Abstract
Keywords
Catatonia, a term coined by Kahlbaum in 1874, has undergone changing definitions and implications over the years [1]. Catatonia is a syndrome with predominantly motor signs such as stupor, mutism, negativism, grimacing, stereotypies and echopraxia/echolalia [2–6]. Besides psychiatric disorders, catatonic signs occur in a wide range of medical disorders-metabolic disorders, such as drug toxicity, and neurological disorderscerebrovascular events, tumour, degenerative disorders, epilepsy, and so on [2]. This fact underscores the need for detailed psychiatric and physical examinations to clarify the cause of such signs.
Studies on adult patients with major psychiatric disorders (schizophrenia, affective disorders, and other psychotic illnesses) have reported an incidence rate of catatonia of 10–37.7% [3–6]; these studies suggest mood disorders are the commonest disorders associated with catatonia [5, 7–9]. A few instruments have been developed to assess catatonic signs; of them some are standardized rating scales [6, 8] while the rest are checklists [2, 5, 10]. In comparison with the adult literature, only limited information is available about the incidence and phenomenology of catatonia in child and adolescent populations. The recent study by Cohen et al. [11], the only systematic study available, has shown an incidence of 0.6% in inpatient adolescents [11]. In this study [11], unlike adult studies, schizophrenia was the most frequent diagnosis. Although paediatric catatonia has been investigated, available studies have shown effectiveness and safety of sedative drugs, the first line agents [11], and electroconvulsive therapy [12–15] in treatment.
The present study was carried out in the light of the paucity of systematic studies investigating catatonia in younger populations. The main goal was to describe the incidence and phenomenology.
Method
This cross-sectional study was carried out at the child and adolescent psychiatric outpatient clinic of the Central Institute of Psychiatry, Ranchi, India, between April and July 2001. The clinic has an annual outpatient attendance rate of about 2800, including new and old patients. As a routine service, all new patients are evaluated in detail by junior resident doctors and then by consultant psychiatrists to decide the appropriate diagnosis and treatment.
General outline of the study
All newly registered patients aged below 18 were screened for catatonia with a 23-item formal catatonia rating scale [8], which has proven interrater reliability (0.93 for the entire scale and 0.95 for the initial 14 items used for screening) and validity, and patients with at least two different signs of the initial 14 items were included. Following psychiatric examination, patients with catatonia received DSM-IV [16] diagnoses, and characteristics were collected on a data sheet. Except for neuroimaging done on necessity basis, a detailed neurological examination and investigations including haemogram, serum electrolytes estimation, thyroid function tests, and liver and renal function tests were carried out. Consent was obtained from relatives.
Statistical analysis
Data analysis was done with standard software package, SPSS, Windows Version 10.1 (SPSS Inc., Chicago, IL). Descriptive statistics were used to illustrate sample characteristics. Mann–Whitney ‘U’ test was used to examine group differences. The level of significance (α) of ≤ 0.05 (two-tailed) was adopted.
Results
Of the 198 patients screened, 46 had an affective disorder, 16 a nonaffective psychosis (schizophrenia, psychosis not otherwise specified, brief reactive psychosis) and the rest had other diagnoses. Among them, 11 (5.5% of the entire sample and 17.7% of the patients with affective and nonaffective psychotic disorders) had at least two signs of catatonia. While nine of 11 patients with catatonia warranted inpatient treatment, the remaining two were treated as outpatients. Except for one patient with depression who had biochemical evidences of hypothyroidism, none of the others with catatonia had identified biochemical abnormalities. Neuroimaging (CT brain scan) done in one patient was unremarkable.
Sample characteristics
The mean age of the patients was 13.63 (SD = 2.11; range 10–16). Seven were males. Five were illiterate (having no formal education). Three had a past history of affective disorder and five a family history of psychiatric disorder (affective disorder (n = 3), psychosis unclassified (n = 1), obsessive–compulsive disorder (n = 1) and alcohol dependence (n = 1)). In terms of current diagnosis, six patients had depression (four major and two bipolar), two mania, one schizophrenia and two psychoses unclassified. Two patients were also diagnosed as mentally retarded. The mean duration of illness and catatonia at contact were 119 (SD = 160; range 16–540) days and 51 (SD = 104; range 7–360) days, respectively. The number of catatonic signs were three (n = 1), four (n = 3), six (n = 3), seven (n = 1), eight (n = 2) or nine (n = 1).
Severity of catatonia
Mean catatonic scores were significantly greater for males and patients with mental retardation; there was no difference for other demographic and clinical variables (Table 1).
Differences in mean catatonia scores
Distribution of catatonic signs
Stupor/immobility, mutism and posturing/catalepsy were seen across all groups. Conversely, excitement, echo phenomena and perseveration were seen only in mania, and verbigeration, waxy flexibility, ambitendency, automatic disturbances and combativeness solely in the depressive group. Likewise, excitement, echo phenomenon, perseveration, waxy flexibility, ambivalence and automatic obedience were seen only in patients without mental retardation whereas verbigeration was observed exclusively in a patient who had retardation. Other catatonic signs, except grimacing, stereotypy, mannerism, gegenhalten, and grasp reflex that were not seen in any patient, were noted across different groups with differential occurrence (Table 2).
Distribution of catatonic signs in different psychiatric diagnoses
Discussion
The incidence of catatonia is greater than that found by Cohen et al. [11]. In accord with a standardized instrument [8], the presence of two or more signs was considered diagnostic of catatonia. This is less stringent than that of another criterion – asking for at least four signs [6]; however, notably, 10 of our 11 patients had at least four signs. Most patients had an affective disorder, particularly, major depression. This finding, resembling earlier findings [2, 11, 12, 17], differs from that of Cohen et al. [11] who reported schizophrenia as the most common diagnosis. This discrepancy may be explained by the fact that a higher proportion of our patients had affective disorders. Severity of catatonia, evidenced by mean catatonia scores, was comparable between affective and nonaffective disorders.
Most patients were males. Differing from a series on younger patients showing a female preponderance [2], our finding raises a query whether male gender has a predisposition for catatonia. An exploration of genetic and hormonal influences might help to clarify this possibility. Besides male gender, mental retardation seemed to be related with severity; this finding also needs further investigation.
Another set of interesting findings relates to the distribution of catatonic signs. Although similar to another study [11], stupor/immobility, mutism, posturing/catalepsy, rigidity and negativism, were present in affective as well as nonaffective psychoses; other signs such as excitation, echo phenomenon and verbigeration were seen only in affective disorders. Also, strikingly, in consonance with earlier observations [11, 12], staring was noted only in affective disorders. Our study has also documented signs such as mitgehen, ambitendency, perseveration, autonomic disturbances and combativeness, not reported previously [11]. There may be variations in the distribution of catatonic signs across different psychiatric diagnoses and cultures. The latter issue needs validation with crosscultural data.
The main limitations of our study are the small sample and lack of standardized assessment of psychopathology. Generalizability of our findings is also restricted as only psychiatric outpatients were included. Metabolic and toxicological screens could not be done to rule out distant causes of organicity. In view of these limitations, our findings should be considered as preliminary. However, because catatonia may be critical [18] and prolonged catatonia can lead to complications such as pulmonary embolism and bladder infection [19], immediate diagnosis and treatment are crucial; a longitudinal study is essential to clarify course and outcome in a paediatric sample.
Footnotes
Acknowledgements
We thank Max Fink for his comments on an earlier draft.