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Hazy definition may hamper catatonia care

Feb. 12, 2015, 9:22 AM

Catatonia, a syndrome characterized by muscular rigidity and a trance-like mental stupor, can at times manifest with great excitement and confusion. And while it is often associated with schizophrenia, it can present in patients with either medical or psychiatric conditions. For this reason, the condition has often confused clinicians.

The more restrictive definition of catatonia in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the standard classification of mental disorders in the United States, is possibly resulting in a lower detection of catatonia, especially in patients with no known psychiatric history.

A Vanderbilt University Medical Center study, published online in Schizophrenia Research, is calling for a better understanding of the structure of catatonia and improved screening tools for diagnosing the condition.

Jo Ellen Wilson, M.D.

“We need to better understand what we’re talking about when we talk about catatonia,” said Jo Ellen Wilson, M.D., instructor in Psychiatry and VA Quality Scholar and co-author of the study. “Do we understand what it comprises? Are we defining catatonia correctly?” Wilson said.

“Our answer, to both of those questions, is likely ‘no.’ The current DSM definition of catatonia might be too narrow. We need to devise new screening instruments to help us describe catatonia in various clinical settings. We want clinicians to be aware when they have a patient with altered mental status and its presentation is just not adding up, that catatonia should be a consideration. It’s also important to study these patients because both the short- and long-term outcomes of catatonia are not understood.”

Patients with catatonia are normally given benzodiazepine medications (like name brands Ativan, Valium and Xanax) and are often treated with electroconvulsive therapy (ECT) as well.

“The treatments we have for catatonia are extremely effective nearly 100 percent of the time, and for some patients can be life saving. That’s why it’s so important to diagnose it accurately and begin treatment promptly.”

The study is co-authored by Kathy Niu, M.D., a former Vanderbilt medical student, and supervised by Stephan Heckers, M.D., William B. and Henry P. Test Professor of Schizophrenia and chair of the Department of Psychiatry. The authors retrospectively screened the medical records of 339 acutely ill medical and psychiatric patients, the largest cohort of catatonic patients that has been studied, with the Bush Francis Catatonia Rating Scale (BFCRS). The prevalence and severity of catatonia signs were examined and diagnoses were compared using the BFCRS, DSM-4 and DSM-5.

“This study confirmed that DSM-5 criteria are more restrictive than previous criteria sets, potentially excluding patients with catatonia from meeting diagnostic criteria,” she said.

Additionally, this study, through the use of various statistical methods, confirmed that greater than half of the variance of the syndrome is not accounted for by the gold standard assessment tool.

“It’s a very diverse syndrome, and that’s what makes it so difficult to define and to diagnose,” Wilson said. “In its classical presentation, people stare or are trance-like. There’s a hyperactive form where patients have bizarre extra movements and mannerisms. They pace; they can be agitated. Catatonia can be brief, or it can go on for days or much longer than that. Some rare forms can be chronic or recurrent. Additionally, there are more severe forms that can lead to significant vital sign abnormalities and need for life support measures.”

Wilson is currently working with other VUMC faculty members from the ICU Delirium and Cognitive Impairment Study Group, including her mentor Wes Ely, M.D., MPH, Robert Dittus, M.D., MPH, Heckers, Pratik Pandharipande, M.D., MSCI, and Tim Girard, M.D., MSCI, studying the “the surprising number” of patients in both the Medical and Surgical Intensive Care Units who have no psychiatric history, but display catatonic features.

“We think it’s extraordinarily common in the medical setting,” she said, adding that it can often co-exist with delirium.

Wilson became interested in studying catatonia as a fourth-year medical student at Vanderbilt University School of Medicine when she helped diagnose catatonia in a young patient on life support in Vanderbilt’s Pediatric Intensive Care Unit. She authored a case report on that patient that appeared in the November/December 2013 issue of Psychosomatics journal.

Other authors of the Schizophrenia Research study include Vanderbilt’s Stephen Nicolson, M.D., and statistician Stephen Levine, Ph.D., of the Department of Community Mental Health, at the University of Haifa, Israel.

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