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Catatonia
James Robert Brašić, MD, MPH
Acknowledgements
This research is sponsored by The Essel Foundation, the
National Alliance for Research on Schizophrenia and
Depression (NARSAD), the Rett Syndrome Research
Foundation (RSRF), the Tourette Syndrome Association
(TSA), the National Institutes of Health (NIH), and the
Department of Psychiatry of Bellevue Hospital Center and the
New York University School of Medicine in New York, New
York. The cooperation of the Health and Hospitals
Corporation of the City of New York is gratefully
acknowledged. Dr. Brašić is a member of the Medical Advisory
Board of the Tourette Syndrome Association of Greater
Washington in Silver Spring, Maryland.
Syndrome
A constellation of symptoms,
signs, and laboratory findings
associated with a family history
and a natural history
Symptoms
The subjective complaints of
the patient
Signs
The objective findings of the
examiner
Family History
The traits and conditions of
other members of the genetic
family of the proband
Proband
The identified patient
Natural History
The course of the proband
without treatment
 An indication of the
prognosis
Neuropsychiatric
syndromes
Delirium
Dementia
Parkinsonism
Tardive dyskinesia
Parkinsonism
Pillrolling Tremor
 Rigidity
 Bradykinesia
Parkinsonism
Parkinson Disease
Following infections, eg,
encephalitis
Following toxic exposures
Secondary to administration of
dopamine receptor blocking drugs
Catatonia
a state of apparent
unresponsiveness to external stimuli
in a person who is apparently awake
difficult to differentiate from
diffuse encephalopathy and
nonconvulsive status epilepticus
Brasic JR. Catatonia www.emedicine.com
Catatonia
occurrence in children, adolescents, and
adults
association with a heterogeneous group
of comorbid conditions
 symptoms and signs of impairment of
the expression of voluntary thoughts and
movements
Brasic JR. Catatonia www.emedicine.com
Catatonia
typically episodic
usually periods of remission
morbidity and mortality of
comorbid conditions
Brasic JR. Catatonia www.emedicine.com
Neuroleptic Malignant Syndrome
Elevated temperature
Rigidity
Delirium
Dysregulation of the autonomic
nervous system
Brasic JR. Catatonia www.emedicine.com
Neuroleptic Malignant Syndrome
 Exposure to antipsychotic
medications, including typical and
atypical antipsychotic medications
Brasic JR. Catatonia www.emedicine.com
Vulnerability for Catatonia
Mental retardation
Pervasive developmental
disorders
Other developmental disabilities
Brasic JR. Catatonia www.emedicine.com
Catatonia
Vaslav Nijinsky, the dancer and
choreographer (Ostwald, 1994)
Brasic JR. Catatonia www.emedicine.com
Frequency of Catatonia in the US
Decrease in the past century overall
Decrease in Iowa from 1920-1966 (Morrison, 1974)
7% of psychiatric inpatients in a university
hospital in New York (Fink and Bush, 1994)
Brasic JR. Catatonia www.emedicine.com
Frequency of Catatonia outside the US
Vastly different rates
Great difference in various regions
Varying degrees of ascertainment
Differing diagnostic categories
Undiagnosed cases
Brasic JR. Catatonia www.emedicine.com
Various Measures of Frequency of
Catatonia of inpatients at psychiatric
hospitals
0.5% in Great Britain in the 1950s (Johnson, 1993)
7% in Stony Brook, New York (Fink and Bush, 1994)
10% in Canada (Rosebush and Gaind, 1993)
11% in Finland in 1953-1955 (Rogers, 1991)
11.4% in Colombia (Escobar, 2000)
16.9% in Spain (Peralta, 1997)
Brasic JR. Catatonia www.emedicine.com
Decrements in Varying Measures of the
Frequency of Catatonia Outside the US
6% in the 1850s to 0.5% in the
1950s in Great Britain (Johnson,
1993)
37% in 1933-1935 to 11% in 19531933 in Finland (Rogers, 1991)
Brasic JR. Catatonia www.emedicine.com
Age-adjusted Relative Risk for Death in
Catatonic Schizophrenia in Monroe
County, New York, in 1960-1969
(Guggenhein, 1974)
Thrice the relative risk of the
general county population
Same as other forms of
schizophrenia and mental illness
Brasic JR. Catatonia www.emedicine.com
Frequency of
Catatonia in Different
Races
Unknown
Brasic JR. Catatonia www.emedicine.com
Female-to-male Ratios
1.1:1 for schizophrenia in Monroe County,
New York, in 1960-1969 (Guggenheim, 1974)
1.3:1 for catatonic schizophrenia in Monroe
County, New York, in 1960-1969 (Guggenheim,
1974)
1.3:1 for catatonia in psychiatric inpatients in
a municipal hospital of New York City
(Abrams, 1976)
Brasic JR. Catatonia www.emedicine.com
Ages of Patients with
Catatonia
Adults
Adolescents
Rare in Children
Brasic JR. Catatonia www.emedicine.com
History of Patients with
Catatonia
Unobtainable
from
patients
Obtainable from
collateral sources
Brasic JR. Catatonia www.emedicine.com
Primary Features of Catatonia
Immobility
Stupor
Posturing
Rigidity
Staring
Grimacing
Withdrawal
Brasic JR. Catatonia www.emedicine.com
Behavioral Responses to Others of
People with Catatonia
Mutism
Negativism
Echopraxia
Echolalia
Waxy flexibility
Brasic JR. Catatonia www.emedicine.com
Historical Features of People with
Catatonia
Stereotypies
Mannerisms
Verbigeration
Brasic JR. Catatonia www.emedicine.com
Historical Features of People with
Excited State of Catatonia
Impulsivity
Combativeness
Autonomic instability
Short-lived
Precipitate collapse from exhaustion
Brasic JR. Catatonia www.emedicine.com
Possible Precipitating Events of
People with Catatonia
Infection
Trauma
Toxins
Substances
Brasic JR. Catatonia www.emedicine.com
History of Similar Episodes of Catatonia
Precipitating events for prior and current
episodes
Interventions to relieve prior episodes
Brasic JR. Catatonia www.emedicine.com
Treatable Causes of Catatonia
Neuroleptic malignant syndrome
Encephalitis
Nonconvulsive status epilepticus
Acute psychosis
Brasic JR. Catatonia www.emedicine.com
Behaviors Suggesting Catatonia Only
When Examiner is Present
Inconsistent with catatonia
Somatoform disorders
Factitious disorders
Malingering
Psychogenic movement
disorders
Brasic JR. Catatonia www.emedicine.com
Somatoform disorders
Conversion disorder
Somatization disorder
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of
Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasicconversion.pdf
Somatoform disorders
Conversion disorder
Somatization disorder
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of
Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasicconversion.pdf
Somatoform disorders
Conversion disorder
Psychogenic movement disorders
Sincere Reports of Individual
Perceptions of Experiences
Catatonia
Somatoform disorders
Neurological disorders
Schizophrenia
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of
Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasicconversion.pdf
Fabricated Reports of False Experiences
Factitious disorders
Munchausen syndrome
Munchausen syndrome by proxy
Malingering
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of
Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasicconversion.pdf
Fabricated Reports of False Experiences
Factitious disorders
Munchausen syndrome
Munchausen syndrome by proxy
Malingering
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of
Psychiatry 2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasicconversion.pdf
Fabricated Reports of False
Experiences
Factitious
disorders
Munchausen syndrome by proxy
Munchausen syndrome
Munchausen syndrome by proxy
Malingering
Internal Motivation for the Sick Role
● Present in factitious disorder
● Absent in catatonia
● Absent in malingering
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of Psychiatry
2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf
External motivation,
e. g., to get out of jail, school, work
● Present in malingering
● Absent in catatonia
● Absent in factitious disorder
American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, fourth edition, text revision (DSM-IV-TR™) American Psychiatric
Association, Washington, DC, 2000
Brašić JR. Conversion disorder in childhood. German Journal of Psychiatry
2002;5(2):54-61 http://www.gjpsy.uni-goettingen.de/gjp-article-brasic-conversion.pdf
Readily Apparent Signs of
Catatonia in an Emergency Setting
● Rigidity
● Gegenhalten
● Grasp reflex
Brasic JR. Catatonia www.emedicine.com
Gegenhalten
● “To hold against” in German
● Increasing resistance to passive
movement of the limbs
● Apparently deliberate opposition to
the examiner’s movements
Brasic JR. Catatonia www.emedicine.com
Diagnostic Criteria for Catatonia,
(American Psychiatric Association, 1994)
● Motoric immobility
● Excessive motor activity
● Extreme negativism or mutism
● Peculiarities of voluntary movement
● Echolalia or echopraxia
Brasic JR. Catatonia www.emedicine.com
Diagnostic Criteria for Catatonia,
(American Psychiatric Association, 1994)
● Two of the items required in
schizophrenia and mood disorder
● One item is required to diagnose
catatonia in general medical
conditions
Brasic JR. Catatonia www.emedicine.com
Excited State of Catatonia
● May injure self
● May assault others
● May experience autonomic
instability (hyperthermia,
tachycardia, and hypertension)
● May collapse from exhaustion
Brasic JR. Catatonia www.emedicine.com
Immobile State of Catatonia (Akinesia, Stupor)
● May not move
● May appear unresponsive to external stimuli
● May be unable to eat
● May require parenteral nutrition and fluids
● May exhibit catalepsy, the persistent maintenance
of spontaneous or imposed postures
Brasic JR. Catatonia www.emedicine.com
Negativistic Phenomena in Catatonia
● Gegenhalten (“To hold against” in German), the apparent
resistance of the movement of the extremities by the examiner
● Mitgehen (“To go along with” in German)
(Klatt E, Klatt G. Langenscheidt’s Standard Dictionary of the English and German Languages. Berlin: Langenscheidt, 1970),
movement in the direction of a slight push from the
examiner in spite of the command to remain still
Motor persistence, the maintenance of a posture
when commanded to not maintain the posture
withdrawal from all usual activities
refusal to eat
Brasic JR. Catatonia www.emedicine.com
Inability to Appropriately Modulate
Impulse Inhibition in Catatonia
Automatic obedience, the
performance of tasks at the
command of the examiner even
though the tasks are inappropriate
or dangerous
Brasic JR. Catatonia www.emedicine.com
Peculiarities of Movement in
Catatonia
 Stereotypies, repetitive
performing of apparently
meaningless activities
 Verbigeration, repetitive
apparently meaningless utterances
Brasic JR. Catatonia www.emedicine.com
Stereotypies in Catatonia
 Nose wrinkling
 Repetitive movements of the mouth and the jaw
 Repetitive eye movements
 Repetitive tapping of the foot, the finger, or the hand
 Repetitive abdomen patting, shoulder shrugging, or body rocking
 Mannerisms, postures, gaze fixation
 Choreoathetoid movements of the trunk and extremities
Brasic JR. Catatonia www.emedicine.com
Verbigeration, Verbal
Stereotypies, in Catatonia
 Sniffing
 Clicking  Repetitive eye
movements
 Snorting
 Nonmeaningful sounds
Brasic JR. Catatonia www.emedicine.com
oPreservation in
Catatonia
 Inappropriate repetition of acts
Brasic JR. Catatonia
www.emedicine.com
oEchophenomena in
Catatonia
 Echolalia, the repetition of the
words spoken by the examiner
 Echopraxia, the repetition of
the motor acts performed by the
examiner
Brasic JR. Catatonia
oInappropriate Formality of
Speech in Catatonia
 Vouvoyer, the use of vous [ie,
the formal form of “you”] to
address one’s spouse in French
Brasic JR. Catatonia
www.emedicine.com
oLatah betul or "real latah" or "true latah"
 A phenomenon present in
Malaysia
 The apparent loss of control over behavior
 Echolalia
 Echopraxia
 Automatic obedience
Brasic JR. Catatonia
www.emedicine.com
oLaboratory Work Up in Catatonia
Complete blood counts, electrolytes,
and chemical analyses of blood
 Serum creatine kinase, white blood
cell counts, and liver function tests
 Ceruloplasmin
Brasic JR. Catatonia
www.emedicine.com
oImaging in Catatonia
Imaging the head by magnetic
resonance imaging (MRI) or
computed tomography (CT)
Electroencaphalography
Brasic JR. Catatonia
www.emedicine.com
oMedical Care in Catatonia
Admission to a neurological or a medical
intensive care unit for neuroleptic
malignant syndrome, encephalitis, or
nonconvulsive status epilepticus
Admission to a psychiatric intensive
care unit for acute psychosis
Brasic JR. Catatonia
www.emedicine.com
oTreatment for Catatonia
Avoid traditional neuroleptics
Parenteral nutrition for refusal to eat
Intravenous (IV) fluids and monitoring
of vital signs for autonomic instability
Electroconvulsive treatments (ECT) for
malignant catatonia or catatonia unresponsive
to pharmacotherapy after 5 days
Brasic JR. Catatonia
www.emedicine.com
oPharmacotherapy for Catatonia
Lorazepam (Ativan)
Risperidone (Risperdal)
Carbamazepine (Tegretol, Carbatrol, Epitol)
Dantrolene
Brasic JR. Catatonia
www.emedicine.com