Kahlbaum's catatonia revisited.

Modern psychiatric nosologies separate catatonia along the lines of presumed etiology: bipolar, major depression, schizophrenia and due to a general medical condition. The presence of catatonia has always held diagnostic and prognostic value. Kahlbaum's description of catatonia includes careful documentation of phenomenology and the course of the illness. Since there were no effective treatments in his time, Kahlbaum was documenting the natural history of the illness. A review of classic studies of the natural history of catatonia demonstrates that the syndrome is episodic, may have few other psychotic signs, may have periods of remission and may, in some cases, be associated with the disorganized subtype of schizophrenia. The literature of the past 100 years supports the validity of Kahlbaum's description for a subset of patients with catatonia.

The universal field hypothesis of catatonia and neuroleptic malignant syndrome.

Catatonia and neuroleptic malignant syndrome (NMS) are uncommon disorders that can be life-threatening. Many researchers consider them as clinically divergent entities; however, they share similar and overlapping literature on causative agents, phenomenology, and treatment response. This hypothesis considers both disorders as a single entity that result from variable combinations of the following: 1) gamma-aminobutyric acid (GABA) hypoactivity at the GABAA receptor; 2) dopamine hypoactivity at the D2 receptor; 3) serotonin hyperactivity at the 5-HT1A receptor and hypoactivity at the 5-HT2A receptor; and 4) glutamate hypoactivity at the N-methyl-D-aspartate (NDMA) receptor. In this paper, evidence to support this hypothesis is limited to retrospective human studies of catatonia and NMS. The four components of the hypothesis are: 1) GABAA agonists have been shown to alleviate catatonia and NMS; 2) D2 antagonism is proportional to the relative likelihood of NMS and catatonia; 3) 5-HT1A agonism with 5-HT2A antagonism is implicated in catatonia and NMS; 4) NMDA receptor antagonists, such as phencyclidine and ketamine, reduce glutamate transmission. This hypothesis proposes that it is the interaction of these systems that prediposes, initiates, and maintains the twin syndromes of catatonia and NMS.

Polymorphisms in PTEN in breast cancer families.

Germline mutations in PTEN are the underlying genetic defect in Cowden disease, which is associated with a lifetime risk of 25-50% of developing breast cancer. To investigate the role of PTEN in inherited breast cancer in the absence of manifestations of Cowden disease, we screened 177 unrelated subjects with breast cancer who also had a family history of breast cancer in at least one relative. We found no disease associated PTEN mutations in this cohort, supporting previous studies suggesting that PTEN mutations do not contribute to inherited susceptibility to breast cancer without associated manifestations of Cowden disease. We did identify an association between a common polymorphism in intron 4 and lower mean age of diagnosis of breast cancer. While preliminary, these findings suggest that further study is warranted to determine whether this allelic variant of PTEN could function as a low penetrance breast cancer susceptibility allele.

Clinical electroencephalograms in patients with catatonic disorders.

Catatonia is a neuropsychiatric syndrome of motor signs most frequently found in affective disorders and schizophrenia. Catatonic disorder due to a general medical condition has been added to the DSM-IV nosology. Laboratory studies, such as electroencephalography (EEG) may assist in the differential diagnosis of catatonic disorders. Twenty-six patients hospitalized on a general psychiatric unit or medical psychiatric unit received electroencephalograms (EEGs) as part of their routine care. Clinical EEG abnormalities were reported in 17 of these patients. The presence of abnormalities was associated with age greater than 40, diagnosis of neuroleptic malignant syndrome and the presence of general medical conditions associated with the development of catatonia. Although no specific EEG patterns were associated with catatonic disorder due to general medical conditions, these findings suggest that the EEG is an important tool in the evaluation of patients presenting with catatonia.

Catatonic disorder due to general medical conditions.

Catatonia is a neuropsychiatric syndrome that may present a difficult diagnostic dilemma. Catatonic disorder due to general medical conditions must be considered in every patient with catatonic signs. Four patients with this disorder are presented. In these patients, general medical conditions associated with catatonic disorder included dystonia, HIV encephalopathy, progressive multifocal leukoencephalopathy, encephalitis, and renal failure. Three of these patients had multifactorial presentations of medical conditions or prior psychiatric disorders. A critical literature review concerning catatonia and associated nonpsychiatric medical conditions only infrequently supported causal relationships between organic factors and the development of catatonia. The majority of patients have multifactorial etiologies.

Catatonia on the consultation-liaison service: a replication study.

OBJECTIVE: The aim of this study is to identify the frequency, presentation, identification, treatment recommendations and outcome of patients with catatonia in the general hospital setting. METHOD: All patients seen on a consultation-liaison (C-L) service over a six-month period were screened prospectively for catatonic disorders. Research and DSM-IV criteria for catatonic disorder were applied. Treatment and outcome were naturalistic. RESULTS: Five (1.6%) of 297 patients met restrictive criteria for catatonic disorder. Data were extracted from medical charts. Case reports are presented to reflect the diagnosis and treatment. Extensive medical treatment was required in most cases and most had an unfavorable outcome. CONCLUSION: Catatonia is infrequent but underrecognized in medical-surgical settings. The C-L clinician should screen for catatonic signs in order to diagnose and treat patients with the catatonic disorders.

ECT in the treatment of the catatonic syndrome.

OBJECTIVE: To determine the efficacy of ECT in the treatment of the catatonic syndrome and to identify predictors of good response. METHOD: 28 cases of catatonia in 22 patients admitted to a psychiatry or medical psychiatry inpatient unit between January 1989 and June 1992 were retrospectively evaluated. Cases were included if they met criteria for catatonia as described by Kahlbaum, i.e., 4 or more signs including immobility, mutism, withdrawal, staring, rigidity, posturing/gimacing, negativism, waxy flexibility, echo phenomena, stereotypy, and verbigeration. Primary diagnoses were: Major Depressive Disorder (8), Bipolar Affective Disorder (5), schizophrenia (5), schizoaffective disorder (2) and organic mental disorder (2). Mean age was 54.5 years; sex ratio was 15 females to 7 males. Patients received a mean of 12.0 treatments with mean seizure duration 50.9 s (by EEG) per treatment. RESULTS: By Kahlbaum criteria, resolution of the catatonic syndrome occurred in 26 out of 28 cases (93%). The mean number of signs present per patient prior to ECT was 5.6 versus 0.93 following ECT (p = 0.00001). Overall, ECT brought about resolution of 83.5% of all symptoms with 98% resolution of primary symptoms and 74% resolution of secondary symptoms. CONCLUSIONS: ECT is an effective treatment of the catatonic syndrome. ECT is effective in the resolution of both cardinal (primary) and secondary signs of catatonia. In this study, there is not a statistically significant difference in the effectiveness of the resolution of catatonic symptoms in persons with affective disorder versus schizophrenia.

Rapid relief of anxiety in cancer patients with both alprazolam and placebo.

This study evaluated 36 cancer patients who were enrolled in a randomized, double-blind, placebo-controlled trial conducted over a 4-week period to evaluate the efficacy of alprazolam in the treatment of anxiety associated with cancer. Hamilton Anxiety Scale scores declined significantly between baseline and the end of the first week of the study in both treatment groups. There was no significant difference in response between the patients receiving alprazolam and placebo. Similar results were obtained from other instruments. These results suggest that nondrug factors or spontaneous improvement may play a more important role than pharmacotherapy in the treatment of anxiety associated with cancer.

Screening for depression and anxiety in cancer patients using the Hospital Anxiety and Depression Scale.

Nine hundred and thirty inpatients and outpatients with cancer were approached to complete the Hospital Anxiety and Depression Scale (HADS). Eight hundred and nine (86.9%) of those approached participated in this screening. Using the suggested cutoff score of 8 for the anxiety and depression subscales, we found that 47.6% of this population would warrant further psychiatric evaluation. Twenty-three percent (23.1%) had scores 11 or greater and would be the most likely to have had anxiety (17.7%) or depressive (9.9%) disorders based on DSM-III-R criteria. Patients with active malignant disease and inpatient status were more likely to have higher depression scores. The HADS was an easily administered tool that identified a large proportion of cancer patients as having high levels of anxiety or depression. However, clinical psychiatric interviews were not performed, so it is not possible to determine what proportion of patients would benefit from treatment.

Catatonia on the consultation-liaison service.

Catatonia is a syndrome that requires both nonpsychiatric medical and psychiatric evaluation. The authors report on six patients with catatonia that were seen by a psychiatric consultation-liaison service. Five of these patients had medical conditions reported to cause catatonia. Treatment recommendations included the following: 1) subcutaneous heparin for deep venous thrombosis prophylaxis, 2) a trial of lorazepam, and 3) transfer to a medical/psychiatric unit or locked psychiatric unit. Catatonia was most parsimoniously attributed to the primary psychiatric illness in five of the patients and to corticosteroid treatment in the sixth patient. These findings suggest that clinicians should use the proposed criteria, past psychiatric history, physical exam, and laboratory and radiological studies when evaluating patients with symptoms of catatonia.

Elevated CSF protein in male patients with depression.

Elevation of total protein is the most frequent pathologic finding in the cerebrospinal fluid (CSF) examination. It occurs in a variety of situations, such as inflammation or tumors of the central nervous system (CNS), degenerative disorders, and subarachnoid hemorrhage, or as a result of traumatic taps. It has also been reported, for unknown reasons, in patients with psychiatric disease. In a study of hormone changes in depression, 9 of 24 (38%) patients (13 male, 11 female) were found to have elevated CSF protein levels (greater than 45 mg/dl), whereas no elevations were found in healthy controls (8 male, 9 female). Eight of the patients with the elevated CSF protein levels were male (62%) and one was female (9%). Depressed patients had significantly higher CSF protein levels (44.7 +/- 18.0 mg/dl) than controls (31.5 +/- 6.0 mg/dl) (t = 3.32, df = 30.37, p = 0.002). No relationship was found between CSF protein levels and (1) the use of medication (tricyclic antidepressants, lithium carbonate, or monoamine oxidase inhibitors) or (2) post-dexamethasone suppression test cortisol levels. Female controls, however, tended to have lower protein levels than male controls, whereas female patients had significantly lower levels than male patients. Protein electrophoresis was performed on 21 of the 41 subjects (13 patients, 8 controls). Male patients had nonsignificantly higher absolute concentrations of CSF albumin and the globulin fractions when compared to male controls. These differences in CSF protein do not suggest monoclonal CSF protein production, nor are they the result of this elevated peripheral protein.(ABSTRACT TRUNCATED AT 250 WORDS)