James Robert Brašić, MD, MPH Catatonia James Robert Brašić, MD, MPH

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.

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

Symptoms The subjective complaints of the patient

Signs The objective findings of the examiner

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

Proband The identified patient

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

Neuropsychiatric syndromes Delirium Dementia Parkinsonism Tardive dyskinesia

Parkinsonism Pillrolling Tremor  Rigidity  Bradykinesia

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

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

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

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

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

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

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

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

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

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

Brasic JR. Catatonia www.emedicine.com 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

6% in the 1850s to 0.5% in the 1950s in Great Britain (Johnson, 1993) 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

Same as other forms of schizophrenia and mental illness 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

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

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

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

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

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

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

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

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

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

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

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

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

Somatization disorder 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.pdf

Somatization disorder 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.pdf

Somatization disorder Somatoform disorders Conversion disorder Psychogenic movement disorders Somatization disorder

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.pdf

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.pdf

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.pdf

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

● Present in factitious disorder ● Absent in catatonia 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.pdf

e. g., to get out of jail, school, work 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.pdf

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

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

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

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 Brasic JR. Catatonia www.emedicine.com

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

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

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

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

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

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

Verbigeration, Verbal Stereotypies, in Catatonia  Sniffing  Clicking  Repetitive eye movements  Snorting  Nonmeaningful sounds Brasic JR. Catatonia www.emedicine.com

Preservation in Catatonia  Inappropriate repetition of acts Brasic JR. Catatonia www.emedicine.com

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

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

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

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

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

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

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

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