Transcript catatonia 2012

Catatonia
Dr. Rajdeep Routh
ST5 Old Age Psychiatry
Leverndale Hospital, Glasgow
Sept., 2012
Overview
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Introduction
History
Classification
Clinical Features
Differential Diagnosis
Treatment
Future
Bibliography
Introduction
• Neuropsychiatric syndrome of disturbed motor functions
amid disturbances in mood and thought process
• Prevalence:
– rare
– has been suggested that catatonia is under-recognised and
under-diagnosed
– 9%–15% of patients admitted to a typical acute care psychiatric
service meet diagnostic criteria for catatonia (Rosebush P.I.
2010)
• More common in mood disorders (28%-31% of catatonic
patients had mixed mania or mania)
• Only 10%-15% - underlying diagnosis of schizophrenia
History
• Before 1874: “Stupor”/ stupidite´
• delineation of catatonia as a disease comparable to
general paralysis of the insane (GPI)
• Two schools emerged
– one view supported the proposal of catatonia as a disease of its
own.
– The opposing view was that it was a complication of different
pathophysiologies and not a distinctive disease
Contd.
• The Kraepelin Position
– First agreed with Kahlbaum
– By the time of the sixth edition of his textbook in 1899 catatonia
had become a category of dementia praecox along with
hebephrenia and paranoid dementia.
• Bleuler
– had a milder view of schizophrenia
– brought Kraepelin’s view that catatonia equaled schizophrenia to
North America
Contd.
• Karl Jaspers,
– portrayed catatonia as an illness with special characteristics like
opposing pairs of symptoms (negativism vs automatic
obedience).
• Kurt Schneider’s
– psychology of catatonia, which he found unknowable:
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• ‘‘Sometimes it seems as though the patient is like a dead camera:
He sees everything, hears everything, understands everything and
yet is capable of no reaction, of no affective display, and of no
action. Even though fully conscious he is mentally paralyzed.’’
– He considered Catatoinia a complication of many illnesses and
rejected Kraepelin’s formulations
Contd.
• highly influential figure in British psychiatry.
• In 1954, he became the lead author—in collaboration with Eliot
Slater and Martin Roth—of that era’s principal English language
psychiatry textbook, “Clinical Psychiatry”
• Mayer-Gross’s position on catatonia was resolutely Kraepelinian
that catatonia was a type of schizophrenia.
Is it really a part of Schizophrenia?
• George Kirby (1913) pictured catatonia as typically occurring among
patients with manic-depressive illness
• August Hoch(1921) described 25 psychiatric patients in stupor.
Thirteen with manic-depressive illness had a favorable prognosis
and 12 with general medical illnesses or schizophrenia had a poor
prognosis
• Lange (1922) reported an experience with 200 patients found
catatonia to be more common among the manic-depressive
patients than among those with dementia praecox.
• The neurologic connection was established from studies of epidemic
encephalitis by Von Economo (1931) who described catatonia in
many patients in the acute and chronic phases of the illness
The Debate Continues
• Stauder (1934) reported Malignant Catatonia in 27 patients with an
acute onset and a lethal outcome
• A periodic form of catatonia with hormonal connections was
described by Gjessing.
• Taylor and Abrams: 4 publications between 1973 and 1979,
reported catatonia to be more common among manic and
depressed patients
• Morrison found catatonia in more than 10% of 500 patients, most
commonly among those with mood disorders.
• Gelenberg described catatonia among patients with neurologic and
general medical illnesses
• 1980: identification of the NMS with accompanied by fever,
tachycardia, hypertension, and tachypnea
Classification: DSM
• 1952: Schizophrenic reaction: catatonic type
• 3rd. Edition 1980: ignored new reports and again
catalogued catatonia as a type of schizophrenia
• 4th. Edition 1994:
– diagnosis of ‘schizophrenia, catatonic type’ (code 295.20)
– If a physical cause is identified the diagnosis is ‘catatonic
disorder due to a medical condition’ (code 293.89)
– no separate diagnostic category for catatonia due to either
depression or mania, but catatonia can be added as a specifier
in mood disorders
World Health Association’s International
Classification of Diseases (ICD)
• 6th. Ed. 1948: ‘‘catatonic type’’ among the ‘‘schizophrenic
disorders.’’
• 10th. Edition 1992: unchanged;
‘‘For reasons that are poorly understood, catatonic
schizophrenia is now rarely seen in industrial countries,
though it remains common else where.’
– Catatonic schizophrenia (category F20.2)
– Pt. With severe depression is in a stupor- a diagnosis of ‘severe
depressive episode with psychotic symptoms’ (F32.3)
– manic stupor will be diagnosed as having ‘mania with psychotic
symptoms’ (F30.2)
– Catatonia due to physical causes is diagnosed as ‘organic
catatonic disorder’ (F06.1).
Clinical Features
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Stupor
Posturing
Waxy flexibility (cerea flexibilitas)
Negativism (Gegenhalten)
Automatic obedience
Ambitendency
Psychological pillow
Forced grasping
Obstruction
Contd.
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Echopraxia
Aversion
Mannerisms
Stereotypies
Excitement
Speech abnormalities
– Echolalia, logorrhoea and verbigeration
Rating scales for catatonia
• General agreement among researchers that the
syndrome is poorly recognised
• Bush–Francis Catatonia Rating Scale (BFCRS)
– most widely used
– 23 items
– shorter, 14-item screening version
• Modified Rogers Scale (MRS)
Catatonia Subtypes
• Non-malignant
– Retarded/ withdrawn- appear awake and watchful, but with
minimal spontaneous speech and movement. Stupor, mutism,
negativism, and posturing are common signs
– excited - excessive purposeless motor activity associated with
disorganised speech, disorientation, aggression, and violence
• “Lethal" or "malignant" catatonia- escalating fever and
autonomic instability
– Resembles neuroleptic malignant syndrome (NMS)
– Some authors also consider toxic serotonin syndrome as a
subtype of malignant catatonia
Van Den Eede & Sabbe (2004);
Taylor & Fink (2003)
Differential Diagnosis
• Mood disorders
– Increasing age
• Underlying seizure activity
– Temporal lobe epilepsy
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Abrupt discontinuation of clozapine
Cocaine, Ecstasy, Ciprofloxacin
Metabolic abnormalities- Hyponatraemia
Prior brain injury and physical illness at onset of psychosis
Hysteria
Idiopathic
– females
Mechanism
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deficiency of cortical gamma-aminobutyric acid (GABA)
hyperactivity of glutamate
sudden and massive blockade of dopamine
PET Scan has identified abnormalities in metabolism
bilaterally in the thalamus and frontal lobes
• fear response (Moskowitz 2004)
Investigations
• Comprehensive physical examination, with specific
emphasis on neurological signs
• Bloods- FBC, Renal, LFT, TFT, Glucose, CK
• Drug Screen
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ECG
CT/ MRI
EEG
Culture
LP
Auto-Antibody Screen
Treatment
• Supportive care/ high level of nursing care
• Treatment with subcutaneous heparin, urinary catheterization
• May require IV fluids, Nasogastric tube feeds or PEG tube
placement.
• Benzodiazepines are the drugs of choice for catatonia
– Lorazepam was the most commonly used treatment, resolving symptoms in 70%
of reported cases.
– Other benzodiazepines such as diazepam, oxazepam, and clonazepam have
also been reported to treat catatonia
– Zolpidem, like the benzodiazepines, is a GABA-A agonist and has been reported
in one case series to be effective in the treatment of catatonia
– continue the benzodiazepines until the causative illness has been fully treated
• ECT
– ECT alone resulted in resolution of symptoms in 85%
– In malignant catatonia, the response to ECT was 89%,
Electroconvulsive Therapy
• Most reports of successful treatment of catatonia use bilateral ECT
• Discontinuation of Benzodiazepines before ECT?
– One case report described exacerbation of catatonia
– Some physicians describe discontinuing benzodiazepine
treatment just prior to ECT,
– whereas others recommend continuing benzodiazepines during
and beyond the ECT treatments.
– A synergistic effect between benzodiazepines and ECT has also
been postulated
• Emergency ECT is the treatment of choice for malignant catatonia
NMDA Antagonists
• When benzodiazepines and ECT fail or are not an option
• Amantadine
– anticholinergic side effects
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Memantine
Antiepileptics/ Mood Stabilisers
• Topiramate
• Carbamazepine
• Combination of lithium and an antipsychotic may be an
option in treatment-resistant catatonic stupor
Antipsychotics
• generally not recommended during a catatonic phase
• catatonia represents a highly significant risk factor for
subsequent neuroleptic malignant syndrome
• atypical antipsychotics may have a role in the treatment
of non-malignant catatonia (Van Den Eede et al 2005)
– Multiple case reports and retrospective studies indicating the
successful treatment of catatonia with atypical antipsychotics
(olanzapine, risperidone, ziprasidone, aripiprizole, and
clozapine)
– Reports of atypical antipsychotics causing catatonia, though
these studies were largely in patients with schizophrenia and
only one focused on a patient with a medical illness
• Advice- use atypical antipsychotics in catatonic patients
with caution, given the risk of NMS
Prognosis
• Two-thirds show marked improvement or remission
• High incidence of recurrent catatonic episodes was
reported for idiopathic catatonia and catatonia due to
affective disorders
• Following ECT high relapse rate within a year
– continuation ECT is an efficacious treatment for maintaining
response (Suzuki et al 2005)
In Future
• divorce from schizophrenia
• recognition as an independent syndrome
– sufficiently common to warrant classification as an independent
syndrome similar to delirium
References
• Daniels J., Catatonia: Clinical aspects and
neurobiological correlates, Journal of Neuropsychiatry
and Clinical Neurosciences, 2009, 21, (4): 371-380
• Fink, Shorter, and Taylor, Catatonia Is not
Schizophrenia: Kraepelin’s Error and the Need to
Recognize Catatonia as an Independent Syndrome in
Medical Nomenclature,Schizophrenia Bulletin, 2010
• Rajagopal S., Catatonia, Advances in Psychiatric
Treatment, 2007, 13, (1): 51-59
Questions
Thanks