Distribution and frequency of clinical criteria and rating scales for diagnosis and assessment of catatonia in different study types.

BACKGROUND: A comprehensive assessment of catatonic symptoms is decisive for diagnosis, neuronal correlates, and evaluation of treatment response and prognosis of catatonia. Studies conducted so far used different cut-off criteria and clinical rating scales to assess catatonia. Therefore, the main aim of this study was to examine the frequency and distribution of diagnostic criteria and clinical rating scales for assessing catatonia that were used in scientific studies so far. METHODS: We conducted a systematic review using PubMed searching for articles using catatonia rating scales/criteria published from January 1st 1952 (introduction of catatonic schizophrenia to first edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM]) up to December 5th, 2022. RESULTS: 1928 articles were considered for analysis. 1762 (91,39 %) studies used one and 166 (8,61 %) used ≥2 definitions of catatonia. However, 979 (50,7 %) articles did not report any systematic assessment of catatonia. As for clinical criteria, DSM criteria were used by the majority of studies (n = 290; 14.0 %), followed by International Classification of Diseases (ICD) criteria (n = 61; 2.9 %). The Bush-Francis Catatonia Rating Scale (BFCRS) was found to be by far the most frequently utilized scale (n = 464; 22.4 % in the respective years), followed by Northoff Catatonia Rating Scale (NCRS) (n = 31; 1.5 % in the respective years). CONCLUSION: DSM and ICD criteria as well as BFCRS and NCRS were most frequently utilized and can therefore be recommended as valid instruments for the assessment of catatonia symptomatology.

Catatonia and Delirium: Assessment of Comorbidity, Prevalence, and Therapeutic Response in Medically Ill Inpatients From a University Hospital.

BACKGROUND: Catatonia is a cluster of motor features present in multiple psychiatric and clinical diseases. It may be confused with delirium because both entities are classified according to the type and degree of psychomotor activity. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for catatonia secondary to medical conditions exclude comorbid catatonia and delirium; besides, there have been increasing reports about a comorbid presentation. This study aimed to describe the prevalence of comorbid catatonia and delirium, the therapeutic response to lorazepam, and the clinical characteristics of patients with an earlier diagnosis of delirium. METHODS: A total of 120 consecutive patients at a university hospital with an earlier diagnosis of delirium were evaluated using the Delirium Scale (confusion assessment method for the intensive care unit) and the Bush-Francis Catatonia Rating Scale for catatonia. In cases of a positive diagnosis of catatonia or catatonia/delirium, a therapeutic trial with intramuscular lorazepam was performed. FINDINGS: Thirty-one patients (26%) were positive for both catatonia and delirium, and 8 patients (7%) had catatonia. Sixty-six patients (55%) were positive only for delirium, and 5 patients (4%) were negative for delirium and catatonia. Lorazepam tests were applied on 22 patients. One in 9 patients with catatonia/delirium responded positively to lorazepam. Patients with catatonia had a 60% positive response rate. CONCLUSIONS: This is the first study on lorazepam use in catatonia-delirium patients; however, further studies are needed to determine the safety and efficacy of lorazepam in these patients. Catatonia and catatonia/delirium are underdiagnosed in inpatient wards and should be routinely assessed in patients with an altered mental status.

Presença de risco de transtorno do estresse pós-traumático em policiais militares feridos por arma de fogo / Presence of risk of posttraumatic stress disorder in military police officers wounded by firearms / Presencia de riesgo de trastorno de estrés postraumático en policías militares heridos por armamiento de fuego

Este estudo teve como objetivo identificar o risco de desenvolvimento de transtorno de estresse pós-traumático (TEPT), bem como sua associação com pensamentos ou tentativas suicidas e a saúde mental de policiais militares feridos por arma de fogo, na Região Metropolitana de Belém (RMB), nos anos de 2017 a 2019. A pesquisa contou com a participação de 30 entrevistados, que responderam o Inventário Demográfico e a Lista de verificação de TEPT para o DSM-5 (PCL-5). Para análise dos dados, utilizou-se a técnica estatística Análise Exploratória de Dados e a técnica multivariada Análise de Correspondência. Os resultados revelaram a existência de risco de desenvolvimento do transtorno de forma parcial ou total em uma expressiva parcela da população entrevistada, tendo homens como maioria dos sintomáticos, com média de 38 anos, exercendo atividades operacionais e vitimados em via pública quando estavam de folga do serviço. O ferimento deixou a maioria com sequelas, com destaque para dores crônicas, limitações de locomoção e/ou mobilidade e perda parcial de um membro. E, ainda, policiais sintomáticos apresentaram comportamentos suicidas, relatando já terem pensado ou tentado tirar a própria vida. Desta forma, conclui-se que policiais militares são expostos constantemente a traumas inerentes a sua profissão. Quando há ameaça de vida, como nos casos de ferimentos por arma de fogo, são suscetíveis a sequelas físicas decorrente do ferimento, somadas a sequelas mentais tardias, como o surgimento de sintomatologias de TEPT e ideação suicida.(AU)

This study aimed to identify the risk of developing post-traumatic stress disorder (PTSD) and its associations around suicidal thoughts or attempts and mental health in military police officers injured by firearms, in the Metropolitan Region of Belem (RMB), from 2017 to 2019. The research had the participation of 30 respondents who answered the Demographic Inventory and the PTSD checklist for DSM-5 (PCL-5). For data analysis, we used the statistical technique Exploratory Data Analysis and the multivariate technique Correspondence Analysis. The results revealed the existence of risk of developing partial or total disorder in a significant portion of the interviewed population, with men as most of the symptomatic individuals, with mean age of 38 years, developing operational activities and victimized on public roads when they were off duty. The injuries left most of them with sequelae, especially chronic pain, limited locomotion and/or mobility, and partial loss of a limb. In addition, symptomatic officers showed suicidal behavior, such as reporting they had thought about or tried to take their own lives. Thus, we conclude that military policemen are constantly exposed to traumas inherent to their profession. When their lives are threatened, as in the case of firearm wounds, they are susceptible to physical sequelae resulting from the injury, in addition to late mental sequelae, such as the appearance of PTSD symptoms and suicidal ideation.(AU)

Este estudio tuvo como objetivo identificar el riesgo de desarrollo de trastorno de estrés postraumático (TEPT) y sus asociaciones con pensamientos o tentativas suicidas y la salud mental en policías militares heridos por armamiento de fuego, en la Región Metropolitana de Belém (Brasil), en el período entre 2017 y 2019. En el estudio participaron 30 entrevistados que respondieron el Inventario Demográfico y la Lista de verificación de TEPT para el DSM-5 (PCL-5). Para el análisis de datos se utilizaron la técnica estadística Análisis Exploratoria de Datos y la técnica multivariada Análisis de Correspondencia. Los resultados revelaron que existen riesgos de desarrollo de trastorno de estrés postraumático de forma parcial o total en una expresiva parcela de la población de policías entrevistados, cuya mayoría de sintomáticos eran hombres, de 38 años en media, que ejercen actividades operacionales y fueron victimados en vía pública cuándo estaban de día libre del servicio. La lesión dejó la mayoría con secuelas, especialmente con dolores crónicos, limitaciones de locomoción y/o movilidad y la pierda parcial de un miembro. Aún los policías sintomáticos presentaran comportamiento suicida, tales como relataran qué ya pensaron o tentaron quitar la propia vida. Se concluye que los policías militaran se exponen constantemente a los traumas inherentes a su profesión. Cuando existe amenaza de vida, como en los casos de heridas por armamiento de fuego, son expuestos a secuelas físicas transcurridas de la herida, sumado a secuelas mentales tardías, como el surgimiento de sintomatologías de TEPT y la ideación suicida.(AU)

Electroconvulsive therapy use in the adult U.S. correctional setting: A case report and literature review.

Mr. C is a 45-year-old male inmate who was found in his cell unresponsive and mute. He had poor food and fluid intake for the last four days and was later found standing in place, frozen, and resistant to movement when encouraged by a corrections officer to rest in his bed. His symptoms were consistent with catatonia, a severe motor syndrome that can be life-threatening. The patient had a psychiatric history of bipolar I disorder with multiple past episodes of catatonia. Lorazepam was ineffective at reversing his catatonic symptoms, and his serum creatinine kinase level eventually began to rise, suggestive of muscle breakdown and worsening severity. The treating psychiatrist wanted access to electroconvulsive therapy (ECT) to treat Mr. C's catatonia but encountered numerous legal and logistical barriers which made this treatment option unavailable. The article reviews the scant literature on ECT use in the adult U.S. correctional system, identifies barriers, and discusses a recommended ECT referral process for inmates.

Hard routes of mental health in Portugal: what can we offer to an adolescent with serious mental illness and multiple social risk factors?

Worldwide, millions of children and adolescents are suffering due to a lack of efficient mental healthcare. Although some progress has been made to address the mental health problems in this age group, currently, even developed countries fail in providing psychiatric patients with the best practice care. We present a case of a Portuguese adolescent with a first episode of psychosis in whom multiple social and environmental risk factors were identified as triggers to his clinical presentation, as well as fundamental determinants of prognosis in the short and long term. In this case, we demonstrate how social determinants, including poverty, family dysfunction and difficulties in accessing appropriate mental healthcare, strongly influence the development, maintenance and prognosis in early psychosis during adolescence. Furthermore, we consider the implications of an absence of community-based mental healthcare and rehabilitation services and reasons for why this may complicate the management and limit opportunities to this patient population.

Catatonia Education: Needs Assessment and Brief Online Intervention.

OBJECTIVES: There are no studies investigating physicians' knowledge of catatonia. The authors aimed to assess and increase physicians' awareness of catatonia. METHODS: A survey with clinical questions about catatonia was administered, followed by a brief online teaching module about catatonia and a post-education survey. RESULTS: Twenty-one psychiatry residents (response rate, 70%) and 36 internal medicine residents (response rate, 34%) participated in the pre-education survey. Psychiatry residents identified 75% of the correct answers about catatonia, compared to 32% correct by internal medicine residents (p < 0.001). Twenty participants (response rate, 35%) completed the online education module and second survey, which resulted in a significant improvement in correct response rates from 60 to 83% in all the participants (p < 0.001). CONCLUSIONS: Residents' baseline knowledge of catatonia is low, particularly among internal medicine residents. A brief online module improved resident physicians' knowledge of catatonia. Educational strategies to improve recognition of catatonia should be implemented.

Catatonia in patients with autism: prevalence and management.

Although recent studies have shown that catatonia can occur in patients with autism spectrum disorders (ASDs), the overlap of the behavioral features between these disorders raises many diagnostic challenges. In fact, in clinical practice it is common to misinterpret catatonic symptoms, including mutism, stereotypic speech, repetitive behaviors, echolalia, posturing, mannerisms, purposeless agitation and rigidity, as features of ASDs. The current medical treatment algorithm for catatonia in ASDs recommends the use of benzodiazepines. Electroconvulsive therapy (ECT) is indicated when patients are unresponsive, or insufficiently responsive, to benzodiazepines. Other pharmacological options are also described for the treatment of catatonic patients resistant to benzodiazepines and ECT, and there is evidence for the effectiveness of a psychological treatment, co-occurring with medical treatments, in order to support the management of these patients. In this article we provide a summary of studies exploring catatonia in ASDs and our clinical experience in the management and treatment of this syndrome through the presentation of three brief case studies. Moreover, we review the mechanisms underlying symptoms of catatonia in ASDs, as well as the diagnostic challenges, providing an outline for the management and treatment of this syndrome in this clinical population.

Blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders.

The blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders (ASDs), which are submitted in this chapter aim to increase early recognition and treatment of catatonia in ASDs, show the urgency of controlled treatment trials, and increase collaborative and interdisciplinary research into the co-occurrence of these two enigmatic disorders. Catatonia should be assessed in any patient with ASDs when there is an obvious and marked deterioration in movement, pattern of activities, self-care, and practical skills, compared with previous levels, through a comprehensive diagnostic evaluation of medical and psychiatric symptoms. A formal diagnosis should be ascertained using ASD specific criteria for catatonia that takes into account baseline symptoms like muteness, echophenomena, stereotypy, negativism, or other psychomotor abnormalities. Any underlying medical and neurological conditions should be treated, and culprit medications or other substances that may cause catatonia should be eliminated. Separate treatment blueprints are presented for mild, moderate, and severe catatonia, featuring combinations of a psychological approach developed by Shah and Wing and medical treatments that have shown efficacy in catatonia: lorazepam challenge, lorazepam trial, lorazepam continuation, and bilateral electroconvulsive therapy (ECT). These treatment modalities in themselves are well established. Side effects and complications are known and manageable. Legal, ethical, and practice guidelines governing all treatment aspects should be followed. The treatment blueprints should be viewed as best estimates pending future controlled studies. The blueprint for the future study of catatonia in ASDs describes promising clinical and preclinical research avenues. Longitudinal studies need to assess the possible effect of early recognition and adequate treatment of catatonia in ASDs in order to avoid the impairment associated with chronicity. Effects of current and new anticatatonic treatments should be examined in experimental models of autism and catatonia. Finally, the role of gamma-aminobutyric acid (GABA) dysfunction in autism, catatonia, and abnormal stress responses in these disorders should be further assessed.

Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies.

OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. DATA SOURCES: Electronic bibliographic databases. The reference lists of relevant articles and health services research-related resources were consulted via the Internet. REVIEW METHODS: Identified studies were examined to ascertain whether they met the inclusion criteria for the review. The study quality of relevant articles was assessed using standard checklists and data were abstracted using standardised forms into a database. Where relevant, results from studies were pooled for meta-analysis. Two economic models were developed primarily based on evidence from the clinical effectiveness analysis and limited quality of life studies. RESULTS: Two good-quality systematic reviews of randomised evidence of the efficacy and safety of ECT in people with depression, schizophrenia, catatonia and mania were identified. Four systematic reviews on non-randomised evidence were also identified, although only one of these could be described as good quality. There was no randomised evidence of the effectiveness of ECT in specific subgroups including older people, children and adolescents, people with catatonia and women with postpartum exacerbations of depression or schizophrenia. The economic modelling results for depression did not demonstrate that any of the scenarios had a clear economic benefit over the others, mainly because of the uncertainty surrounding the clinical effectiveness of the different treatments and the quality of life utility gains. Sensitivity analysis surrounding the cost of ECT and the quality of life utility values had little effect on the overall results. The results of the model for schizophrenia adapted to include ECT suggest that clozapine is a cost-effective treatment compared with ECT. For patients who fail to respond to clozapine, ECT treatment may be preferred to the comparative treatment of haloperidol/chlorpromazine. CONCLUSIONS: Real ECT is probably more effective than sham ECT, but as stimulus parameters have an important influence on efficacy, low-dose unilateral ECT is no more effective than sham ECT. ECT is probably more effective than pharmacotherapy in the short term and limited evidence suggests that ECT is more effective than repetitive transcranial magnetic stimulation. Tricyclic antidepressants (TCAs) may improve the antidepressant effect of ECT during the course of treatment. Continuation pharmacotherapy with TCAs combined with lithium in people who have responded to ECT reduces the rate of relapses. Overall, gains in the efficacy of the intervention depending on the stimulus parameters of ECT are achieved only at the expense of an increased risk of cognitive side-effects. Limited evidence suggests these effects do not last beyond 6 months, but there is no evidence examining the longer term cognitive effects of ECT. There is little evidence of the long-term efficacy of ECT. ECT either combined with antipsychotic medication or as a monotherapy is not more effective than antipsychotic medication in people with schizophrenia. More research is needed to examine the long-term efficacy of ECT and the effectiveness of post-ECT pharmacotherapy, the short-term and longer term cognitive side-effects of ECT, and the impact of ECT on suicide and all-cause mortality. Further work is needed to examine the information needs of people deciding whether to accept ECT and how their decision-making can be facilitated. More research is also needed on the mechanism of action of ECT. Finally, the quality of reporting of trials in this area would be vastly improved by strict adherence to the Consolidated Standards of Reporting Trials recommendations. Economic analysis may identify areas in which research would be best targeted by identifying parameters where reducing the level of uncertainty would have the most effect in helping to make the decision on whether ECT is a cost-effective treatment.

Rating chronic: discrepancy between cross-sectional and longitunal assessment

A bush-Francis Catatonia Rating Scale (BFCRS) e o primeiro instrumento valido desenvolvido exclusivamente para a avaliacao da sindrome catatonica. Neste estudo, os autores investigaram a hipotese de que a BFCRS pode ser valida e confiavel para a avaliacao transversal de condicoes catatonicas agudas e cronicas, mas ela pode ser inferior a observacao clinica longitudinal para fornecer informacao sobre a severidade de fenomenos catatonicos em pacientes com esquizofrenia cronica...

Dimensions of schizophrenic positive symptoms: an exploratory factor analysis investigation.

Current psychopathology classifies schizophrenic positive symptoms into four groups: delusions, hallucinations, formal thought disorder, and catatonic symptoms. The present study explores the factor structure of different positive symptoms to refine this classification. The 35 positive symptoms of 429 psychiatric patients, consecutively admitted to any of 95 mental hospitals, with diagnosis of the ICD-10 F20 schizophrenia, were studied. After excluding those items with a base rate of 10% or less, factor analysis yielded six factors. The first factor was loaded by most of Schneider's first-rank symptoms and two specific auditory hallucinations; the second by all the catatonic symptoms and incoherence; the third by bodily delusions/hallucinations; the fourth by delusions of persecution and reference; the fifth by grandiose and religious delusions; and the sixth by visual and miscellaneous hallucinations. The finding that schizophrenic positive symptoms may have more than four dimensions suggests the need for reclassification of schizophrenic symptoms and for reconsideration of evidence-based diagnostic criteria for the disorder.

ECT as a treatment alternative for patients with symptoms of neuroleptic malignant syndrome.

The use of ECT as a treatment alternative in a clinical situation in which it is difficult to determine whether the patient is suffering from neuroleptic malignant syndrome (NMS) or an evolving catatonic state is investigated. Fourteen cases from the literature are reviewed and 3 new cases are presented. In 6 cases, ECT was rapidly effective in treating symptoms of NMS, but cardiac arrhythmias were reported in 4 cases. There was no evidence of malignant hyperthermia (MH) in patients receiving succinylcholine, suggesting that an association between NMS and MH may not be clinically relevant in patients being treated with ECT.

Brain disease and psychiatric illness: when should a psychiatrist order a CAT scan?

Because psychiatric symptoms are frequently the earliest signs of CNS pathology, the author outlines the structural brain diseases that may underlie several psychiatric syndromes and describes the computerized axial tomographic (CAT) scan findings associated with those diseases. On the basis of an awareness of these conditions and a cost-benefit analysis, the following indications for CAT scanning of psychiatric patients are proposed: 1) confusion and/or dementia of unknown cause, 2) first episode of a psychosis of unknown etiology, 3) movement disorder of unknown etiology, 4) anorexia nervosa, 5) prolonged catatonia, and 6) first episode of major affective disorder or personality change after age 50.