual of

mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric Association, Washington, DC, 2000



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Fabricated Reports of False Experiences

Factitious disordersMunchausen syndromeMunchausen syndrome by proxy

MalingeringAmerican Psychiatric Association. Diagnostic and statistical manual of




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Factitious disordersMunchausen syndromeMunchausen syndrome by proxy

MalingeringAmerican Psychiatric Association. Diagnostic and statistical manual of




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Munchausen syndrome by proxy

Malingering

Factitious disorders

Munchausen syndrome

Munchausen syndrome by proxy

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Internal Motivation for the Sick Role

● Present in factitious disorder ● Absent in catatonia ● Absent in malingering

American Psychiatric Association. Diagnostic and statistical manual of




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External motivation, e. g., to get out of jail, school, work

● Present in malingering ● Absent in catatonia● Absent in factitious disorder




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Readily Apparent Signs of Catatonia in an Emergency

Setting

● Rigidity● Gegenhalten● Grasp reflex


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Gegenhalten

● “To hold against” in German● Increasing resistance to passive movement of the limbs● Apparently deliberate opposition to the examiner’s movementsBrasic JR. Catatonia www.emedicine.com

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Diagnostic Criteria for Catatonia, (American Psychiatric Association, 1994)

● Motoric immobility ● Excessive motor activity● Extreme negativism or mutism● Peculiarities of voluntary movement● Echolalia or echopraxia


http://www.psych.org/

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Diagnostic Criteria for Catatonia, (American Psychiatric Association, 1994)

● Two of the items required in schizophrenia and mood disorder● One item is required to diagnose catatonia in general medical conditions


http://www.psych.org/

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Excited State of Catatonia

● May injure self ● May assault others● May experience autonomic instability (hyperthermia, tachycardia, and hypertension)● May collapse from exhaustionBrasic JR. Catatonia www.emedicine.com

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Immobile State of Catatonia (Akinesia, Stupor)

● May not move ● May appear unresponsive to external stimuli

● May be unable to eat● May require parenteral nutrition and fluids ● May exhibit catalepsy, the persistent maintenance

of spontaneous or imposed postures


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Negativistic Phenomena in Catatonia● Gegenhalten (“To hold against” in German), the apparent resistance of the movement of the extremities by the examiner

● Mitgehen (“To go along with” in German)(Klatt E, Klatt G. Langenscheidt’s Standard Dictionary of the English and German Languages. Berlin: Langenscheidt, 1970),

movement in the direction of a slight push from the examiner in spite of the command to remain still

Motor persistence, the maintenance of a posture

when commanded to not maintain the posture withdrawal from all usual activities

refusal to eat Brasic JR. Catatonia www.emedicine.com

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Inability to Appropriately Modulate Impulse Inhibition in Catatonia

Automatic obedience, the performance of tasks at the command of the examiner even though the tasks are inappropriate or dangerous


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Peculiarities of Movement in Catatonia

Stereotypies, repetitive performing of apparently meaningless activities Verbigeration, repetitive apparently meaningless utterancesBrasic JR. Catatonia www.emedicine.com

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Stereotypies in Catatonia

Nose wrinkling Repetitive movements of the mouth and the jaw Repetitive eye movements Repetitive tapping of the foot, the finger, or the hand

Repetitive abdomen patting, shoulder shrugging, or body rocking

Mannerisms, postures, gaze fixation Choreoathetoid movements of the trunk and extremitiesBrasic JR. Catatonia www.emedicine.com

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Verbigeration, Verbal Stereotypies, in Catatonia

Sniffing Clicking Snorting Nonmeaningful soundsBrasic JR. Catatonia www.emedicine.com

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oPreservation in Catatonia

Inappropriate repetition of acts


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oEchophenomena in Catatonia

Echolalia, the repetition of the words spoken by the examiner Echopraxia, the repetition of the motor acts performed by the examiner


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oInappropriate Formality of Speech in Catatonia

Vouvoyer, the use of vous [ie, the formal form of “you”] to address one’s spouse in French


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oLatah betul or "real latah" or "true latah"

A phenomenon present in Malaysia The apparent loss of control over behavior Echolalia Echopraxia Automatic obedience


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oLaboratory Work Up in Catatonia

Complete blood counts, electrolytes, and chemical analyses of blood Serum creatine kinase, white blood cell counts, and liver function tests Ceruloplasmin


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oImaging in Catatonia

Imaging the head by magnetic resonance imaging (MRI) or computed tomography (CT)Electroencaphalography


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oMedical Care in Catatonia

Admission to a neurological or a medical intensive care unit for neuroleptic malignant syndrome, encephalitis, or nonconvulsive status epilepticusAdmission to a psychiatric intensive care unit for acute psychosis


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oTreatment for Catatonia

Avoid traditional neurolepticsParenteral nutrition for refusal to eatIntravenous (IV) fluids and monitoring of vital signs for autonomic instabilityElectroconvulsive treatments (ECT) for malignant catatonia or catatonia unresponsive to pharmacotherapy after 5 days


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oPharmacotherapy for Catatonia

Lorazepam (Ativan)Risperidone (Risperdal)Carbamazepine (Tegretol, Carbatrol, Epitol) Dantrolene


1 catatonia james robert brašić, md, mph. 2 acknowledgements this research is sponsored by the...

Documents

frequency of catatonia

catatonia of inpatients

catatonia vaslav nijinsky

new york fink

city of new york

university hospital

various measures of

genetic family