2
AcknowledgementsThis 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.
3
Syndrome
A constellation of symptoms, signs, and laboratory findings associated with a family history and a natural history
11
Parkinsonism Parkinson Disease Following infections, eg, encephalitis Following toxic exposures Secondary to administration of dopamine receptor blocking drugs
12
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
13
Catatonia
occurrence in children, adolescents, and adultsassociation with a heterogeneous group of comorbid conditions symptoms and signs of impairment of the expression of voluntary thoughts and movementsBrasic JR. Catatonia www.emedicine.com
14
Catatonia
typically episodic
usually periods of remission
morbidity and mortality of comorbid conditionsBrasic JR. Catatonia www.emedicine.com
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Neuroleptic Malignant Syndrome
Elevated temperatureRigidityDeliriumDysregulation of the autonomic nervous systemBrasic JR. Catatonia www.emedicine.com
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Neuroleptic Malignant Syndrome
Exposure to antipsychotic medications, including typical and atypical antipsychotic medications
Brasic JR. Catatonia www.emedicine.com
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Vulnerability for Catatonia
Mental retardationPervasive developmental disordersOther developmental disabilitiesBrasic JR. Catatonia www.emedicine.com
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Catatonia
Vaslav Nijinsky, the dancer and choreographer (Ostwald, 1994)
Brasic JR. Catatonia www.emedicine.com
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Frequency of Catatonia in the US
Decrease in the past century overallDecrease 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
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Frequency of Catatonia outside the US
Vastly different ratesGreat difference in various regionsVarying degrees of ascertainmentDiffering diagnostic categoriesUndiagnosed cases
Brasic JR. Catatonia www.emedicine.com
21
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
22
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 1953-1933 in Finland (Rogers, 1991)
Brasic JR. Catatonia www.emedicine.com
23
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
25
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
26
Ages of Patients with Catatonia
AdultsAdolescentsRare in Children
Brasic JR. Catatonia www.emedicine.com
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History of Patients with Catatonia
Unobtainable from patientsObtainable from collateral sourcesBrasic JR. Catatonia www.emedicine.com
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Primary Features of Catatonia
ImmobilityStuporPosturingRigidityStaringGrimacingWithdrawal
Brasic JR. Catatonia www.emedicine.com
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Behavioral Responses to Others of People with Catatonia
MutismNegativismEchopraxiaEcholaliaWaxy flexibility
Brasic JR. Catatonia www.emedicine.com
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Historical Features of People with Catatonia
StereotypiesMannerismsVerbigeration
Brasic JR. Catatonia www.emedicine.com
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Historical Features of People with Excited State of Catatonia
ImpulsivityCombativenessAutonomic instabilityShort-livedPrecipitate collapse from exhaustion
Brasic JR. Catatonia www.emedicine.com
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Possible Precipitating Events of People with Catatonia
InfectionTraumaToxinsSubstances
Brasic JR. Catatonia www.emedicine.com
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History of Similar Episodes of Catatonia
Precipitating events for prior and current episodesInterventions to relieve prior episodes
Brasic JR. Catatonia www.emedicine.com
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Treatable Causes of Catatonia
Neuroleptic malignant syndromeEncephalitisNonconvulsive status epilepticusAcute psychosis
Brasic JR. Catatonia www.emedicine.com
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Behaviors Suggesting Catatonia Only When Examiner is Present
Inconsistent with catatoniaSomatoform disordersFactitious disordersMalingeringPsychogenic movement disordersBrasic JR. Catatonia www.emedicine.com
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Somatoform disorders
Conversion disorderSomatization 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
37
Somatoform disorders
Conversion disorderSomatization 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
39
Sincere Reports of Individual Perceptions of Experiences
Catatonia Somatoform disordersNeurological disordersSchizophrenia 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
40
Fabricated Reports of False Experiences
Factitious disordersMunchausen syndromeMunchausen syndrome by proxy
MalingeringAmerican 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
41
Fabricated Reports of False Experiences
Factitious disordersMunchausen syndromeMunchausen syndrome by proxy
MalingeringAmerican 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
42
Fabricated Reports of False Experiences
Munchausen syndrome by proxy
Malingering
Factitious disorders
Munchausen syndrome
Munchausen syndrome by proxy
43
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
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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
45
Readily Apparent Signs of Catatonia in an Emergency
Setting
● Rigidity● Gegenhalten● Grasp reflex
Brasic JR. Catatonia www.emedicine.com
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Gegenhalten
● “To hold against” in German● Increasing resistance to passive movement of the limbs● Apparently deliberate opposition to the examiner’s movementsBrasic JR. Catatonia www.emedicine.com
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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
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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
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Excited State of Catatonia
● May injure self ● May assault others● May experience autonomic instability (hyperthermia, tachycardia, and hypertension)● May collapse from exhaustionBrasic JR. Catatonia www.emedicine.com
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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
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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
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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
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Peculiarities of Movement in Catatonia
Stereotypies, repetitive performing of apparently meaningless activities Verbigeration, repetitive apparently meaningless utterancesBrasic JR. Catatonia www.emedicine.com
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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 extremitiesBrasic JR. Catatonia www.emedicine.com
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Verbigeration, Verbal Stereotypies, in Catatonia
Sniffing Clicking Snorting Nonmeaningful soundsBrasic JR. Catatonia www.emedicine.com
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oPreservation in Catatonia
Inappropriate repetition of acts
Brasic JR. Catatonia www.emedicine.com
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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 www.emedicine.com
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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
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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
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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
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oImaging in Catatonia
Imaging the head by magnetic resonance imaging (MRI) or computed tomography (CT)Electroencaphalography
Brasic JR. Catatonia www.emedicine.com
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oMedical Care in Catatonia
Admission to a neurological or a medical intensive care unit for neuroleptic malignant syndrome, encephalitis, or nonconvulsive status epilepticusAdmission to a psychiatric intensive care unit for acute psychosis
Brasic JR. Catatonia www.emedicine.com
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oTreatment for Catatonia
Avoid traditional neurolepticsParenteral nutrition for refusal to eatIntravenous (IV) fluids and monitoring of vital signs for autonomic instabilityElectroconvulsive treatments (ECT) for malignant catatonia or catatonia unresponsive to pharmacotherapy after 5 days
Brasic JR. Catatonia www.emedicine.com
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