Catatonia

[Mike Harden]

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I know catatonia is usually associated with psychotic disorders, but in rare cases, can it occur in sever major depressive episodes. How frequently does that happen?

 

[clausewitz2]

I know catatonia is usually associated with psychotic disorders, but in rare cases, can it occur in sever major depressive episodes. How frequently does that happen?

Catatonia due to an underlying psychiatric condition is actually significantly more likely to represent a severe depression than a primary psychotic disorder. So, not that unusual.

 

[nitemagi]

Catatonia due to an underlying psychiatric condition is actually significantly more likely to represent a severe depression than a primary psychotic disorder. So, not that unusual.

Source?

 

[splik]

Catatonia is usually associated with mood disorders, less commonly with psychotic disorders. The bulk of catatonia is seen in patients with bipolar disorder, typically during a mixed episode or a depressed episode. These patients typically have some level of psychosis. A variant of catatonia is Bell's mania or delirious mania that presents with frank confusion and catatonia. After that patients with major depressive disorder (depressive stupor), then patients with autism and then after that patients with primary psychotic disorders (e.g. "schizophrenia"). Catatonia can all exist on its own as a mental disorder, the periodic catatonia, or as an hysterical condition (a form of PTSD if you will). catatonia can also occur in the context of delirium and in various medical conditions such as limbic encephalitis, midbrain tumors, SLE, some viral encephalitides, PML, HIV encephalopathy, bvFTD, CJD and so on.

 

[nitemagi]

Agreed, Splik.

 

[thoffen]

Don't forget autism and catatonia.

Challenging to give clear demographic data because rigorous application of criteria will make it far more common than actually diagnosed, and my intuition is that especially applies in medical settings.

 

[NickNaylor]

Don't forget autism and catatonia.

Challenging to give clear demographic data because rigorous application of criteria will make it far more common than actually diagnosed, and my intuition is that especially applies in medical settings.

Somewhat related, but I read a paper recently looking at the assessment of delirium and catatonia in a cohort of “critically ill” patients (I forgot how they defined this), and using the I-CAM and the Bush-Francis found a prevalence of ~40% for delirium, ~30% (!) for catatonia, and an equally large number of people with both conditions.

I need to dig the paper up because I was a pretty shocked at the prevalence of catatonia. I guess catatonia is being misdiagnosed as a hypoactive delirium?

 

[HarryMTieboutMD]

Here we go... this is one of the most confusing topics in psychiatry because people fail to understand the historical background and evolution of criteria. Most people just regurgitate what their attendings tell them or what is in most standard textbooks (unfortunately influenced by Max Fink who is obsolete). But it's always good for me to pull out the classics...

So, the syndrome was originally defined by Kahlbaum in die Katatonie oder das Spannungsirresein in which Kalhbaum describes the illness with psychosis, mania, and melancholia, but focuses on the motoric signs because he was comparing this to General Paresis of the Insane (neurosyphilis for all the neophytes tuning in) and this is how, even prior to Kraepelin, he focused on the illness in terms of longitudinal course. Kraepelin then defined the dementia praecox as the core illness being a destruction of the emotional and volitional spheres of psychic functioning ultimately defined by a terminal state ranging from weak mindedness to profound dementia, where the catatonic syndrome was a variant of the DP (along with paranoid and hebephrenic, reflected in earlier DSMs). If one reads Kraepelin closely (which was required for us as interns), you note that nearly 50% of his patients he called "catatonic" began "in a state of depression" and noted a relapsing course of catatonic stupor and excitement (which is what he thought Kahlbaum meant when he said "mania" though Kraepelin's description of catatonic excitement sounds like actual mania). Either way we would see a strong affective component if we could be transported back to Kraepelin's asylum in Munich and without knowing the terminal state (and having meds at our disposal) we might call these patients Bipolar or psychotic depression.

If, however, you read Kraepelin's Manic Depressive Insanity and Paranoia he clearly describes constellations of symptoms that today we would call "catatonia". It is nonetheless a conceptual error to think that people with bad depression become so psychomotor slowed that they just become "catatonic" (and this si when people imagine flexibilitas cerea without actually knowing what it means). A true melancholic catatonic stupor is something entirely different and they will meet the symptomatic criteria.

The idea that catatonia is more prevalent in affective illness comes from a classic paper by Abrams and Taylor Catatonia. A prospective clinical study. - PubMed - NCBI where 62% had BPAD, 7% had SCZ, 9% had "endogenous depression" and 16% had "coarse brain disease". Notably they used their own criteria (one of our older attendings collaborated with them a long time ago and admitted that A&T tended to over-dx mania) and defined catatonia by "one or more of the following motor signs": mutism, stereotypy, posturing, cat¬ alepsy, automatic obedience, negativism, echolalia/echopraxia, or stupor, as defined by Fish." But you get the idea, and DSM V is probably more "correct" in defining catatonia due to a distinct syndrome.

If you also take Kraepelin's hypothesis of catatonia as an "end stage" of psychosis (complete destruction of the volitional sphere), the differential prevalence could also represent the fact that we treat most schizophrenics (i.e., we don't let them get that psychotic) and that in affective illness the morbid process might be somewhat different (but again- at the end of his career Kraepelin was unconvinced that his dichotomy "carved nature at its joints"

In terms of current nosology the best paper is by Peralta and Cuesta, who are some of the clearest thinkers in terms of phenomenology based diagnoses: Motor features in psychotic disorders. II. Development of diagnostic criteria for catatonia. - PubMed - NCBI They meticulously drew from the various descriptions the most consistent symptoms and then culstered them, producing catatonic and non catatonic groups. They found that all catatonic subjects met at least 3 of the criteria. Unfortunately the didn't label diagnoses beyond that schizophrenia was more prevalent in the non catatonic grouping.

As far as other illnesses- yes, you can get catatonic-looking syndromes, but is it the same? Maybe for anti-NMDA encephalitis/PCP intoxication since this is reasonably well described and mimics SCZ psychosis. The literature on everything else is so poor I'm not convinced it's the same syndrome (or if the raters knew what they were doing when the used the BFRS). Autism is an interesting case- Bleuler of course consider "autism" to be a hallmark attribute of schizophrenia and we know the shared genetic overlap/epidemiology/etc etc etc. Some of our child attendings are world renowned autism experts (in genetics, epidemiology, and neuroimaging) and said that they believe that this is a true catatonic syndrome (interestingly it happens in some of the higher functioning, formerly Aspberger type patients)

 

[deleted736562]

Well, if one looks at the criteria, you have to meet 2 out of 12 to be diagnosed with catatonia. So how can it be the same syndrome? No one knows and I feel this kind of discussion is like splitting hairs.

 

[splik]

I love a bit of history, but what Kahlbaum or Kraepelin (who also believed gymnastics had a role in curtailing homosexuality or contrary sexual feeling as he put it) had to say about catatonia is quite frankly irrelevant. We don't see patients with dementia praecox today so what he had to say about DP is not relevant to our clinical practice (many psychiatrists have persuasively argued that dementia praecox has little to do with the so called "schizophrenias" we see today). I have personally diagnosed catatonia in patients with SLE, VGKC limbic encephalitis, SLE, CJD (it was catatonia and not simply akinetic mutism), bvFTD, OCD, autism, intellectual disability, and so on, but the vast majority of patients I have seen with catatonia have been patients with bipolar disorder. I have seen a lot of patients with catatonia, and usually see several patients a month with the catatonia syndrome and its ilk (including a recent case of ganser syndrome in a patient with catatonic symptoms).

 

[clausewitz2]

In terms of current nosology the best paper is by Peralta and Cuesta, who are some of the clearest thinkers in terms of phenomenology based diagnoses: Motor features in psychotic disorders. II. Development of diagnostic criteria for catatonia. - PubMed - NCBI They meticulously drew from the various descriptions the most consistent symptoms and then culstered them, producing catatonic and non catatonic groups. They found that all catatonic subjects met at least 3 of the criteria. Unfortunately the didn't label diagnoses beyond that schizophrenia was more prevalent in the non catatonic grouping.

I know that you like this paper, and it is an interesting application of more sophisticated mathematical methods to nosology, but it is not the case that they performed a multidimensional analysis that returned two distinct clusters. If you look carefully at the methods section, they stipulated two clusters (catatonic and non-catatonic) as they felt it was most "intuitively compelling." The particular signs that their resulting cluster analysis identified as best separating these two clusters is certainly interesting, but this is very different than asserting that these clusters naturally emerge from the data. It is assumed a priori for the purpose of this analysis that two and only two clusters describe the data. This may reflect the limitations of available statistical packages in 1999, and I suspect if this study was conducted again today by someone conversant with R that we would be seeing a more sophisticated analysis.

Something I do take away from it is that we should probably in clinical practice be putting more weight on mutism, negativism, rigidity and immobility and smack people who want to assert that "Oh, they're not posturing or anything, it's not catatonia."


EDIT: Also this paper uses data drawn entirely from patients who showed psychotic symptoms, which rather begs the question of the intrinsic connection between catatonia and psychosis!

 

[thoffen]

As far as other illnesses- yes, you can get catatonic-looking syndromes, but is it the same? Maybe for anti-NMDA encephalitis/PCP intoxication since this is reasonably well described and mimics SCZ psychosis. The literature on everything else is so poor I'm not convinced it's the same syndrome (or if the raters knew what they were doing when the used the BFRS). Autism is an interesting case- Bleuler of course consider "autism" to be a hallmark attribute of schizophrenia and we know the shared genetic overlap/epidemiology/etc etc etc. Some of our child attendings are world renowned autism experts (in genetics, epidemiology, and neuroimaging) and said that they believe that this is a true catatonic syndrome (interestingly it happens in some of the higher functioning, formerly Aspberger type patients)

That I think is the important question, though unanswerable. I'm personally quite liberal in pursuing Ativan and ECT when the risk is low.

 

[Mike Harden]

Okay, I appreciate your guys' interest in history, but I guess mine is just general interest? For example, say you are in an inpatient setting you have a patient, who came in overnight. They were mobile at that point. You are seeing the patient for the first time. You have little history on them. The patient is kind of "media text-book cationic" (lack better words my friends, lack of better words). Basically, they aren't moving or are barely moving. They aren't responding to you. They are breathing all that fun stuff. Maybe they are sitting up. Maybe they are leaning against a wall. (Take your pick.) I, presume of course, you are going to give them meds to get them out of this state, but would your first bet. (If you had to bet, be psychosis related or mood related.) Obviously, I know there's a lot of grey area here. Let me know if you need me to make up some additions to this little scenario. I do appreciate the discourse. I just kind of have a fascination with this particular issue but not enough to go into psych.

 

[clausewitz2]

Okay, I appreciate your guys' interest in history, but I guess mine is just general interest? For example, say you are in an inpatient setting you have a patient, who came in overnight. They were mobile at that point. You are seeing the patient for the first time. You have little history on them. The patient is kind of "media text-book cationic" (lack better words my friends, lack of better words). Basically, they aren't moving or are barely moving. They aren't responding to you. They are breathing all that fun stuff. Maybe they are sitting up. Maybe they are leaning against a wall. (Take your pick.) I, presume of course, you are going to give them meds to get them out of this state, but would your first bet. (If you had to bet, be psychosis related or mood related.) Obviously, I know there's a lot of grey area here. Let me know if you need me to make up some additions to this little scenario. I do appreciate the discourse. I just kind of have a fascination with this particular issue but not enough to go into psych.

So you are asking "if someone is catatonic, is it mood-related or psychosis-related?" Apart from the conversation upthread having directly addressed this question, if we are just talking about playing the numbers, probably this person has had a history of affective illness at some point in the past.

That is strictly an issue of priors and being a Bayesian about it. Nothing in your scenario really pushes it in one direction or another.

 

[Mike Harden]

So you are asking "if someone is catatonic, is it mood-related or psychosis-related?" Apart from the conversation upthread having directly addressed this question, if we are just talking about playing the numbers, probably this person has had a history of affective illness at some point in the past.

That is strictly an issue of priors and being a Bayesian about it. Nothing in your scenario really pushes it in one direction or another.

No, I was asking about information about catalonia in general for a lay person relating to psychosis and mood disorders. I was asking for some specifics such as, prevalence (data is always nice) and the difference between how cataonia is portrayed in the media vs. the real world. I specifically said I knew I left a lot out of that scenario, as I am an interested party but I am not psych. I am math/sci. I stated that I was leaving the door open to add to the scenario. I am certainly not just looking to upthread to an already answered question. Unless, perhaps I am missing something? I guess, other than my more direct questions, perhaps someone could link me to some fairly readable papers? Like I said I'm not psych, but I have taken all the core sciences, math, a&p, and one pharm class from years ago..........(insert long story). Maybe I could understand a fairly readable paper?

 

[Amygdarya]

No, I was asking about information about catalonia in general for a lay person relating to psychosis and mood disorders. I was asking for some specifics such as, prevalence (data is always nice) and the difference between how cataonia is portrayed in the media vs. the real world. I specifically said I knew I left a lot out of that scenario, as I am an interested party but I am not psych. I am math/sci. I stated that I was leaving the door open to add to the scenario. I am certainly not just looking to upthread to an already answered question. Unless, perhaps I am missing something? I guess, other than my more direct questions, perhaps someone could link me to some fairly readable papers? Like I said I'm not psych, but I have taken all the core sciences, math, a&p, and one pharm class from years ago..........(insert long story). Maybe I could understand a fairly readable paper?

So what exactly are you asking?

 

[OldPsychDoc]

No, I was asking about information about catalonia in general for a lay person ....

My understanding is that Catalonia is now undergoing some uncertainty about its status as an independent region in Spain.
Nevertheless, it remains a wonderful place to visit. Barcelona is one of my all time favorite places in the world.

(Had a patient last week notice my Fink & Taylor Catatonia text on the shelf and immediately started talking about a trip to Barcelona as well...)

 

[Mike Harden]

So what exactly are you asking?

Obviously, I am not be clear. How can I help clear up my language?

 

[clausewitz2]

Obviously, I am not be clear. How can I help clear up my language?

What would you like to use this information for? If it is just personal curiosity, there are textbooks we can point you towards. If you want something actionable a different set of papers suggest themselves.