Catatonia.tutorial

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Catatonia.tutorial

  1. 1. Catatonia in psychiatric classification <ul><li>Michael Alan Taylor & Max Fink </li></ul><ul><ul><li>American journal psychiatry 2003 </li></ul></ul><ul><ul><ul><li>160:1233-1241 / July 2003 </li></ul></ul></ul><ul><li>Review Article </li></ul><ul><li>Finch university of health sciences, North Chicago </li></ul><ul><li>University of Michigan / university of N.Y & Einstein’s college of medicine, Bronx </li></ul>
  2. 2. Objectives <ul><li>Assess the present position in diagnostic classification </li></ul><ul><li>Merits of considering catatonia as separate category with defined criteria </li></ul>
  3. 3. History <ul><li>1874 – KAHLBAUM (die catatonie oder das spannungirresein) </li></ul><ul><li>1919 – Emil kraeplin( dementia praecox & paraphrenia) </li></ul><ul><li>E.Bleuler {Dementia &group of schizophrenias} </li></ul><ul><li>20 th century: codified in ICD & DSM </li></ul>
  4. 4. Controversies <ul><li>Catatonia is a syndrome </li></ul><ul><li>Association between mania and catatonia (20%) </li></ul><ul><li>Association between medical conditions and neurological disorders are high </li></ul><ul><li>should not be linked to schizophrenia (Fink) </li></ul><ul><ul><li>Changes in DSM 4 </li></ul></ul><ul><ul><ul><li>SPECIFIER IN MOOD DISORDER </li></ul></ul></ul><ul><ul><ul><li>Syndrome because of general medical condition </li></ul></ul></ul>
  5. 5. HOW TO CLASSIFY? <ul><li>WERNICKE / KLEIST / LEONHARD(GERMAN SCHOOLS); ‘ DIVIDING’ </li></ul><ul><li>Symptom clusters </li></ul><ul><li>Periodicity </li></ul><ul><li>Specific family patterns </li></ul><ul><li>AMERICAN SCHOOLS; ‘MERGING’ </li></ul><ul><li>NLMS / TOXIC SEROTONIN SYNDROME </li></ul>
  6. 6. QUESTIONING THE BASIC ASSUMPTIONS <ul><li>Is this a distinct syndrome? </li></ul><ul><ul><li>Literature review: INDEX ( Index medicus/ psycINFO / MEDLINE) LIBRARY:NLM/N.Y ACADEMY OF MEDICINE / BRITISH LBRARY </li></ul></ul><ul><li>ROBINS AND GUZE METHOD: </li></ul><ul><ul><li>Establish validity </li></ul></ul><ul><ul><li>Reliability of identification </li></ul></ul><ul><ul><li>Distinguishing from other conditions </li></ul></ul><ul><ul><li>Identifying a course and treatment responsiveness </li></ul></ul><ul><li>GUIDELINES OF BLASHFIELD </li></ul><ul><ul><li>INCLUSION AND EXCLUSION CRITERIA </li></ul></ul>
  7. 7. FINDINGS <ul><li>Catatonia is common </li></ul><ul><li>Can be identified as syndrome </li></ul><ul><li>Known to have other names :malignant catatonia(NLMS/TSS/DELIRIOUS MANIA / BENIGN STUPOR) </li></ul><ul><li>Good response to specific treatment </li></ul><ul><li>Common causes </li></ul><ul><ul><li>Mood disorder </li></ul></ul><ul><ul><li>Medical and neurological conditions </li></ul></ul><ul><ul><li>Non affective psychosis(10-15%) </li></ul></ul><ul><ul><li>Genetic form of catatonia (major gene effect) </li></ul></ul>
  8. 8. How common? <ul><li>7.6% to 38% </li></ul><ul><li>1/3 of non federal hospitals discharge diagnosis, 1996 – 1997(10%overall prevalence, 20% in mood disorders) </li></ul><ul><li>29,875 out of 160,135 </li></ul><ul><li>Thrice that of national suicide rate </li></ul><ul><li>6% adolescent psychiatric patients had catatonia </li></ul><ul><li>Easy to recognize: immobility and stupor </li></ul><ul><li>Classic features are not assessed. gegenhalten,ambitendency,autom.obedience) </li></ul>
  9. 9. Problems of diagnosing <ul><li>Mutism, posturing, negativism,staring, rigidity and echophenomena: common signs occuring in two forms : retarded or excited </li></ul><ul><li>40 or more phenomena as signs(original work 17) </li></ul><ul><li>2 prominent sufficient for DSM </li></ul><ul><li>No duration criteria, arbitrary 24 hours </li></ul><ul><li>Dubious signs: whispered speech, tiptoe walking, hopping, rituals and robotic speech </li></ul>
  10. 10. Is this a syndrome? <ul><li>3 recently published studies : ‘can be reliably assessed whether they are the continuous signs of catalepsy and posturing or intermittent features of ambi tendency and echo phenomena’ </li></ul><ul><li>Inter-rater reliability : well above 0.9 </li></ul><ul><li>Previous studies: factor analytic and cluster analytic studies – identified 2 patterns </li></ul><ul><ul><li>1.catalepsy ,posturing, mutism and negativism (mania & schizophrenia) </li></ul></ul><ul><ul><li>2. Echophenomena, automatic obedience, verbigeration and stereotypies (mania alone) </li></ul></ul>
  11. 11. How to delineate from others? <ul><li>Elective Mutism - stressors, previous personality disorder & no catatonia features </li></ul><ul><li>Mutism with stroke: locked in syndrome, patient uses vertical eye movements to communicate </li></ul><ul><li>Stiff person syndrome: painful spasms precipitated by noise or emotional stimuli </li></ul><ul><li>Malignant hyperthermia: inhalation of muscle relaxants, can be confirmed by biopsy </li></ul><ul><li>Akinetic parkinsonism: burnt out phase of Parkinson's, improve with anticholinergics </li></ul><ul><li>Non-convulsive status epilepticus – EEG may be of help </li></ul><ul><li>Metabolic- background slowing of EEG </li></ul><ul><li>Difficult to validate catatonic excitement , similar in description to manic excitement </li></ul>
  12. 12. Good response to treatment??? <ul><li>No meta analytic studies are done in this area </li></ul><ul><li>Only naturalistic studies available in the treatment areas </li></ul><ul><li>1930 – Amobarbital </li></ul><ul><li>Currently: </li></ul><ul><ul><li>Anticonvulsants like, benzodiazepines & Barbiturates </li></ul></ul><ul><ul><li>ECT </li></ul></ul><ul><ul><li>Excellent acute treatment prognosis </li></ul></ul><ul><li>exposure to typical and atypical antipsychotics worsens the course and outcome </li></ul>
  13. 13. Common causes: <ul><li>Mood : mania, the more severe the disease , the stronger the affinity </li></ul><ul><li>Medical: metabolic, infections like typhoid, HIV, heat stroke and endocrinopathies. </li></ul><ul><li>Drug intoxications and withdrawals </li></ul><ul><li>Neurological: post encephalitic sequelae, bilateral globus pallidal disease, srtokes and general paresis </li></ul><ul><li>10 – 15 % of schizophrenias </li></ul><ul><li>Genetic form:wurzberg findings </li></ul>
  14. 14. Unique category in classification <ul><li>Present criteria problematic </li></ul><ul><ul><li>No differential diagnosis in consideration </li></ul></ul><ul><li>OVERLAPPING PHENOMENA </li></ul><ul><ul><li>Stuporous patients are mute mostly </li></ul></ul><ul><ul><li>Stuporous and mute patients may not have catatonia… </li></ul></ul><ul><ul><li>Catalepsy often have posturing </li></ul></ul><ul><ul><li>No time duration specification </li></ul></ul><ul><ul><li>The danger of delirium accompanying the condition is less well stated </li></ul></ul><ul><ul><li>CATATONIA could be appropriately classified as movement disorders </li></ul></ul>
  15. 15. Proposed category <ul><li>DSM CODE- CATATONIA </li></ul><ul><ul><li>CATEGORY </li></ul></ul><ul><ul><ul><li>1.NON MALIGNANT CATATONIA </li></ul></ul></ul><ul><ul><ul><li>2.DELIRIOUS CATATONIA </li></ul></ul></ul><ul><ul><ul><li>3.MALIGNANT CATATONIA </li></ul></ul></ul><ul><ul><li>SPECIFIER </li></ul></ul><ul><ul><ul><li>SECONDARY TO MOOD DISORDER, </li></ul></ul></ul><ul><ul><ul><li>SECONDARY TO GMC/TOXIC STATE </li></ul></ul></ul><ul><ul><ul><li>SECONDARY TO NEUROLOGICAL CONDTIONS </li></ul></ul></ul><ul><ul><ul><li>SECONDARY TOPSYCHOTIC DISORDER </li></ul></ul></ul>
  16. 16. CONCLUSIONS <ul><li>CATATONIA MEETS ALL FIVE CRITERIA PROPOSED BY BLASHFIELD ET AL. </li></ul><ul><li>SCIENTIFIC LITERATURE OFFERS SUBSTATNTIVE SUPPORT </li></ul><ul><li>MERITS </li></ul><ul><ul><li>GREATER IDENTIFICATION, </li></ul></ul><ul><ul><li>FOCUSED TREATMENT </li></ul></ul><ul><ul><li>IDENTIFYING IN NEW NEUROBIOLOGIC SUBSTRATE </li></ul></ul><ul><ul><li>LET US WAIT AND WATCH </li></ul></ul>

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