[German version of the Northoff catatonia rating scale (NCRS-dv) : A validated instrument for measuring catatonic symptoms]. / Deutsche Version der Northoff Catatonia Rating Scale (NCRS-dv) : Ein validiertes Messinstrument zur Erfassung katatoner Symptome.

The clinical picture of catatonia includes impressive motor phenomena, such as rigidity, dyskinesia, festination, negativism, posturing, catalepsy, stereotypies and mannerisms, along with affective (e. g. aggression, anxiety, anhedonism or emotional lability) and behavioral symptoms (e.g. mutism, autism, excitement, echolalia or echopraxia). In English speaking countries seven catatonia rating scales have been introduced, which are widely used in clinical and scientific practice. In contrast, only one validated catatonia rating scale is available in Germany so far. In this paper, we introduce the German version of the Northoff catatonia rating scale (NCRS-dv). The original English version of the NCRS consists of 40 items describing motor (13 items), affective (12 items) and behavioral (15 items) catatonic symptoms. The NCRS shows high internal reliability (Crombachs alpha = 0.87), high interrater (r = 0.80-0.96) and high intrarater (r = 0.80-0.95) reliability. Factor analysis of the NCRS revealed four domains: affective, hyperactive or excited, hypoactive or retarded and behavior with individual eigenvalues of 8.98, 3.61, 2.98 and 2.82, respectively, which explained 21.5 %, 9.3 %, 7.6 % and 7.2 % of variance, respectively. In conclusion, the NCRS-dv represents a second validated instrument which can be used by German clinicians and scientists for the assessment of catatonic symptoms.

[Catatonia in childhood and adolescence: obstacles to diagnosis and treatment]. / Katatonie in de kindertijd en adole-s-centie: obstakels bij de diagnose en behandeling.

BACKGROUND: Catatonia in children and adolescents is the same as it is for adults; in other words it is a recognisable psychomotor syndrome that follows a characteristic course and responds favourably to treatment with benzodiazepines and/or ect. Therefore, one would not expect to encumber many obstacles to diagnosis and treatment. In fact, the obstacles are fairly numerous. AIM: To explore the obstacles that can hinder a simple approach to diagnosis and treatment and to provide support for the clinicians involved. METHOD: We studied the literature systematically using Limo and keywords. RESULTS: For several decades, particularly in the literature, catatonia was defined as a subtype of schizophrenia. This exclusive link to schizophrenia led to the under-diagnosis of catatonia in patients with other psychiatric conditions and to delays in the administration of the correct treatment. Not only this historical error but also other important problems are complicating the approach to catatonia even today. Among other factors hindering diagnosis and treatment are the belief that catatonia is a rare illness, often denied by family members and some clinicians, the use of neuroleptics and the stigmatisation of benzodiazepines and/or ect. CONCLUSION: Controversy about catatonia continues. Although diagnosis and treatment are clearly defined, catatonia is still putting professionals to the test. In our essay we offer some practical guidance and advice.

Relapses and recurrences of catatonia: 30-case analysis and literature review.

OBJECTIVE: Relieving catatonia helps identify the underlying etiology and its treatment. However, catatonia may reemerge after some time, but there are few data on the relapses and recurrences of catatonia. We aimed to investigate the characteristics of patients with relapses or recurrences of catatonia as well as the efficacy of the lorazepam-diazepam protocol on them. METHODS: Patients with catatonia who had more than one episode of catatonia and were treated with the lorazepam-diazepam protocol were identified. Their medical charts were reviewed, and interview was conducted. RESULTS: Thirty patients were identified. Nineteen (63.3%) were diagnosed with schizophrenia, five (16.7%) with major depressive disorder, two (6.7%) with bipolar disorder, and four (13.3%) with general medical conditions. In the 68 relapses and relapses the lorazepam-diazepam protocol was used, full response was reported in 54 (79.4%) of them. Twelve of 19 (63.2%) patients with schizophrenia were treated with clozapine. Twenty (66.7%) out of 30 patients were maintained on oral lorazepam by the time of discharge. Literature review showed similar prevalence of schizophrenia in patients with more than one episode of catatonia, and a wide variety of treatment options. CONCLUSION: The lorazepam-diazepam protocol was mostly effective in managing relapses and recurrences of catatonia. Maintenance clozapine and oral lorazepam were beneficial in a significant number of patients.

[Changes to Schizophrenia Spectrum and other psychotic disorders in DSM-5]. / Psychotische Störungen im DSM-5. Die revisionen.

This article provides an overview of the main changes in the chapter "Schizophrenia Spectrum and Other Psychotic Disorders" from DSM-IV-TR to DSM-5, which, once again, does not make allowance for potential characteristics of children and adolescents. Changes in the main text include abandoning the classical subtypes of Schizophrenia as well as of the special significance of Schneider's first-rank symptoms, resulting in the general requirement of two key features (one having to be a positive symptom) in the definition of Schizophrenia and the allowance for bizarre contents in Delusional Disorders. Further introduced are the diagnosis of a delusional obsessive-compulsive/body dysmorphic disorder exclusively as Obsessive-Compulsive Disorder, the specification of affective episodes in Schizoaffective Disorder, and the formulation of a distinct subchapter "Catatonia" for the assessment of catatonic features in the context of several disorders. In Section III (Emerging Measures and Models) there is a recommendation for a dimensional description of psychoses. A likely source of confusion lies in the double introduction of an "Attenuated Psychosis Syndrome." On the one hand, a vague description is provided among "Other Specified Schizophrenia Spectrum and Other Psychotic Disorders" in the main text; on the other hand, there is a precise definition in Section III as a "Condition for Further Study." There is some cause to worry that this vague introduction of the attenuated psychosis syndrome in the main text might indeed open the floodgates to an overdiagnosis of subthreshold psychotic symptoms and their early pharmacological treatment.

[The typology of oneiroid-catatonic states in schizophrenia].

OBJECTIVE: To determine the types of oneiroid-catatonic states characteristic of corresponding schizophrenia attacks and their treatment-related changes. MATERIAL AND METHODS: We examined 68 outpatients, 25 men and 43 women, aged from 18 to 54 years, using psychopathological and follow-up methods. Results and conclusion. Two groups of oneiroid states were described. Oneiroid-catatonic states with the predominance of visual (optical) component derangement of consciousness were characteristic of the first group and oneiroid states with the prevalence of sensory component of derangement of consciousness were described in the second group. The second group was divided into two subgroups by the severity of the visual component (minimal and mixed). The types of oneiroid-catatonic states determined the dynamics of the attack in whole and were related to treatment (drug-induced pathomorphosis). These results are significant for differential diagnosis, treatment, and prognosis of the disease.

Successful use of right unilateral ECT for catatonia: a case series.

Catatonia is a neuropsychiatric syndrome involving motor signs in association with disorders of mood, behavior, or thought. Bitemporal electrode placement electroconvulsive therapy (ECT) is a proven effective treatment for catatonia, and this mode of ECT delivery is the preferred method of treatment in this condition. Studies in major depressive disorder have demonstrated that suprathreshold, nondominant (right) hemisphere, unilateral electrode placement ECT has fewer adverse effects, especially cognitive adverse effects, than bitemporal ECT. This case series describes the use of right unilateral (RUL) ECT in 5 patients with catatonia. Before ECT, all 5 patients in this series initially failed therapy with benzodiazepines and psychotropic medications. Each catatonic patient received a series of 8 to 12 RUL ECT in an every-other-day series. After ECT, 4 of the 5 patients had a full recovery from catatonia. One patient achieved only partial response to RUL ECT, and no additional benefit was obtained with bitemporal ECT. All patients in this case series tolerated RUL ECT without major adverse effects. This case series illustrates successful use of RUL ECT in patients with catatonia and adds to the early literature demonstrating its effective use in treating this complex condition.

Chronic catatonic schizophrenia treated successfully with right unilateral ultrabrief pulse electroconvulsive therapy: case report.

Catatonia is a syndrome with prominent motor and behavioral symptoms commonly seen in acutely ill psychiatric patients. Catatonic symptoms have been considered as positive predictors of response to electroconvulsive therapy (ECT); however, few studies so far have addressed the role of ECT treatment technique in schizophrenia. We present the case of a 41-year-old woman with chronic catatonic schizophrenia who was treated successfully with a course of ultrabrief right unilateral ECT.

[Follow-up of a 16-year-old adolescent with early-onset schizophrenia and catatonic symptoms]. / Suivi thérapeutique d'un adolescent de 16ans souffrant de schizophrénie précoce avec symptômes catatoniques.

INTRODUCTION: The aim of this paper is to underline the need of a systematic monitoring (1) of atypical antipsychotics and (2) of catatonic symptoms in child psychiatry. We present in this paper the clinical history of a 16-year-old adolescent inpatient needing a prescription of atypical antipsychotic drug. We present the most relevant results of our clinical monitoring over 7 months. CASE REPORT: A 16-year-old Caucasian male adolescent, by the name of Paul, was admitted in August 2009 to an Adolescent University Psychiatry Unit for an acute psychotic disorder. On admission, he presented paranoid delusion, auditory hallucinations and impulsive movements. The score on the Bush-Francis Catatonia Rating Scale (BFCRS) was 17 (the threshold score for the diagnosis of catatonic symptoms is 2). Laboratory tests showed the lack of blood toxic levels, creatine phosphokinase (CPK) level was 684 IU/L. Paul was treated with clonazepam (0.05 mg/kg/d). This particular day was considered to be day #1 of the clinical drug monitoring. Immediately after, regular follow-up of catatonic symptoms was performed. On day #15, the CPK level returned to normal with improvement of clinical catatonia but with still a score of 4 on the BFCRS scale. Auditory hallucinations and delusion persisted. Risperidone treatment was begun (1mg/d and 1.5mg/d after 24 hours), associated with oral clonazepam (0.05 mg/kg/d). On day #17, after 48 hours of improvement of delusion, the catatonic symptoms rapidly worsened. Risperidone was stopped; Paul was transferred to intensive care where he was treated with clonazepam IV (0.1mg/kg/d). The score on BFCRS scale was 20, Paul presented no fever and the CPK level was below 170 IU/L. The diagnosis was a relapse of the catatonic episode, which was caused by the administration of risperidone. On day #24, no improvement in the state of catatonia was obtained. The treatment was changed with the following combination of medicine: clonazepam (0.1mg/kg/d)-lorazepam (5mg/d)-carbamazepine (10mg/kg/d). With this combination, the state of catatonia improved quickly and on day #31, he was transferred to the adolescent psychiatry unit. However, delusion and hallucinations persisted; a treatment with olanzapine was started at 5mg/d and then progressively increased to 20mg/d for 10 days. On day #115, after 3 months with olanzapine, no improvement of the hallucinatory and delusional symptoms was observed; the diagnosis of early-onset refractory schizophrenia was established. The Therapeutic Drug Monitoring (TDM) confirmed the good compliance; clozapine was introduced and progressively increased up to 250 mg/d. On day #199, after 3 months under clozapine (250 mg/d), the speech was coherent and delusion was rare. During this period, no relapse of the catatonic state was observed. DISCUSSION: In this case, the BFCRS scale was sensitive to catatonic symptom diagnosis. CPK levels vary differently for each atypical antipsychotic and are not a specific complication indicator. In complex cases, the TDM seems useful when choosing atypical antipsychotics. CONCLUSION: The association of two benzodiazepines (clonazepam-lorazepam) with carbamazepin allowed the improvement of catatonic symptoms. Plasma levels of atypical antipsychotics helped the practitioner in deciding the type of care required: plasma levels confirmed the patient's treatment adherence and thus reinforced the choice of clozapine.

[Schizophrenia and aggressive behaviour: the impact of catatonic phenomena]. / Schizophrenie und aggressives Verhalten - die Bedeutung katatoner Phänomene.

OBJECTIVE: Patients suffering from schizophrenic psychoses show an increased risk for aggressive and violent behaviour. This raises the question if such acts are associated with specific psychopathological symptoms such as catatonic features. METHODS: Based on clinical case reports, psychopathological symptoms and clinical course in five patients with schizophrenic psychoses and episodes of aggressive behaviour are described. In this connection, the role of catatonic features is analysed. RESULTS: In the reported cases, aggressive behaviour patterns can be described as stable catatonic symptoms. Attempts to provide community-based treatment failed in each of these five patients. CONCLUSIONS: General adult psychiatry should provide effective treatment strategies and adequate care systems for patients with psychosis, catatonic symptoms and aggression.

[Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases].

Psychopathology and clinical features of oneiroid-catatonic conditions during endogenous diseases remain a topical problem in modem psychiatry. The author describes psychopathologcal features of oneiroid depending on the form of the affect and presents new data on its relation to peculiarities of the development of attacks.

[Use of aripiprazole in the treatment of catatonia]. / Az aripiprazol alkalmazása katatóniában.

INTRODUCTION: Successful aripiprazole treatment of catatonia was reported in some recent case reports. METHOD: Review of the literature and three case reports. RESULTS: In the presented cases it was demonstrated that aripiprazole was effective in the treatment of catatonia in patients with schizophrenia, major depression or brief psychotic disorder. CONCLUSION: Besides benzodiazepines and electroconvulsive therapy, aripiprazole might be an alternative treatment for catatonia, however randomized controlled trials are required to prove the effectiveness of aripiprazole in patients with catatonia.

Are there valid subtypes of schizophrenia? A grade of membership analysis.

BACKGROUND/AIMS: Cluster analysis has had limited success in establishing whether there are subtypes of schizophrenia. Grade of membership (GoM) analysis is a multivariate statistical technique which has advantages when, as in schizophrenia, individuals conforming to pure types are uncommon and mixed forms are frequent. METHODS: GoM analysis was applied to 118 chronic schizophrenic patients. The patients were of all clinical subtypes, including 13 with simple schizophrenia. Both current and 'lifetime' symptoms were assessed, and two different rating systems were used. RESULTS: Specifying 3 pure types resulted in robust findings across analyses. One pure type corresponded to paranoid schizophrenia, one to simple schizophrenia and the third combined elements of hebephrenic and catatonic schizophrenia. Specifying 4 pure types split the original 3 pure types in ways which were not clinically intuitive. CONCLUSION: GoM analysis divides schizophrenia into subtypes along conventional lines, with the proviso that hebephrenic and catatonic schizophrenic patients are not separable, at least in the chronic stage of the illness.

The catatonia conundrum: evidence of psychomotor phenomena as a symptom dimension in psychotic disorders.

To provide a rational basis for reconceptualizing catatonia in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), we briefly review historical sources, the psychopathology of catatonia, and the relevance of catatonic schizophrenia in contemporary practice and research. In contrast to Kahlbaum, Kraepelin and others (Jaspers, Kleist, and Schneider) recognized the prevalence of motor symptoms in diverse psychiatric disorders but concluded that the unique pattern and persistence of certain psychomotor phenomena defined a "catatonic" subtype of schizophrenia, based on intensive long-term studies. The enduring controversy and confusion that ensued underscores the fact that the main problem with catatonia is not just its place in Diagnostic and Statistical Manual of Mental Disorders but rather its lack of conceptual clarity. There still are no accepted principles on what makes a symptom catatonic and no consensus on which signs and symptoms constitute a catatonic syndrome. The resulting heterogeneity is reflected in treatment studies that show that stuporous catatonia in any acute disorder responds to benzodiazepines or electroconvulsive therapy, whereas catatonia in the context of chronic schizophrenia is phenomenologically different and less responsive to either modality. Although psychomotor phenomena are an intrinsic feature of acute and especially chronic schizophrenia, they are insufficiently recognized in practice and research but may have significant implications for treatment outcome and neurobiological studies. While devising a separate category of catatonia as a nonspecific syndrome has heuristic value, it may be equally if not more important to re-examine the psychopathological basis for defining psychomotor symptoms as catatonic and to re-establish psychomotor phenomena as a fundamental symptom dimension or criterion for both psychotic and mood disorders.