1. 1 Catatonia James Robert Brašić, MD, MPH

2. 2 Acknowledgements This 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.

3. 3 Syndrome A constellation of symptoms, signs, and laboratory findings associated with a family history and a natural history

4. 4 Symptoms The subjective complaints of the patient

5. 5 Signs The objective findings of the examiner

6. 6 Family History The traits and conditions of other members of the genetic family of the proband

7. 7 Proband The identified patient

8. 8 Natural History The course of the proband without treatment An indication of the prognosis

9. 9 Neuropsychiatric syndromes Delirium Dementia Parkinsonism Tardive dyskinesia

10. 10 Parkinsonism Pillrolling Tremor Rigidity Bradykinesia

11. 11 Parkinsonism Parkinson Disease Following infections, eg, encephalitis Following toxic exposures Secondary to administration of dopamine receptor blocking drugs

12. 12 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

13. 13 Catatonia occurrence in children, adolescents, and adults association with a heterogeneous group of comorbid conditions symptoms and signs of impairment of the expression of voluntary thoughts and movements Brasic JR. Catatonia www.emedicine.com

14. 14 Catatonia typically episodic usually periods of remission morbidity and mortality of comorbid conditions Brasic JR. Catatonia www.emedicine.com

15. 15 Neuroleptic Malignant Syndrome Elevated temperature Rigidity Delirium Dysregulation of the autonomic nervous system Brasic JR. Catatonia www.emedicine.com

16. 16 Neuroleptic Malignant Syndrome Exposure to antipsychotic medications, including typical and atypical antipsychotic medications Brasic JR. Catatonia www.emedicine.com

17. 17 Vulnerability for Catatonia Mental retardation Pervasive developmental disorders Other developmental disabilities Brasic JR. Catatonia www.emedicine.com

18. 18 Catatonia Vaslav Nijinsky, the dancer and choreographer (Ostwald, 1994) Brasic JR. Catatonia www.emedicine.com

19. 19 Frequency of Catatonia in the US Decrease in the past century overall Decrease in Iowa from 1920-1966 (Morrison, 1974) 7% of psychiatric inpatients in a university hospital in New York (Fink and Bush, 1994) Brasic JR. Catatonia www.emedicine.com

20. 20 Frequency of Catatonia outside the US Vastly different rates Great difference in various regions Varying degrees of ascertainment Differing diagnostic categories Undiagnosed cases Brasic JR. Catatonia www.emedicine.com

21. 21 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

22. 22 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) Brasic JR. Catatonia www.emedicine.com

23. 23 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 Brasic JR. Catatonia www.emedicine.com

24. 24 Frequency of Catatonia in Different Races Unknown Brasic JR. Catatonia www.emedicine.com

25. 25 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) Brasic JR. Catatonia www.emedicine.com

26. 26 Ages of Patients with Catatonia Adults Adolescents Rare in Children Brasic JR. Catatonia www.emedicine.com

27. 27 History of Patients with Catatonia Unobtainable from patients Obtainable from collateral sources Brasic JR. Catatonia www.emedicine.com

28. 28 Primary Features of Catatonia Immobility Stupor Posturing Rigidity Staring Grimacing Withdrawal Brasic JR. Catatonia www.emedicine.com

29. 29 Behavioral Responses to Others of People with Catatonia Mutism Negativism Echopraxia Echolalia Waxy flexibility Brasic JR. Catatonia www.emedicine.com

30. 30 Historical Features of People with Catatonia Stereotypies Mannerisms Verbigeration Brasic JR. Catatonia www.emedicine.com

31. 31 Historical Features of People with Excited State of Catatonia Impulsivity Combativeness Autonomic instability Short-lived Precipitate collapse from exhaustion Brasic JR. Catatonia www.emedicine.com

32. 32 Possible Precipitating Events of People with Catatonia Infection Trauma Toxins Substances Brasic JR. Catatonia www.emedicine.com

33. 33 History of Similar Episodes of Catatonia Precipitating events for prior and current episodes Interventions to relieve prior episodes Brasic JR. Catatonia www.emedicine.com

34. 34 Treatable Causes of Catatonia Neuroleptic malignant syndrome Encephalitis Nonconvulsive status epilepticus Acute psychosis Brasic JR. Catatonia www.emedicine.com

35. 35 Behaviors Suggesting Catatonia Only When Examiner is Present Inconsistent with catatonia Somatoform disorders Factitious disorders Malingering Psychogenic movement disorders Brasic JR. Catatonia www.emedicine.com

36. 36 Somatoform disorders Conversion disorder Somatization 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic- conversion.pdf

37. 37 Somatoform disorders Conversion disorder Somatization 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic- conversion.pdf

38. 38 Somatoform disorders Somatization disorder Conversion disorder Psychogenic movement disorders

39. 39 Sincere Reports of Individual Perceptions of Experiences Catatonia Somatoform disorders Neurological disorders Schizophrenia 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic- conversion.pdf

40. 40 Fabricated Reports of False Experiences Factitious disorders Munchausen syndrome Munchausen syndrome by proxy Malingering 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic- conversion.pdf

41. 41 Fabricated Reports of False Experiences Factitious disorders Munchausen syndrome Munchausen syndrome by proxy Malingering 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic- conversion.pdf

42. 42 Fabricated Reports of False Experiences Munchausen syndrome by proxy Malingering Factitious disorders Munchausen syndrome Munchausen syndrome by proxy

43. 43 Internal Motivation for the Sick Role ● Present in factitious disorder ● Absent in catatonia ● Absent in malingering 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf

44. 44 External motivation, e. g., to get out of jail, school, work ● Present in malingering ● Absent in catatonia ● Absent in factitious 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.pdfhttp://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf

45. 45 Readily Apparent Signs of Catatonia in an Emergency Setting ● Rigidity ● Gegenhalten ● Grasp reflex Brasic JR. Catatonia www.emedicine.com

46. 46 Gegenhalten ● “To hold against” in German ● Increasing resistance to passive movement of the limbs ● Apparently deliberate opposition to the examiner’s movements Brasic JR. Catatonia www.emedicine.com

47. 47 Diagnostic Criteria for Catatonia, (American Psychiatric Association, 1994)American Psychiatric Association ● Motoric immobility ● Excessive motor activity ● Extreme negativism or mutism ● Peculiarities of voluntary movement ● Echolalia or echopraxia Brasic JR. Catatonia www.emedicine.com

48. 48 Diagnostic Criteria for Catatonia, (American Psychiatric Association, 1994)American Psychiatric Association ● Two of the items required in schizophrenia and mood disorder ● One item is required to diagnose catatonia in general medical conditions Brasic JR. Catatonia www.emedicine.com

49. 49 Excited State of Catatonia ● May injure self ● May assault others ● May experience autonomic instability (hyperthermia, tachycardia, and hypertension) ● May collapse from exhaustion Brasic JR. Catatonia www.emedicine.com

50. 50 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 Brasic JR. Catatonia www.emedicine.com

51. 51 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

52. 52  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  Brasic JR. Catatonia www.emedicine.com

53. 53  Peculiarities of Movement in Catatonia  Stereotypies, repetitive performing of apparently meaningless activities  Verbigeration, repetitive apparently meaningless utterances  Brasic JR. Catatonia www.emedicine.com

54. 54  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 extremities  Brasic JR. Catatonia www.emedicine.com

55. 55  Verbigeration, Verbal Stereotypies, in Catatonia  Sniffing  Clicking  Snorting  Nonmeaningful sounds  Brasic JR. Catatonia www.emedicine.com

56. 56 o Preservation in Catatonia  Inappropriate repetition of acts  Brasic JR. Catatonia www.emedicine.com

57. 57 o Echophenomena in Catatonia  Echolalia, the repetition of the words spoken by the examiner  Echopraxia, the repetition of the motor acts performed by the examiner  Brasic JR. Catatonia www.emedicine.com

58. 58 o Inappropriate Formality of Speech in Catatonia  Vouvoyer, the use of vous [ie, the formal form of “you”] to address one’s spouse in French  Brasic JR. Catatonia www.emedicine.com

59. 59 o Latah betul or "real latah" or "true latah"  A phenomenon present in Malaysia  The apparent loss of control over behavior  Echolalia  Echopraxia  Automatic obedience  Brasic JR. Catatonia www.emedicine.com

60. 60 o Laboratory 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  Brasic JR. Catatonia www.emedicine.com

61. 61 o Imaging in Catatonia Imaging the head by magnetic resonance imaging (MRI) or computed tomography (CT) Electroencaphalography  Brasic JR. Catatonia www.emedicine.com

62. 62 o Medical Care in Catatonia Admission to a neurological or a medical intensive care unit for neuroleptic malignant syndrome, encephalitis, or nonconvulsive status epilepticus Admission to a psychiatric intensive care unit for acute psychosis  Brasic JR. Catatonia www.emedicine.com

63. 63 o Treatment for Catatonia Avoid traditional neuroleptics Parenteral nutrition for refusal to eat Intravenous (IV) fluids and monitoring of vital signs for autonomic instability Electroconvulsive treatments (ECT) for malignant catatonia or catatonia unresponsive to pharmacotherapy after 5 days  Brasic JR. Catatonia www.emedicine.com

64. 64 o Pharmacotherapy for Catatonia Lorazepam (Ativan) Risperidone (Risperdal) Carbamazepine (Tegretol, Carbatrol, Epitol) Dantrolene  Brasic JR. Catatonia www.emedicine.com