Why Do Neurologists Miss Catatonia in Neurology Emergency? a Case

Home , Akinetic mutism, Catalepsy, Catatonia, Karl Ludwig Kahlbaum

Clinical Neurology and Neurosurgery 184 (2019) 105375

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Clinical Neurology and Neurosurgery

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Why do neurologists miss catatonia in neurology emergency? A case series T and brief literature review ⁎ Sucharita Ananda, Vimal Kumar Paliwala, , Laxmi S Singha, Ravi Uniyalb a Department of Neurology, SGPGIMS, Raebareli road, Lucknow, UP, India b Department of Neurology, King George Medical University, Lucknow, UP, India

ARTICLE INFO ABSTRACT

Keywords: Catatonia is a well-described clinical syndrome characterized by features that range from mutism, negativism Catatonia and stupor to agitation, mannerisms and stereotype. Causes of catatonia may range from organic brain disorders Extrapyramidal disorder to psychiatric conditions. Despite a characteristic syndrome, catatonia is grossly under diagnosed. The reason for Parkinsonism missed diagnosis of catatonia in neurology setting is not clear. Poor awareness is an unlikely cause because Major depression catatonia is taught among conditions with deregulated consciousness like vegetative state, locked-in state and Schizophrenia akinetic mutism. We determined the proportion of catatonia patients correctly identified by neurology residents in neurology emergency. We also looked at the alternate diagnosis they received to identify catatonia mimics. Twelve patients (age 22–55 years, 7 females) of catatonia were discharged from a single unit of neurology department from 2007 to 2017. In the emergency department, neurology residents diagnosed none of the patients as catatonia. They offered diagnosis of extrapyramidal syndrome in 7, meningitis in 2, and conversion reaction, acute psychosis/encephalopathy and non-convulsive status epilepticus in one each. Their final diagnosis at discharge was catatonia due to general medical condition in 6 (progressive supranuclear palsy in 2, post- status epilepticus, uremic encephalopathy, glioblastoma multiforme and tuberculous meningitis in one each), catatonia due to major depression in 4, schizophrenia and idiopathic catatonia in one each. Extrapyramidal syndrome appeared as common mimic of catatonia. The literature reviewed also revealed the majority of organic catatonia secondary to causes that are usually associated with extrapyramidal features. Therefore, we suggest that neurologists should consider catatonia in patients presenting with extrapyramidal syndromes.

1. Introduction not specified” [1,6]. The causes of catatonia are a myriad ranging from pure psychiatric illnesses to neurological diseases like encephalitis and Catatonia is a mysterious disorder that is characterized by at least neurodegenerative conditions. Despite a characteristic clinical entity, three of the following - negativism (not following or resisting com- catatonia is under recognized in neurology clinics. This can be attrib- mands), bizarre posturing, catalepsy (maintaining the induced anti- uted to frequently changing diagnostic criteria of catatonia, low sensi- gravity postures), mutism, waxy flexibility (resisting passive move- tivity of diagnostic criteria, other neurological conditions sharing ment), grimacing, echolalia, echopraxia, stupor, mannerisms, agitation clinical features with catatonia and poor awareness of this condition and stereotype. Catatonia was first described and proposed as a sepa- [7]. rate disorder by Karl Ludwig Kahlbaum in 1874 [1]. Emil Kraepelin and We performed this retrospective study to understand the reason for later Eugen Bleuler associated catatonia with schizophrenia in the early delayed/missed diagnosis of catatonia in neurology settings. We aimed 1900s [2,3]. Catatonia was a pure psychiatric condition till late 1900s. to determine the proportion of patients that were correctly diagnosed as However later, catatonia was also seen in patients suffering from af- catatonia by neurology residents. We also aimed to compare the initial fective disorders and general medical conditions [3–5]. Therefore, re- diagnosis offered to these patients in the neurology emergency by cent Diagnostic and Statistical Manual of Mental Disorders 5th edition neurology duty residents to the final diagnosis they received at the time (DSM V) criteria classify catatonia as “catatonia secondary to general of discharge from hospital in order to identify the important clinical medical condition”, “catatonia as a specifier for schizophrenia”, “cata- mimics of catatonia. We also reviewed the literature on patients with tonia as a specifier for affective disorders” and “catatonia with cause catatonia secondary to neurological and medical conditions.

⁎ Corresponding author. E-mail address: [email protected] (V. Kumar Paliwal). https://doi.org/10.1016/j.clineuro.2019.105375 Received 2 August 2018; Received in revised form 9 May 2019; Accepted 21 May 2019 Available online 22 May 2019 0303-8467/ © 2019 Elsevier B.V. All rights reserved. S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375

2. Methods

We collected the details of the catatonia patients that were discharged from a single unit of the department of Neurology from 2007 to 2017. The case files of the patients were evaluated for their presenting clinical features, examination findings, initial diagnosis made by the neurology residents, investigations, catatonia days, hospitalization days and the final diagnosis at the time of discharge. Based on the presenting clinical features, all patients were subjected to the DSM V criteria for catatonia. Patients fulfilling the DSM V criteria for diagnosis ofcata- tonia were included in the study. The patients were also subjected to the DSM IV criteria and Bush Francis Catatonia Rating Scale (BFCRS) [6,8,9]. Catatonia was classified as: Etiology Major depressive disorder recurrent Catatonia due to GMC Major depressive disorder recurrent Catatonia due to schizophrenia Catatonia due to GMC (PSP) Catatonia due to GMC (PSP) Major depressive disorder recurrent Catatonia related to GMC (bi-fronatalepilepsy, gliosis, SE) Catatonia due to GMC (Glioblastoma multiforme frontal lobe) Catatonia due to GMC (TBMparadoxical with reaction) tuberculoma? Major depressive disorder recurrent Operated case of Schwannoma Catatoniaotherwise not specified

1 Malignant catatonia - characterized by presence of hyperthermia, fever and features of neuroleptic malignant syndrome 2 Periodic type which can be either hyperkinetic or hypokinetic [10].

3. Results Precipitating cause Prokinetics (domperidone) Acute renal failure,? prokinetics “Bhang” (cannabis) addiction Twelve patients fulfilled the DSM V criteria for the diagnosis of – Septicemia – Status epilepticus Antipsychotic drugs None catatonia. All twelve patients also fulfilled DSM IV criteria and BFCRS. Seven patients were females. Age of the patients ranged from 22 to 55 years. Duration of catatonic symptoms was less than 5 days in 4 patients and 5 to 15 days in 7 patients and 1 month in 1 patient. The clinical details of the patients are given in Table 1. The frequencies of different clinical features of catatonia inde- creasing order were waxy flexibility, mutism, negativism, catalepsy, stereotypies, agitation and echolalia. None of our patient had stupor, mannerisms, posturing, grimacing and echo-praxia. Initial diagnosis that was offered to patients after their first clinical examination in the emergency department was extrapyramidal syndrome (seven patients). Two patients were diagnosed with meningitis, and one each was diagnosed as acute psychosis/encephalopathy, conversion reaction and non-convulsive status epilepticus. The neurology residents diagnosed none of the patient with catatonia or with any brain metastasis of tumor/Metastasis primary psychiatric condition. The final diagnosis at the time of discharge were catatonia due to general medical condition (GMC) in six patients, catatonia due to major depressive disorder recurrent in four Duration Initial Diagnosis 1 month Drug induced extrapyramidal5 disorder days Acute7 psychosis/encephalopathy days Drug7 induced days extrapyramidal disorder Conversion reaction patients, catatonia due to schizophrenia in one patient and catatonia 15 days PSP, Operated carcinoma breast with suspicion7 of days3 days Extrapyramidal syndrome, hypertension Non-convulsive15 SE days Chronic meningitis?Chronic2 subdural days hematoma TBM2 relapse,? days paradoxical reaction,? VP None 5 shunt days failure Drug induced None extrapyramidal syndrome Drug induced extrapyramidal syndrome? Recurrence not otherwise specified in one patient. Seven patients who were offered a diagnosis of extrapyramidal syndrome in the neurology emergency by duty residents actually suf- fered from catatonia secondary to major depressive disorder recurrent (four patients), progressive supra-nuclear palsy (PSP) (two patients) and catatonia not otherwise specified (one patient). Six patients with the final diagnosis of “catatonia due to general medical condition” had PSP in two patients, acute renal failure, epilepsy with bi-frontal gliosis, glioblastoma multiforme (GBM) and tuberculous meningitis (TBM) in one patient each. None of our patient had malignant catatonia. Two patients had hyperkinetic episodic catatonia whereas ten patients had hypokinetic episodic catatonia. Prokinetic drugs precipitated catatonia in two patients. Cannabis intake, status epilepticus and septicemia were the probable precipitating causes of catatonia in one patient each. (Table 1) Ten patients received lorazepam and two patients received dia- zepam for the control of catatonia symptoms. Four patients received additional dopaminergic treatment (amantadine and levodopa in two each), four patients received anti-depressants for major depression and rigidity gaze palsies on fever, trivial head trauma 2 months back hydrocephalus with VP shunt (6 months) two patients received anti-psychotic drugs. Six patients showed complete recovery from catatonia whereas six patients showed partial recovery with residual features in the form of waxy flexibility in all six patients, additional negativism in two and mutism in one. Three of these patients with partial recovery had PSP, and one each had GBM, S.No Age/sex Clinical Features 12 22Y/F Mask-like face,3 40Y/M negativism, mutism, stereotypies, waxy-flexibility, Excessive talkativeness, echolalia,4 26Y/M stereotypies, catalepsy Mutism, waxy-flexibility, catalepsy, 29Y/F rigidity Mutism, negativism, catalepsy, waxy-flexibility 56 50Y/F7 Mutism, catalepsy, waxy-flexibility,8 51Y/M mask like face, reduced 50Y/F blink rate, Negativism, mutism, waxy-flexibility,9 26Y/F with fever, dyspnea, Mutism, Negativism,chest Catalepsy, waxy-flexibility Agitation, waxy10 55Y/F flexibility, rales stereotypies, mood fluctuations Mutism, 32 Negativism, Y/F waxy-flexibility,11 4 days recent onsetPSP, DM, sepsis of headache,12 off and Fever, mutism, 30Y/F cataplexy, waxy-flexibility, negativism 45/MFTC of TBM Fever, mutism, cataplexy, negativism, waxy Mutism, flexibility withdrawal, waxy flexibility, cataplexy

TBM and epilepsy with acute renal failure. Table 1 Initial diagnosis, presenting clinical features and etiology of catatonia. GMC – General medical condition, PSP – Progressive supranuclear palsy, SE – Status epilepticus, FTC – Follow through case, TBM – Tuberculous meningitis, VP shunt – Ventriculo-peritoneal shunt.

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4. Discussion medical comorbidity (Table 2)[11–32]. Common causes of catatonia among the patients suffering from medical conditions were en- In this retrospective study, we tried to assess the yield of catatonia cephalitis, encephalopathy, drug induced, Tourette syndrome, epilepsy as a diagnosis in the neurology emergency. We could also identify the and stroke. Smith et al found 75 of 92 patients suffering from medical important mimic of catatonia. Though none of the patients were diag- condition and having catatonia due to an underlying psychiatric con- nosed as catatonia, seven patients were diagnosed as extrapyramidal dition [14]. Similarly, 120 of 560 catatonia patients suffering from a syndrome, which appears to be a close mimic of catatonia. Rest of the primary psychiatric condition (15 studies, Table 2) had catatonia sec- five patients received a nearly correct etiological diagnosis. ondary to a general medical condition. Most common causes of organic Nevertheless, it is important to identify catatonia despite correctly catatonia in psychiatric patients were drug induced, encephalitis and identifying its cause because catatonia is potentially reversible in the neurodegenerative disorders. The review of these studies shows that majority by the use of long-acting benzodiazepines. By this study, we catatonia is reported from medical departments as often as from psy- tried to answer some questions. Is catatonia really under diagnosed? Is chiatry departments. Therefore, we suggest that medical and neurology it a rare disease? Does it require training in the psychiatry departments fraternity needs to learn to identify catatonia not only because it can be to correctly diagnose catatonia? Which departments generally see these organic catatonia, but also due to the fact that an organic cause may patients? Why catatonia was misdiagnosed as extrapyramidal disorder? underlie catatonia in patients suffering from psychiatry condition. Catatonia is under diagnosed especially in the general medicine and In this study, the first impression of the neurology residents of these neurology settings. In a Dutch study that included 139 acutely psy- patients was a valuable input to understand how physicians may per- chotic patients, treating physicians could diagnose catatonia in only 2% ceive the clinical features of catatonia. Catatonia was mostly confused patients as compared to 18% patients that were diagnosed by the re- with the extrapyramidal disorder. However, if we look at the traditional search group. [7] teachings in the neurology clinics, the differential diagnoses of cata- Catatonia is not a rare syndrome. In a meta analysis of all the pre- tonia are vegetative state, locked-in state and akinetic-mute state. These valence studies on patients with catatonia published from 1935 to conditions share the pathophysiology of “deregulated consciousness” 2017, the mean prevalence of catatonia among medical and psychiatry with catatonia. However, these conditions do not share many clinical patients was 9.0%. We found only twelve patients that were diagnosed features with catatonia except for mutism, negativism and on rare oc- as catatonia in one treating neurology unit in last one decade. This casions cataplexy. Mutism and negativism in these conditions are due to suggests that catatonia is often missed in patients presenting to the paresis of voluntary muscles and cataplexy is secondary to profound emergency departments. rigidity or spasticity depending upon the underlying etiology. Unlike We believe that diagnosis of catatonia does not require training in catatonia, all these conditions occur after a clinical event that produces the psychiatry settings but requires a high index of suspicion. The a significant and usually an irreversible brain injury. above-mentioned Dutch study was performed in a psychiatry setting On the other hand, extrapyramidal syndromes may have several but still, the yield of the diagnosis was low. similarities with catatonia (Table 3). Extrapyramidal syndromes may Which medical departments see these patients? To answer this occur secondary to idiopathic Parkinson’s disease, Parkinson plus syn- question, we reviewed all the studies that included patients with cata- dromes, drug/toxin induced parkinsonism and advanced stage of de- tonia suffering from any general medical conditions or primary psy- mentias. Two of our patients had advanced stage of PSP. Majority of the chiatric illness with medical/neurological co-morbidities. We included causes of organic catatonia in the studies that were reviewed in Table 2 only those studies that clearly presented the break-up of the underlying had conditions that presents with significant extrapyramidal features etiology of catatonia. By using the key words – catatonia, waxy-flex- like post-encephalitis sequelae, neurodegenerative disorders, late stage ibility, catalepsy, mutism, negativism in Pubmed Central and Google of dementia and drug-induced extrapyramidal syndrome. Some experts scholar, we found 7 studies on catatonia due to medical conditions and suggest that the presence of drug induced extrapyramidal syndrome is a 15 studies on catatonia due to primary psychiatric disease with a risk factor for the development of catatonia [9,33]. Movement disorder

Table 2 Classification of catatonia in studies with medical patients and psychiatric patients with comorbid medical and neurological conditions.

Variables Studies with medical/Neurological patients Psychiatric patients with medical comorbidity

Granata Kakooza Jaimes Smith Cavanna Carroll Barnes No. of studies=15 et al. [11] et al. [12] Albornoz et al. et al. [15] et al. [16] et al. [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32] [13] [14] [17] N=16 N=8 N=10 N=95 N=48 N =261 N =25 N =560

Catatonia due to GMC 10 20 261 5 120 1.Neurodegenerative 2 4 8 – 16 2. Encephalopathy – 3 25 – 4 3. Tumors – 1 13 – 1 4. Encephalitis 16* – 6 40 3 29 5. Epilepsy – 3 25 – 8 6.Developmental – 3 – – 9 7.Stroke 1 – 31 – 5 8.Drug induced 1 45 42 9. Others 8** 6 – 48*** 74 2 6 Catatonia due to affective – 64 – 9 194 disorder Catatonia due to – 11 – 1 246 schizophrenia Catatonia not otherwise – – – 10 specified

* NMDAR encephalitis. ** Nodding head syndrome. *** Tourette syndrome.

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Table 3 Similarities and differences between catatonia and extrapyramidal disorders.

Feature Extrapyramidal disorder Catatonia

Bradykinesia Present Present Rigidity Present Present Tremors Present Absent Staring looks Present Absent Hypomimia Present Present Gait abnormality Short-shuffling gait Refusal to walk Psycho-motor withdrawal Present Present Mutism Advanced stage of Parkinson plus syndromes and dementia Present Negativism Absent Present Gagenhalten (waxy-flexibility) Present Present Catalepsy Absent Present Agitation Present Present Posturing & mannerisms Rare (in advanced dementia and Parkinson disease due to drug related motor complications) Present Echolalia, echopraxia & stupor Present in advanced dementia and parkinsonism Present Response to levodopa, amantadine Present Present Response to lorazepam Absent Prompt response in majority

associated with catatonia can be hypokinetic or hyperkinetic type [34]. Disorders: DSM-V, American Psychiatric Association, Washington DC, 2013. The hypokinetic type movements are mutism, rigidity, waxy- flexibility [7] F.M. van der Heijden, S. Tuinier, N.J. Arts, et al., Catatonia: disappeared or under- diagnosed? Psychopathology 38 (2005) 3–8. and cataplexy. This was the most common type of catatonia in our [8] American Psychiatric Association, Diagnostic and Statistical Manual of Mental patients. The hyperkinetic type consists of features like hyperthermia, Disorders, 4th edition, DSM-IV). American Psychiatric Association, Washington, extreme rigidity and is a fatal condition if not treated appropriately. DC, 1994. [9] G. Bush, M. Fink, G. Petrides, et al., Catatonia. I. Rating scale and standardized Four of our patients had history of intake of offending drugs prior to the examination, Acta Psychiatr. Scand. 93 (1996) 129–136. onset of catatonia. Catatonia also improves with levodopa and aman- [10] M.A. Taylor, M. Fink, Catatonia in psychiatric classification: a home of its own, Am. tadine that may further anchor the belief of a neurologist on the di- J. Psychiatry 160 (2003) 1233–1241. agnosis of Parkinsonism in their patients. Therefore, we suggest that [11] T. Granata, S. Matricardi, F. Ragona, E. Freri, F. Zibordi, F. Andreetta, et al., Pediatric NMDAR encephalitis: a single center observation study with a closer look patients presenting with extrapyramidal syndrome should also be at movement disorders, Eur. J. Paediatr. Neurol. 22 (2018) 301–307. evaluated for catatonia. [12] A. Kakooza-Mwesige, D.M. Dhossche, R. Idro, D. Akena, J. Nalugya, B.T. Opar, Our study had several limitations. It was a retrospective study. Our Catatonia in Ugandan children with nodding syndrome and effects of treatment with lorazepam: a pilot study, BMC Res. Notes 8 (2015) 825. study had small number of patients which might be due to either missed [13] W. Jaimes-Albornoz, J. Serra-Mestres, Prevalence and clinical correlations of cat- diagnosis or missed patients on the retrospective chart review due to atonia in older adults referred to a liaison psychiatry service in a general hospital, lack of the term “catatonia” on the discharge tickets. We described the Gen. Hosp. Psychiatry 35 (2013) 512–516. [14] J.H. Smith, V.D. Smith, K.L. Philbrick, N. Kumar, Catatonic disorder due to a outcome of our patients at the time of discharge from the hospital. general medical or psychiatric condition, Neuropsychiatry Clin Neurosci 24 (2012) Many more patients of catatonia are expected to show complete re- 198–207. covery over a longer follow up. A prospective study can be more ap- [15] A.E. Cavanna, M.M. Robertson, H.D. Critchley, Catatonic signs in Gilles de la Tourette syndrome, Cogn. Behav. Neurol. 21 (2008) 34–37. propriate to discuss the outcome of catatonia. [16] B.T. Carroll, T.J. Anfinson, J.C. Kennedy, et al., Catatonic disorder due to general medical conditions, J. Neuropsychiatry Clin. Neurosci. 6 (1994) 122–133. 5. Conclusion [17] M.P. Barnes, M. Saunders, T.J. Walls, I. Saunders, C.A. Kirk, The syndrome of Karl ludwig kahlbaum, J Neurol Neurosurg Psychiatry 49 (1986) 991–996. [18] G. Northoff, J. Wenke, L. Demisch, J. Eckert, B. Gille, B. Pflug, Catatonia: short-term Catatonia is a common clinical syndrome that presents both in the response to lorazepam and dopaminergic metabolism, Psychopharmacology (Berl.) psychiatry and neurology/medicine departments. Catatonia is under 122 (1995) 182–186. diagnosed in the neurology/medicine departments. Catatonia patients [19] J.W. Lee, Serum iron in catatonia and neuroleptic malignant syndrome, Biol. Psychiatry 44 (1998) 499–507. show many clinical features that may easily be confused with extra- [20] L. Lykouras, P. Oulis, E. Daskalopoulou, K. Psarros, G.N. Christodoulou, Clinical pyramidal disorders. Some neurodegenerative disorders like dementias subtypes of schizophrenic disorders: a cluster analytic study, Psychopathology. 34 and Parkinson-plus syndromes may present with catatonia. A subset of (2001) 23–28. [21] J.W.Y. Lee, Neuroleptic-induced catatonia, J. Clin. Psychopharmacol. 30 (2010) psychiatry patients with catatonia may also have an underlying organic 3–10. cause of catatonia. Due to improvement in catatonia with dopaminergic [22] M. Raffin, L. Zugaj-Bensaou, N. Bodeau, et al., Treatment use in a prospective drugs, neurologists may further tend to diagnose patients with catatonia naturalistic cohort of children and adolescents with catatonia, Eur. Child Adolesc. Psychiatry 24 (2015) 441–449. as Parkinsonism. Therefore, a high index of suspicion especially for [23] D. Cohen, J.D. Nicolas, M.F. Flament, et al., Clinical relevance of chronic catatonic patients presenting with extrapyramidal disorder is required to diag- schizophrenia in children and adolescents: evidence from a prospective naturalistic nose catatonia. study, Schizophr. Res. 76 (2005) 301–308. [24] J.H. Tuerlings, J.A. van Waarde, B. Verwey, A retrospective study of 34 catatonic patients: analysis of clinical care and treatment, Gen. Hosp. Psychiatry 32 (2010) References 631–635. [25] X. Benarous, A. Consoli, M. Raffin, et al., Validation of the pediatric catatonia rating scale (PCRS), Schizophr. Res. 176 (2016) 378–386. [1] K.L. Kahlbaum, Catatonia. Translated by Levi Y, Pridon T, Johns Hopkins University [26] S. Grover, A. Ghosh, D. Ghormode, Do patients of delirium have catatonic features? Press, 1973. An exploratory study, Psychiatry Clin. Neurosci. 68 (2014) 644–651. [2] B. Pfuhlmann, G. Stober, The different conceptions of catatonia: historical overview [27] A. Dutt, S. Grover, S. Chakrabarti, A. Avasthi, S. Kumar, Phenomenology and and critical discussion, Eur. Arch. Psychiatry Clin. Neurosci. 251 (2001) 14–17. treatment of Catatonia: a descriptive study from north India, Indian J. Psychiatry 53 [3] M. Fink, E. Shorter, M.A. Taylor, Catatonia is not schizophrenia: kraepelin’s error (2011) 36–40. and the need to recognize catatonia as an independent syndrome in medical no- [28] Al Sayegh, D. Reid, Psychiatrist 34 (2010) 479–484. menclature, Schizophr. Bull. 36 (2010) 314–320. [29] O. Cottencin, F. Warembourg, M.B. de Chouly de Lenclave, et al., Catatonia and [4] J. Daniels, Catatonia: clinical aspects and neurobiological correlates, J. consultation-liaison psychiatry study of 12 cases, Prog. Neuropsychopharmacol. Neuropsychiatry Clin. Neurosci. 21 (2009) 371–380. Biol. Psychiatry 31 (2007) 1170–1176. [5] A. Francis, M. Fink, F. Appiani, et al., Catatonia in diagnostic and statistical manual [30] T. Ishida, H. Sakurai, K. Watanabe, S. Iwashita, M. Mimura, H. Uchida, Incidence of of mental disorders, fifth edition, J. ECT 26 (2010) 246–247. deep vein thrombosis in catatonic patients: a chart review, Psychiatry Res. 241 [6] American Psychiatric Association, Diagnostic and Statistical Manual of Mental (2016) 61–65.

4 S. Anand, et al. Clinical Neurology and Neurosurgery 184 (2019) 105375

[31] M. Espinola-Nadurille, J. Ramirez-Bermudez, G.L. Fricchione, M.C. Ojeda-Lopez, service, Australas. Psychiatry 24 (2016) 164–167. A.F. Perez-González, L.C. Aguilar-Venegas, Catatonia in neurologic and psychiatric [33] S.A. Rasmussen, M.F. Mazurek, P.I. Rosebush, Catatonia: Our current understanding patients at a tertiary neurological center, J. Neuropsychiatry Clin. Neurosci. 28 of its diagnosis, treatment and pathophysiology, World J. Psychiatry 6 (2016) (2016) 124–130. 391–398. [32] J. Kaelle, A. Abujam, H. Ediriweera, M.D. Macfarlane, Prevalence and symptoma- [34] S. Wijemanne, J. Jankovic, Movement disorders in catatonia, J. Neurol. Neurosurg. tology of catatonia in elderly patients referred to a consultation-liaison psychiatry Psychiatry. 86 (2015) 825–832.