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Catatonia in Psychiatric Classification: A Home of its Own. Authors Michael Alan Taylor, M.D Max Fink, M.D Am. J. Psychiatry, July 2003 Presented by Dr. Adel Desouky. Catatonia in psychiatric classification. Historical Overview 1. Kahlbaum ( 1874 ) :
1.Kahlbaum ( 1874) :
translated to English in 1973 characterized catatonia as a specific disturbance in motor functioning that represents a phase in a progressive illness that includes stages of mania, depression and psychosis and that typically end in dementia.
2.Kraepline & Bleuler (1919) :
confirmKahlbaum’s views that catatonia is a dementia praecox
3.Rogers (1992) :
Reported that most clinicians of the 20th century considered catatonia as an exclusive subtype of schizophrenia (codified in all DSM & ICD editions)
4.Abrams and Tyalor ( 1977) :
Re-established that most catatonic patient have a mood disorder particularly mania and that 20 % of patients with mania exhibit catatonic features.
5.Gelenberg ( 1976) :
Documented the association of catatonia with neurologic and general medical conditions and emphasized that catatonia should be considered a syndrome not a disease.
6.Fink and Taylor ( 1991) :
Argued that catatonia should not be linked exclusively to schizophrenia and that classification systems could better reflect the evidence that catatonia occurs in many illnesses.
7.White DAC & Colleagues (1992-2001) :
Viewing catatonia as a syndrome present in a variety of psychiatric disorders, took an opposite approach. They considered the merits of merging similar conditions such as the neuroleptic malignant syndrome and the toxic serotonin syndrome as medication-related variants of malignant catatonia.
Catatonia is Common
* The phenomena that define catatonia are the motor abnormalities that occur in association with changes in thought, mood and vigilance.
* The most common signs are: (DSM & ICD)
mutism, posturing, negativism, staring, rigidity & echophenomena. These signs occur in 2 forms: a. retarded-stuporous or b. excited-delirious variety
1. Elective mutism:
Is usually associated with pre-existing personality disorders, stress, and no other catatonic features, does not respond to benzodiazepines or ECT.
2. Locked in syndrome:
The mutism of the locked-in syndrome is associated with total immobility except for vertical eye movements and blinking. These patients typically try to communicate by these movements, whereas patients with catatonia make little or no effort to communicate.
3.The Stiff person syndrome:
Is associated with painful spasms that are precipitated by touch, noise, or emotional stimuli. Does not respond to benzodiazepine, can be relieved by baclofen.
4. Malignant hyperthermia:
Is an autosomal dominent transmitted muscle sensitivity to inhalation anesthetics and depolarizing muscle relaxants. Occurs after surgical procedure. Confirmed by muscle biopsy.
5. Akinetic parkinsonism:
Usually occurs after years of illness with parkinsonian symptoms and dementia. Relieved by anticholinergic drugs not by benzodiazepines.
6. Malignant catatonia:
Is acute onset of excitement, delirium, fever, autonomic instability and catalepsy.
7. Neuroleptic malignant syndrome:
Is a specific example of malignant catatonia. Associated with exposure to antipsychotic drugs which cause dopaminergic blockade.
8. Serotonin syndrome:
Is also similar to malignant catatonia except for gastro-intestinal features.
9. Delirious mania:
Patient with this syndrome exhibit many signs of catatonia and respond to the same treatment algorithm (BDZ&ECT)
Good Response to Specific Treatment
*1930: First reported catatonic patient treated with amobarbital.
*1934: First reported catatonic schizophrenic patient treated with ECT.
*Recently: drugs with anticonvulsant properties, particularly: benzodiazepines and barbiturates and ECT effectively relieve catatonic episodes regardless of severity or etiology.
*Exposure to either typical or atypical antipsychotic drugs, however, usually worsens catatonia or induce the malignant form.
1. Mood Disorder
* Kahlbaum (1874): observed that most catatonic episodes were preceded by episodes of depression and mania.
* Bleuler (1908): commented that " as a rule catatonic symptoms mix with manic and the melancholic conditions”
* Kraepelin (1919): reported that nearly 50% of catatonic attacks begin with a depressive episode, that catatonia is often associated with mania and that dementia praecox patients with catatonia were likely to recover.
* Fink and Taylor (2003): claimed that many authors suggest that 25% or more of manic patients have enough catatonic features to meet the DSM criteria, and that more than half of catatonic patients have manic-depressive illness.
2. General Medical and Neurological Conditions
* Metabolic disturbances & endocrinopathies.
* Viral infection, typhoid fever & heat stroke.
* Autoimmune disease; all of which are commonly associated with delirium and catatonia.
* Drug intoxication: as opiate intoxication
* Drug withdrawal: benzodiazepine and dopaminergic drugs withdrawal
* Neurological conditions: parkinsonism, post encephalitic states, parietal and frontal lobe lesions.
* In children: catatonia may be caused by a developmental or seizure disorders.
3. Non affective psychoses
About 10%-15% of patients with catatonia met the criteria for schizophrenia. Catalepsy, mannerisms, posturing and mutism are the features traditionally associated with catatonic schizophrenia
4. Genetic Form of Catatonia
One form of catatonia has been described as familial and as having a suspected major gene effect. A follow up study of these patients found their prognosis to be poor and BDZ & ECT were not effective
. It has many causes and responds to specific treatment.
1. Non malignant catatonia(Kahlbaum syndrome):
it responds to lorazepam (6 -20 mg/day)
2. Delirious catatonia (delirious mania, excited catatonia): it requires high doses of lorazepam for relief, responds best to ECT, and are typically made worse by antipsychotic drugs.
3. Malignant catatonia(neuroleptic malignant syndrome, serotonin syndrome):
It requires life supportive measures, treatment of fever and dehydration, and high doses of a benzodiazepine; ECT may be required if medication does not quickly resolve the condition.
Specifiers for catatonia
(reflect differences in etiology)
a. Secondary to a mood disorder.
b. Secondary to a general medical condition or toxic state.
c. Secondary to a neurological disorder.
d. Secondary to a psychotic disorder.