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Catatonia in Depression: Prevalence, Clinical J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.60.3.326 on 1 March 1996

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Catatonia in Depression: Prevalence, Clinical J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.60.3.326 on 1 March 1996 32632ournal ofNeurology, Neurosurgery, and Psychiatry 1996;60:326-332 Catatonia in depression: prevalence, clinical J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.326 on 1 March 1996. Downloaded from correlates, and validation of a scale Sergio E Starkstein, Gustavo Petracca, Alejandra Teson, Eran Chemerinski, Marcelo Merello, Ricardo Migliorelli, Ramon Leiguarda Abstract mute and immobile, with staring expression, Objectives-To examine the clinical cor- gaze fixed into space, with an apparent com- relates of catatonia in depression, to vali- plete loss of will, no reaction to sensory stim- date a scale for catatonia, and to assess uli, sometimes with the symptom of waxy the validity of the DSM-IV criteria of the flexibility completely developed, as in catatonic features specifier for mood dis- catalepsy, sometimes of a mild degree, but orders. clearly recognisable," and labelled this state Methods-A series of 79 consecutive "vesania katatonica".2 Stressing that catatonia patients with depression and 41 patients was not related to "affective" melancholy with Parkinson's disease without depres- sensu strictu, Wernicke suggested the term sion were examined using the modified "motilitatpsychose", and suggested that this Rogers scale (MRS), the unified disorder may be the result of dysfunction of a Parkinson's disease rating scale "psychomotor path", producing either akine- (UPDRS), and the structured clinical sis, parakinesis, or hyperkinesis.3 Whereas interview for DSM-III-R (SCID). Kahlbaum and Wernicke placed catatonia Results-Sixteen of the 79 depressed within the range of the affective disorders, patients (20%) had catatonia. Depressed Kraepelin4 considered catatonia as a type of patients with catatonia had significantly schizophrenia, and this disorder aroused little higher scores on the MRS than non-cata- interest until recently. tonic depressed patients matched for In a series of studies, Taylor and Abrams' severity of depression, or non-depressed and Abrams and Taylor6 found catatonic signs patients with Parkinson's disease such as stereotypies, posturing, catalepsy, matched for severity of motor impair- automatic obedience, negativism, echolalia, ment. Depressed patients with catatonia echopraxia, or stupor in more than a quarter were older, had a significantly higher fre- of a consecutive series of patients with mania. quency of major depression, more severe In a study that included 55 consecutive psy- cognitive impairments, and more severe chiatric admissions of patients featuring one or deficits in activities of daily living than more catatonic signs, Abrams and Taylor depressed non-catatonic patients. The found that over two thirds had an affective dis- DSM-IV criteria of catatonia separated order.6 On the other hand, motor disorders http://jnnp.bmj.com/ depressed catatonic patients from have often been reported in depressed patients with Parkinson's disease patients. Rogers et al7 showed that patients matched for motor impairment, with a with primary depression and newly diagnosed specificity of 100%. Catatonic signs did patients with Parkinson's disease had a slower not improve after apomorphine. response on a computerised task than normal Conclusions-catatonia is most prevalent control subjects. A follow up evaluation six among elderly patients with severe months later showed that both in patients with depression. The study showed the validity Parkinson's disease and in depressed patients, on October 1, 2021 by guest. Protected copyright. Department of of the MRS for the diagnosis of catatonia improvement in mood was significantly associ- Neuropsychiatry as the ated with on the psychomotor E Starkstein in depressed patients, well as speci- improvement G Petracca ficity of the DSM-IV criteria of the cata- task. Fleminger8 also showed that patients A Tes6n tonic features specifier. with depressive motor retardation had raised E Chemerinski scores on a clinical rating scale of parkinsonian R Migliorelli R Carrea (3 Neurol Neurosurg Psychiatry 1996;60:326-332) signs, but he also found significant differences Department of Clinical between the movement disorder in depressed Neurology, Institute of patients and that in patients with Parkinson's Neurological Research, Keywords: catatonia; depression; dopamine; disease. Buenos Aires, Parkinson's disease Argentina Despite these important studies, several S E Starkstein issues regarding catatonia still remain M Merello In 1843 the French psychiatrist Baillarger unsolved. Firstly, there is only one structured R Leiguarda described a delusional syndrome in alienated scale for the assessment of catatonic signs (the Correspondence to: scale and this scale Dr Sergio E Starkstein, Raul patients occurring in a state of stupor, with modified Rogers (MRS))9 Carrea Institute of fixed gaze, a facial expression of frozen aston- has only been assessed with schizophrenic Neurological Research, whether the cri- Montaineses 2325,1428 ishment, muteness, and indifference.' As these patients. Secondly, DSM-IV"0 Buenos Aires, Argentina. patients also had suicidal ideation, Baillarger teria of catatonia (catatonic features specifier Received 18 April 1995 termed this state "melancholie avec stupeur". of mood disorder) can distinguish depressed and in revised form a with catatonia from 25 September 1995 Thirty nine years later, Kahlbaum described patients phenomenologi- Accepted 31 October 1995 state "in which the patient remains completely cally similar disorders (for example, severe Catatonia in depression: prevalence, clinical correlates, and validation ofa scale 327 Parkinson's disease) has not been examined. relatives, two first degree relatives were inter- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.326 on 1 March 1996. Downloaded from Thirdly, the clinical correlates of catatonia in viewed. Diagnoses of axis I disorders were depressed patients have hardly been consid- made based on the RDC-FH. ered, and the mechanism is still unknown. In this study we examined a consecutive Hamilton depression and anxiety scales series of 79 patients with depression for the (HAM-D, HAM-A) 16 17 presence of catatonia using a comprehensive The HAM-D and HAM-A are interviewer psychiatric and neurological evaluation that rated scales that measure symptoms of depres- included the MRS and the UPDRS." To sion and anxiety. determine the validity of the DSM-IV criteria of catatonia we also examined a consecutive Mini mental state examination (MMSE) 18 series of 41 non-depressed patients with The MMSE is an 11 item examination found Parkinson's disease. Finally, we assessed the to be valid and reliable in assessing global cog- response to apomorphine in a sample of cata- nitive deficits. tonic patients and patients with Parkinson's disease to examine the importance of Functional independence measure (FIM)'9 dopaminergic dysfunction in the mechanism The FIM assesses self care, sphincter control, of catatonia. mobility, locomotion, communication, and social cognition. Higher scores indicate less impairment in activities of daily living. Patients and methods PATIENTS Social ties checklist (STC)'0 Depression group This is a 10 item scale which assesses the This group included a consecutive series of 79 quantity and quality of social supports. Scores patients that were examined in the range from 0 to 10, and higher scores indicate Department of Neuropsychiatry at the Raul better social supports. Carrea Institute of Neurological Research because of depression. Our institute provides Diagnosis of catatonia psychiatric care to a large section of Buenos The diagnosis of catatonia (catatonic features Aires and is not a tertiary care centre. Patients specifier of the DSM-IV) was made by the with depression seen at our institute are repre- psychiatrist based on the PSE findings. The sentative of a normal psychiatric population PSE includes a section that rates the presence and are not more likely to have coexisting neu- of catatonic signs such as self neglect, bizarre rological disorders or other medical condi- appearance, slowness and underactivity, agita- tions. Patients included in this group had to tion, gross excitement and violence, dis- meet the DSM-III-R"2 criteria for either major tractibility, mannerisms, posturing, and depression, bipolar disorder-mixed, bipolar stereotypies. These signs are rated 0 (symptom disorder-depressed, or dysthymia. All patients absent), 1 (present in fairly severe degree, or underwent CT or MRI, and none of them had very severe but intermittent during interview), structural brain lesions. and 2 (present in very severe degree and almost continuous during interview). The psy- Parkinson's disease group chiatric evaluation was carried out immedi- http://jnnp.bmj.com/ This group consisted of 41 consecutive ately before or after the neurological patients with Parkinson's disease and no examination. depression that were seen in the neurology clinic of our institute at regular follow ups. All NEUROLOGICAL EXAMINATION patients had positive clinical responses to lev- The neurological evaluation was carried out by odopa. a neuropsychiatrist blind to the psychiatric data, and consisted of the following items: PSYCHIATRIC EXAMINATION on October 1, 2021 by guest. Protected copyright. After informed consent and blind to neurolog- Unified Parkinson's disease rating scale ical findings, depressed patients and patients (UPDRS) I I with Parkinson's disease were assessed with This scale has three sections: activities of daily the following tests: living,
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