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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 ) :

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catatonia in psychiatric classification a home of its own

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
Catatonia in psychiatricclassification

Historical Overview

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

catatonia in psychiatric classification3
Catatonia in psychiatric classification

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.

catatonia in psychiatric classification4
Catatonia in psychiatric classification

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 in psychiatric classification5
Catatonia in psychiatric classification

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

catatonia in psychiatric classification6
Catatonia in psychiatricclassification

Differential diagnosis

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.

catatonia in psychiatric classification differential diagnosis
Catatonia in psychiatric classificationDifferential Diagnosis

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.

catatonia in psychiatric classification differential diagnosis8
Catatonia in psychiatric classificationDifferential Diagnosis

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)

catatonia in psychiatric classification9
Catatonia in psychiatric classification

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.

catatonia in psychiatric classification common causes of catatonia
Catatonia in psychiatricclassificationCommon Causes of Catatonia

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.

catatonia in psychiatric classification common causes of catatonia11
Catatonia in psychiatric classificationCommon Causes of Catatonia

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.

catatonia in psychiatric classification causes of catatonia
Catatonia in psychiatric classificationCauses of Catatonia

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

slide13
Catatonia in psychiatric classificationA unique category for catatonia in Psychiatric classification
  • Catatonia is recognizable and definable syndrome that can be identified as readily as delirium.

. It has many causes and responds to specific treatment.

  • When catatonia is not recognized and not properly treated, it has adverse consequences for the patient
  • Catatoniacould appropriately be included as a syndrome in DSM-IV category of "Movement disorders”.
catatonia in psychiatric classification subtypes of catatonia reflect differences in lethality
Catatonia in psychiatric classificationSubtypes of catatonia : (reflect differences in lethality)

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.

catatonia in psychiatric classification15
Catatonia in psychiatric classification

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.

catatonia in psychiatric classification conclusions
Catatonia in psychiatric classificationConclusions
  • Catatonia can be distinguished from other behavioural syndromes by recognizable cluster of clinical features.
  • Catatonia is sufficiently common to warrant classification as an independent syndrome.
  • Catatonia can be reliably identified, has a typical course, responds to specific treatments and is worsened by other treatments
catatonia in psychiatric classification conclusions17
Catatonia in psychiatric classificationConclusions
  • It is associated with many pathophysiologic processes and most often with mood disorder.
  • These findings, which are consistent with established methods of defining distinct diagnostic groups, support consideration of catatonia as an individual category in psychiatric diagnostic systems
catatonia in psychiatric classification a home of its own19

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