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Effects of striatal lesions with kainic acid on morphine-induced "catatonia" and increase of striatal dopamine turnover.

The influence of striatal lesions (head of the caudate nucleus) with kainic acid on "catatonia" and on the increase of the dopamine metabolite DOPAC in the striatum after systemic morphine administration was measured in rats. These lesions strongly prevented the morphine-induced muscular rigidity, measured as activity in the electromyogram EMG) of the gastrocnemius-soleus muscle of non-anesthesized animals. On the other hand, the decrease of locomotion (akinesia) measured using an Animex Activity Meter and an activity wheel, was not prevented or reduced. The lesions did not influence the inhibitory effect of morphine on the activation of flexor alpha-motoneurones, either. These results suggest that the head of the caudate nucleus plays an important role in mediating morphine rigidity, but not akinesia or inhibition of the activation of flexor alpha-motoneurones. Opioid-induced "catatonia" ought to be regarded as a mixture both of rigidity and of akinesia. Morphine led to a rapid decrease, followed by a slow increase of striatal DOPAC concentration. Lesions induced by kainic acid slightly inhibited the decrease and markedly enhanced the increase of DOPAC. Accordingly, an intact nigro-striato-nigral loop is not necessary for the increase of striatal dopamine turnover, observed after morphine administration. The different sites of action, which are likely to mediate all these effects of morphine, are discussed.

3,4-Dihydroxyphenylacetic Acid↗

Neuroleptic malignant syndrome and catatonia. A report of three cases.

In a series of 1007 consecutively admitted patients, 3 cases of neuroleptic malignant syndrome (NMS) were identified (0.3%). All three patients were affected by mood disorders with congruent psychotic features, had shown catatonia just before the onset of NMS, and had been treated with low neuroleptic doses. All of them presented low serum iron levels. The relationship between NMS and catatonia and possible therapeutic decisions are discussed.

Adult↗

Catatonia with high CSF lactate in a case of diabetes with associated conditions.

A case of reversible catatonia in a well controlled insulin-dependent diabetic is described. The course of catatonia was characterized by very high CSF lactate values (serial semiautomatic determinations) during more than one month, beyond the clinical recovery. The CSF lactate elevations seem to reflect cerebral hypoxia. The uncommon coincidence of diabetes with cerebral atrophy, mental weakness, and perceptive deafness migh suggest the classification of this case of diabetes in the group 'associated with certain conditions and syndromes'.

Adult↗

Periodic catatonia: confirmation of linkage to chromosome 15 and further evidence for genetic heterogeneity.

We earlier reported significant evidence for linkage on chromosome 15q15 in periodic catatonia, a sub-phenotype of schizophrenic psychoses. The disorder is characterized by qualitative hyperkinetic and akinetic psychomotor disturbances through acute psychotic episodes and debilitating symptoms in the long term, with psychomotor weakness, grimacing facial movements and apathy. Here, we confirm mapping of a major gene locus on chromosome 15q15 in a second genome scan in a new set of four multiplex families. Non-parametric multipoint linkage analyses identified a broad region with a maximum peak of Z(all) =3.91 ( P=0.006) and Z(lr) =3.04 at D15S1234 ( P=0.001), satisfying conventional criteria for confirmed linkage. Parametric affected-only analyses under an autosomal dominant model gave a maximum HLOD score of 1.65 (D15S1234) with an estimated 47% of families being linked. Analysis of individual families showed that one large family showed linkage, whereas two others could be clearly excluded, confirming genetic heterogeneity. No other locus reached suggestive levels of significance. Haplotype analysis on chromosome 15 in this and previously linked families placed the susceptibility region to a 11-cM interval between marker D15S1042 and D15S659. Periodic catatonia is the first sub-phenotype of schizophrenic psychoses with confirmed linkage despite the existence of considerable genetic heterogeneity.

Catatonia↗

Plasma homovanillic acid concentrations in catatonia.

We investigated the dopamine metabolite plasma homovanillic acid (plasma HVA) levels in 37 catatonic patients on the day of admission before initial medication as well as in 17 healthy controls. In a prospective study catatonic syndrome was diagnosed according to criteria of Lohr and Wiesniwski (1987) and Rosebush et al (1990) whereas comorbid diagnosis was made by Diagnostic and Statistical Manual of Mental Disorders, 3rd ed, revised (DSM III/R) (APA 1987). On the day of admission blood samples were taken before initial medication. Compared to controls (80.1 +/- 40.1 pmol/mliter) catatonic patients showed significantly (P = 0.0286) increased plasma HVA (140.9 +/- 53.6 pmol/mliter). Catatonic patients free of neuroleptic medication (n = 21) differed significantly (p = 0.0416) from controls whereas neuroleptically treated catatonics (n = 16) did not. Our findings of increased plasma HVA in catatonia are explained by an alteration in either mesolimbic or mesocortical dopaminergic function, as is assumed in the case of schizophrenia. As an alternative, it may be due to increased nigrostriatal function, which can lead, as shown in animal experiments with the dopamine agonist amphetamine, to hypokinetic states resembling catatonia in humans.

Adolescent↗

Speech-prompt catatonia: a case report and review of the literature.

The clinical picture of speech-prompt catatonia, one of the six catatonic subtypes in Leonhard's classification, is demonstrated by a case report. The Leonhardian catatonic subtypes offer a radically different way of approaching the problem of catatonia. The need for a reevaluation of Leonhard's intricate, clinically oriented system, rich in psychopathological details, is emphasized.

Adult↗

Catatonia and burns.

Two case reports describing symptoms of catatonia associated with thermal injury are reported. The incidence of catatonia in a burn unit was found to be about three times that in a general hospital.

Adult↗

ECT and the youth: catatonia in context.

Electroconvulsive therapy (ECT) has been in psychiatric practice for well over half a century, but it continues to incite controversy. However, it is regarded amongst psychiatrists as a safe and effective treatment and at times even a lifesaver. It offers a fairly swift but a time-limited response, opening up opportunities for initiation of more longer lasting treatments. The use of ECT in the youth is limited, and as such good studies are few and far between. The recent Practice Parameters by the American Academy of Child and Adolescent Psychiatry, specifically addressing ECT in adolescents, is indeed a welcome addition. Electrocovulsive therapy is as effective in the youth as it is in the adults, and the indications and contraindication are the same. The administration of ECT follows the same general principles in all age groups. One particular indication is of the use in catatonia, a motor syndrome that could occur with affective disorders, schizophrenia or medical conditions, in which it is considered to be extremely effective. The association between catatonia and autism and spectrum disorders has been noted, and in this situation, ECT is considered by some to be effective. Ethical considerations and that of capacity and informed consent are of paramount importance as are the human rights. Working in partnership with the parents/carers all the way is a must. The lack of information leaflets on ECT especially designed for young patients and their parents has to be rectified soon. Registers based on geographical health regions for those below the age of 18 will assist tremendously in epidemiological studies as well as pave the way toward more evidence-based studies that are essential.

Adolescent↗

Psychological approaches to chronic catatonia-like deterioration in autism spectrum disorders.

The psychological dysfunctions that may underlie catatonia-like deterioration in autism spectrum disorders are discussed. Clinical observation suggests that an important factor is ongoing stress. The evidence for this from research and clinical observation is considered. The lack of evidence concerning the most appropriate medical treatments is discussed. A psychological approach designed for individual needs by relevant professionals and applied by parents and/or caregivers is described. This can be helpful whether or not medical treatments are used. It involves detailed holistic assessment of the individual and their circumstances to highlight possible precipitating stress factors in view of their underlying autism and cognitive/psychological functioning. The overall aim of this approach is to restructure the individual's lifestyle, environment and resolve cognitive/psychological factors to reduce the stress. An eclectic approach is used to find individual strategies in order to provide external goals and stimulation to increase motivation and keep the person engaged and active in meaningful and enjoyable pursuits. The approach describes ways of using verbal and physical prompts as external stimuli to overcome the movement difficulties and emphasizes maintaining a predictable structure and routine for each day. The importance of educating caregivers and service providers to understand the catatonia-like behavior is emphasized. Advice is given on management of specific problems such as incontinence, freezing in postures, eating problems, and episodes of excitement.

Adolescent↗

Motor features in psychotic disorders. II. Development of diagnostic criteria for catatonia.

Existing diagnostic criteria for catatonia have been based exclusively on theoretical assumptions. The present study aimed to develop empirical criteria for diagnosing catatonia. The same patient population (n=187) described in Part I (Peralta, V., Cuesta, M.J., Motor features in psychotic disorders. I. Factor structure and clinical correlates. Schizophr. Res., 00, 000-000) was used in this study. Fourteen catatonic signs with potential diagnostic value were cluster-analyzed to derive groups with and without a catatonic syndrome. Taking the cluster solution as the reference standard, the diagnostic value for individual signs was examined by means of multiple discriminant analysis, ROC analysis, and the parameters of sensibility, specificity, positive predictive power and negative predictive power. Cluster analysis divided the sample into a catatonic group (n=32) and a noncatatonic group (n=155). Discriminant analysis showed that 11 of the 14 potential diagnostic signs discriminated among groups: immobility/stupor, mutism, negativism, oppositionism, posturing, catalepsy, automatic obedience, echophenomena, rigidity, verbigeration and withdrawal. ROC analysis showed that any combination of three or more of these symptoms best fitted the cluster-derived catatonic syndrome. In conclusion, patients displaying three or more classical motor signs may be diagnosed with confidence as suffering from a catatonic syndrome.

Adult↗

Delayed onset of late movement-related cortical potentials and abnormal response to lorazepam in catatonia.

Catatonia is a psychomotor syndrome with an inability to execute and terminate movements completely, leading consecutively to akinesia and posturing, which both respond almost immediately to benzodiazepines, i.e. gaba-potentiators like lorazepam. However, pathophysiological mechanisms of cortical motor and gaba-ergic dysfunction remain unclear. We therefore investigated movement-related cortical potentials (MRPs) and movement kinematics during a motor task before and after lorazepam. Ten akinetic catatonic patients were compared with 10 psychiatric (similar age, sex, medication, and underlying psychiatric disease but without catatonic syndrome) and 20 healthy controls. MRPs from frontal (F), central (C), and parietal (P) sites were recorded to obtain measures of early and late readiness potential and movement potential. Kinematic measures included parameters for amplitude of movements, peak velocity, average duration of movements, elevation angle, and angle velocity. The motor task consisted in self-initiated extension of the right index finger. All catatonic and psychiatric control patients received intravenous lorazepam (1mg), whereas healthy controls were subjected to a placebo-controlled (10 received lorazepam, 10 received placebo) double-blind study design.Catatonics showed a significantly delayed onset of late readiness and movement potential in central electrodes (Cz, C3) compared with psychiatric and healthy controls. This delayed onset correlated significantly with catatonic motor symptoms and movement duration. Lorazepam led to significantly stronger delays in onset of late readiness potential in left fronto-parietal (F3, C3, P3) electrodes in catatonic patients than in psychiatric and healthy controls. It is concluded that delayed latencies in late MRP components in catatonic patients may reflect their inability to execute and terminate movements completely. Differential and stronger response to lorazepam in catatonia suggests dysfunction in inhibitory control of cortical motor function with increased gaba-ergic sensitivity.

Adult↗

Catatonia, autism, and ECT.

We describe the clinical presentation, course, and treatment response of a 14-year-old boy with catatonic stupor. This patient, with a preexisting diagnosis of autism, displayed mutism, akinesia, and an extreme level of rigidity, waxy flexibility, posturing, including the psychological pillow, facial grimacing, and other involuntary movements of his upper extremities. In addition he had symptoms suggestive of a depressive disorder as well as some non-specific psychotic symptoms. Intravenous injection of sodium amytal failed to resolve any motor symptoms, although he showed a good response to the zolpidem test. A course of electroconvulsive therapy (ECT) caused dramatic and sustained relief of catatonic stupor without a change in the symptoms of autism. The presentation of catatonia in autism and the use of ECT in children are discussed, and the available literature reviewed. This is the first description of the use of ECT in the treatment of catatonia coinciding with autism and we confirm its efficacy.

Adolescent↗

Increase of serum creatine phosphokinase in catatonia: an investigation in 32 acute catatonic patients.

We investigated serum creatine phosphokinase (CPK) and associated parkinsonic (SEPS) and dyskinetic (AIMS) movements in 32 hospital admitted acute catatonic patients. Thirty-two (N = 24 without neuroleptics on admission) catatonic patients were compared with 32 non-catatonic dyskinetic psychiatric patients, 32 non-catatonic non-dyskinetic psychiatric patients and 32 healthy controls. CPK was significantly higher (P = 0.015) in catatonics (mean 255.75, S.D. +/- 226.54) than in healthy controls (38.6, +/- 27.4) and non-catatonic non-dyskinetic psychiatric patients (57.1, +/- 120.8) whereas there was no significant difference between catatonics and non-catatonic dyskinetic psychiatric patients (453.4, +/- 128.5). There were significantly positive correlations between CPK and AIMS, as well as significantly negative correlations between CPK and SEPS, in all three groups. Our results suggest that increased serum CPK in catatonia may be related to occurrence of dyskinetic movements. Furthermore, we were able to distinguish a parkinsonic (low CPK, low AIMS, high SEPS) and a dyskinetic (high CPK, high AIMS, low SEPS) subtype in catatonia.

Acute Disease↗

Ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal.

To describe ictal catatonia as a manifestation of de novo absence status epilepticus following benzodiazepine withdrawal. Ictal catatonia was documented by concurrent EEG recordings. A catatonic syndrome, first diagnosed as a psychogenic reaction, was found to be an ictal event by EEG recording. De novo absence status and benzodiazepine withdrawal should be considered when a catatonic syndrome suddenly occurs in elderly patients.

Aged↗

[Catatonia].

Catatonia is a neuropsychiatric syndrome characterized by mental, motor and behavioral symptoms. It occurs in up to 18 % of acute admissions and is most frequently associated with affective and psychotic disorders. It is also seen in dissociative disorders, pervasive developmental disorders, mental retardation and organic psychiatric disorders. Catatonic syndromes are impressive states that can be reliably and validly diagnosed both clinically and with psychometric measurements and they can be treated effectively. Despite this, they are often not recognized in clinical practice, are not part of the therapeutic strategy and thus remain untreated. The following article is intended to give a review of the most pertinent questions related to the diagnosis and treatment of catatonia in order to improve clinicians' ability to recognize and treat catatonic symptoms and syndromes adequately.

Benzodiazepines↗

["Catatonia alternans" and differential typology of psychomotor psychoses].

A case of "Catatonia alternans" ist presented with regard to the literature on 48-hour-cycles in affective psychosis and periodic catatonias. The clinical association of catatonic and affective syndromes, depending on classificational convention, is discussed. This case illustrates that rapid syndromal switches with 48-hour-cycles do not only occur as purely affective syndromes, but also as catatonic syndromes.

Affective Disorders, Psychotic↗

[Differential diagnosis of malignant hyperthermia, febrile catatonia and neuroleptic malignant syndrome. A case comparison].

Malignant Hyperthermia (MH), Lethal Catatonia (LC), and Neuroleptic Malignant Syndrome (NMS) are known as rare potential lethal diseases. MH and NMS--both being drug-induced--have in common some main symptoms. LC and NMS, on the other hand, are hardly distinguishable by clinical means. After presentation of the case reports the differential diagnosis of the syndromes is discussed. While there is strong evidence for the MH to be drug-induced, the NMS cannot be explained sufficiently in this way. Clinically both can be differentiated. Lethal catatonia is a syndrome rather than a specific disease. Differential diagnosis for NMS is possible by the neuroleptic withdraw-trial.

Adult↗

[Differential diagnosis of acute life threatening catatonia and malignant neuroleptic syndrome--a case report].

This study reports the development of a severe life threatening catatonia in a 19 years old woman. Initially she displayed paranoia and hallucinations, which were complicated under neuroleptic treatment by extended rigor, temperature and autism. ECT led to a certain improvement of all symptoms, but complete recovery was only reached after neuroleptic drug withdrawal. The course of this case shows that the differential-diagnosis between genuine "pernicious" catatonia and the neuroleptica malignant syndrome is very difficult clinically. Therefore, before the application of ECT, an observation period without any neuroleptic drugs is recommended in similar cases with rigor, stupor and raised temperature, to avoid additional risks by narcosis and ECT itself. Diagnostic and therapeutic outlines are given.

Adult↗