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Catatonia James Robert Bra šić, MD, MPH

Catatonia James Robert Bra šić, MD, MPH. Acknowledgements

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Catatonia James Robert Bra šić, MD, MPH

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  1. Catatonia James Robert Brašić, MD, MPH

  2. Acknowledgements This 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

  4. Symptoms • The subjective complaints of the patient

  5. Signs • The objective findings of the examiner

  6. Family History • The traits and conditions of other members of the genetic family of the proband

  7. Proband • The identified patient

  8. Natural History • The course of the proband without treatment • An indication of the prognosis

  9. Neuropsychiatric syndromes • Delirium • Dementia • Parkinsonism • Tardive dyskinesia

  10. Parkinsonism Pillrolling Tremor Rigidity Bradykinesia

  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 adults association with a heterogeneous group of comorbid conditions  symptoms and signs of impairment of the expression of voluntary thoughts and movements Brasic JR. Catatonia www.emedicine.com

  14. Catatonia typically episodic usually periods of remission morbidity and mortality of comorbid conditions Brasic JR. Catatonia www.emedicine.com

  15. Neuroleptic Malignant Syndrome • Elevated temperature • Rigidity • Delirium • Dysregulation of the autonomic nervous system Brasic JR. Catatonia www.emedicine.com

  16. Neuroleptic Malignant Syndrome  Exposure to antipsychotic medications, including typical and atypical antipsychotic medications Brasic JR. Catatonia www.emedicine.com

  17. Vulnerability for Catatonia • Mental retardation • Pervasive developmental disorders • Other developmental disabilities Brasic JR. Catatonia www.emedicine.com

  18. Catatonia • Vaslav Nijinsky, the dancer and choreographer (Ostwald, 1994) Brasic JR. Catatonia www.emedicine.com

  19. Frequency of Catatonia in the US • Decrease in the past century overall • Decrease 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

  20. Frequency of Catatonia outside the US • Vastly different rates • Great difference in various regions • Varying degrees of ascertainment • Differing diagnostic categories • Undiagnosed 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 1950sin 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

  24. Frequency of Catatonia in Different Races • Unknown 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 Adults Adolescents Rare in Children Brasic JR. Catatonia www.emedicine.com

  27. History of Patients with Catatonia Unobtainable from patients Obtainable from collateral sources Brasic JR. Catatonia www.emedicine.com

  28. Primary Features of Catatonia Immobility Stupor Posturing Rigidity Staring Grimacing Withdrawal Brasic JR. Catatonia www.emedicine.com

  29. Behavioral Responses to Others of People with Catatonia Mutism Negativism Echopraxia Echolalia Waxy flexibility Brasic JR. Catatonia www.emedicine.com

  30. Historical Features of People with Catatonia Stereotypies Mannerisms Verbigeration Brasic JR. Catatonia www.emedicine.com

  31. Historical Features of People with Excited State of Catatonia Impulsivity Combativeness Autonomic instability Short-lived Precipitate collapse from exhaustion Brasic JR. Catatonia www.emedicine.com

  32. Possible Precipitating Events of People with Catatonia Infection Trauma Toxins Substances Brasic JR. Catatonia www.emedicine.com

  33. History of Similar Episodes of Catatonia Precipitating events for prior and current episodes Interventions to relieve prior episodes Brasic JR. Catatonia www.emedicine.com

  34. Treatable Causes of Catatonia Neuroleptic malignant syndrome Encephalitis Nonconvulsive status epilepticus Acute psychosis Brasic JR. Catatonia www.emedicine.com

  35. Behaviors Suggesting Catatonia Only When Examiner is Present Inconsistent with catatonia Somatoform disorders Factitious disorders Malingering Psychogenic movement disorders Brasic JR. Catatonia www.emedicine.com

  36. Somatoform disorders Conversion disorder Somatization 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 disorder Somatization 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

  38. Somatoform disorders Conversion disorder Psychogenic movement disorders Somatization disorder

  39. Sincere Reports of Individual Perceptions of Experiences Catatonia Somatoform disorders Neurological disorders Schizophrenia 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 disorders Munchausen syndrome Munchausen syndrome by proxy 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

  41. Fabricated Reports of False Experiences Factitious disorders Munchausen syndrome Munchausen syndrome by proxy 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

  42. Fabricated Reports of False Experiences Munchausen syndrome by proxy Factitious disorders Munchausen syndrome Munchausen syndrome by proxy Malingering

  43. Internal Motivation for the Sick Role ●Present in factitious disorder ● Absent in catatonia ● Absent inmalingering 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

  44. 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

  46. Gegenhalten ● “To hold against” in German ● Increasing resistance to passive movement of the limbs ● Apparently deliberate opposition to the examiner’s movements Brasic JR. Catatonia www.emedicine.com

  47. 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

  48. 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

  49. Excited State of Catatonia ● May injure self ● May assault others ● May experience autonomic instability (hyperthermia, tachycardia, and hypertension) ● May collapse from exhaustion Brasic JR. Catatonia www.emedicine.com

  50. 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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