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PROGRESSIVE CASE CONFERENCE: PART 1

Catatonia: Introduction Joseph L. Kugler and Joseph J. Cooper

OVERVIEW

Catatonia is an incredibly common psychiatric syn- drome. Yet it is misperceived by many clinicians as either rare or as a historic syndrome which has disappeared. Modern studies show about 10% of inpatient psychiatric patients suffer from catatonia1. In truth, the only thing which has disappeared is clinicians’ ability to properly identify catatonia’s signs and symptoms2,3. In this series of modules, we will introduce learners to the syndrome of catatonia through an example in the inpatient psychiatric hospital, identify common symptoms of catatonia, and review techniques necessary for identify- ing signs on motor and cognitive exams. We then review the normal motor regulatory systems in the brain and finally review what is known about dysfunction in these systems in catatonia.

MODULE A — RECOGNIZING THE CLINICAL SYNDROME

LEARNING OBJECTIVES At the completion of this session, participants will be able to: 1. Name and define core symptoms of catatonia 2. Recognize catatonic symptoms in a clinical case 3. Use the Bush-Francis Catatonia Rating Scale 4. Perform motor exams on patients, when indicated 5. List the most common causes of catatonia and be

able to generate a differential diagnosis

PROGRESSIVE CASE CONFERENCE (45-60 mins) This session is designed to be conducted using a real- time, interactive, web document. We recommend using google drive to create a new “google doc.” If you’re running the session with a small group of people, you can send them each invites. Alternatively, you can click “share” in the top right corner to make the document public and then go to tinyurl.com to create an easy to remember link that you distribute to the group. 1. Print paper copies of the student version of the case

in advance or post it for them progressively. 2. Ask students to work in groups of two or three to

answer the questions.

3. Give them the link to your shared google doc and ad- vise them that you will be posting links to additional resources as you go.

4. Note: for the rest of the Facilitator’s Guide we will use: • Black text indicating the materials that students

are given; • Red text to indicating “stage directions” for the

instructor; • Blue text indicating the correct answers in a ready

to post format; For most sections, you will ask students to work on their own to answer questions and then discuss them as a group. Keep this document and your running google doc open simultaneously. To share the correct answers with the group, you should cut & paste the blue text directly from this document into the google doc.

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PROGRESSIVE CASE CONFERENCE: PART 2

Catatonia: Module A Joseph L. Kugler and Joseph J. Cooper

[Break the class into groups of two or three and ask them to read the vignette and start answering the questions be- low. Share the link to the google doc and advise them that the main portion of this session is an “open book”, “open internet” experience – they should be looking up what they don’t know and you will post helpful links that they can use to find answers along the way.]

CLINICAL VIGNETTE:

Part 1

You’re on call overnight covering the emergency depart- ment (ED). At 2AM, you get a call from the ED doc alerting you to a 34-year-old man, brought in by police, who just got medicated and they want you to see. His friends called 911 after he locked himself in his room for several days. Police had to taze him due to agitation in his apartment. In the ED he was agitated, yelling, and mostly incoherent. He is now quiet after getting haloperidol 5mg and diphenhydr- amine 25mg intramuscularly.

Questions: 1. What’s your differential diagnosis as you walk over to

see the patient? 2. What other things do you have in mind?

Answers: 1. Decompensation of chronic psychotic disorder; drug-

induced psychosis; mania; delirium 2. SAFETY!!!; ensuring he is robed and has had belongings

taken away; ensure interviewing space is safe and secu- rity is in place if needed

Part 2

You gather more history from police notes and chart, and then attempt to interview the patient: He is a musician, on arrival of EMS, he rapidly became more agitated, intrusive, and was screaming continuously. Police forced entry, he was not answering coherently. He was repetitively yelling, “Is everything OK, Mr. Rothstein?”

“Here we are! Here we are!” and “let me in! let me in! let me in!”. He was covered in feces and urine. When the

police attempted to talk to him, he threw a soiled shirt at an officer and was tazed. Initially in ED he was awake, but uncooperative. Without provocation, Mr. R became agitated, pacing, and gesticulating wildly around the room. He refused to allow staff to clean him of feces. He was medicated, as above. On exam, the patient is malodorous. At times he looks excited and at times withdrawn, barely moving. He stands stiffly and motionless for several minutes at a time, not making any eye-contact, nor answering any questions. He then becomes spontaneously verbal and, though dif- ficult to understand, makes grandiose statements as to his wealth and power to help others through his music. At times, mid-sentence, his speech unravels into perse- verative, but logically-disconnected phrases. He doesn’t respond to gentle interruption. After several minutes he suddenly stands, and walks over to the corner, turning his back to you for 2-3 minutes. He then turns three times to the left and three times to the right and tiptoes out of the room. As you follow him out into the hall, he grabs a tech by the arm and will not let go, staring ahead blankly. A code is called. After receiving 5mg haloperidol IM, and 50mg diphenhydramine he is put transiently in restraints.

Questions: 1. What is your differential diagnosis now? 2. What are your next steps?

Answers: 1. Decompensation of chronic psychotic disorder; drug-

induced psychosis; mania; delirium; catatonia 2. Physical exam, cognitive exam

Part 3

You notice now his head is raised off the pillow. He appears to be in a fetal position but with his arms in the same position as they were in the chair. He repetitively taps his fingers. He continues to stare straight ahead without blinking. On motor exam, he displays initial resistance to any attempts to move his arms. On being asked to relax he ultimately does somewhat but keeps his arms fixed in the position you leave them. His speech continues to be sig- nificantly decreased and impoverished with the exception of a few repetitive utterances, “bothering you, bothering

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you.” After significant latency, he does demonstrate orien- tation to month, year, place, and city. He won’t engage in further cognitive assessment or history gathering.

Questions 3. What is the initial approach for systematically evaluat-

ing this patient? 4. Describe the exam findings in our patient.

After 1-2 minutes, post the following resources to help learners answer the questions: • Oldham MA and Lee HB. Catatonia vis-à-vis de-

lirium: the significance of recognizing catatonia in altered mental status. General Hospital Psychiatry. 37 (2015) 554-559.

• Bush G, Fink M, Petrides G et al. Catatonia I: rat- ing scale and standardized examination. Acta Psychiatr Scand (93): 129-136.

After a couple more minutes, review as a group—again, please note: the sections below are designed so that you can discuss the question from the exercise and then cut and paste the answer key from below directly into their google doc]

3) What is the initial approach for systematically evaluat- ing this patient? Initial clinical evaluation of the patient with suspected catatonia: • Perform a bedside neuropsychiatric assessment

including, at least, observation of arousal level and awareness. Attempt specific assessment of attention, orientation, memory, language, executive function, and visuospatial-constructional ability.

•. Formally evaluate catatonic symptoms: conduct psy- chomotor examination and document findings in a Bush-Francis Catatonia Rating Scale. (Includes review of nursing notes, vital sign trends, dietary and fluid input/output metrics, discuss staff’s observations of patient).

•. Obtain a clear and detailed psychiatric history includ- ing natural history of catatonic presentation. This will very likely include interviewing reliable informants and thoroughly reviewing medical records.

•. Thoroughly review medications and consider possible toxin exposures (illicit substances, environmental expo- sures, and potential iatrogenic precipitants).

•. Appraise likelihood of other conditions in which cata- tonic features for catatonia are commonly expressed.

•. Consider further medical work-up.

4) Describe the exam findings in our patient. • Let’s review some definitions and videos of catatonic

symptoms.

ADDITIONAL RESOURCES

For more on catatonia assessment, Josh Wortzel, MD and Mark Oldham, MD at the University of Rochester, collaborated with Andy Francis, MD, PhD to create a comprehensive suite of catatonia assessment resources using the Bush-Francis Catatonia Rating Scale (BFCRS; freely available at https://bfcrs.urmc.edu/). Some of the highlights include:

1. BFCRS Training Manual and Coding Guide, which describes how to use the BFCRS and explains each item in detail. 2. Educational modules on using the BFCRS, which includes standardized patient videos, test questions with explanations, and answer keys. 3. Videos on scoring individual BFCRS items; also ac- cessible on the hyperlinked PDF version of the BFCRS.

REFERENCES

1. Fink M, Taylor MA: Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge, UK, Cambridge University Press, 2003

2. van der Heijden FM, Tuinier S, Arts NJ, et al: Catatonia: disappeared or under-diagnosed? Psychopathology 38(1):3–8, 2005

3. Cooper JJ, Roig Llesuy J. Catatonia Education: Needs Assessment and Brief Online Intervention. Acad Psychiatry. 2017 Jun;41(3):360-363.

4. Oldham MA and Lee  HB. Catatonia vis-à-vis delirium: the significance of recognizing catatonia in altered mental status. General Hospital Psychiatry. 37 (2015) 554-559.

5. Bush G, Fink M, Petrides G et al. Catatonia I: rating scale and standardized examination. Acta Psychiatr Scand (93): 129-136.

6. Taylor MA. Clinical Examination in Catatonia: From Psychopathology to Neurobiology, American Psychiatric Publishing, 2004, p. 45–52.

7. Fink M and Taylor MA. Signs of Catatonia are Identifiable in Catatonia: a Clinician's Guide to Diagnosis and Treatment, by Max Fink and Michael Alan Taylor, Cambridge University Press, 2003, pp. 19-32

8. Psychiatry Teacher. Catatonia. New Castle University. YouTube, 16 Feb. 2011, [Waxy_Flexibility.mp4, Gegenhalten.mp4, Negativism-Aversion.mp4] https:// www.youtube.com/watch?v=_s1lzxHRO4U

9. Lehmann, Heinz E. Schizophrenia: Catatonic Type. [Catalepsy and Posturing 2.mp4, Posturing_and_ Catalepsy.mp4] Ottawa, Canada: National Film Board of Canada, 1951.

10. Lehmann, Heinz E. Schizophrenia: Hebephrenic Type. [Mannerisms_historic.mp4, Grimacing.mp4] Ottawa: National Film Board of Canada, 1952.

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PROGRESSIVE CASE CONFERENCE: PART 3

Catatonic Symptom Definitions and Videos

Click hyperlinks to watch video clips (5-20 seconds each) of positive catatonic findings; N.B. videos are either historic and obtained from publicly available sources (e.g. YouTube) or patients have provided explicit consent to one of the authors (JLK or JJC) for the use of videos for educational purposes. This consent was obtained after their catatonic episodes had resolved.

HYPOKINETIC SYMPTOMS OF CATATONIA

Negativism — Apparently motiveless resistance to instruc- tions or attempts to move/examine patient. Contrary behavior or doing exact opposite of instruction. • Negativism/Aversion — Behavioral negativism is ex-

hibited here in the form of aversion. Here the patient even appears to “consider” the instructions to shake hands before turning away. This is often misattributed to volitional defiance or willful manipulation of staff, but in catatonia it is unlikely related to conscious motivation.

• Negativism — Behavioral negativism is exhibited here. On being instructed to “look at me,” Nathan turns his gaze towards the examiner but mostly keeps his eyes closed.

Gegenhalten — (A motoric type of catatonic negativism) Patient resists physical manipulations, whether light or vigorous, with strength equal to that applied, as if bound to stimulus of examiners’ actions. • Gegenhalten — This patient resists attempts to exam-

ine him with a force equal to that being applied by the examiner

Mutism — Patient with silence or markedly reduced speech and unresponsiveness. Not always associated with immobility or stupor. Staring — fixed gaze or decreased blink rate, with little to no visual scanning of environment. Stupor — Unresponsiveness, hypoactivity, and reduced arousal during which patient fails to respond to questions. Most severe when patient is immobile and does not re- spond to painful stimuli. • Immobility, Stupor, Staring, Mutism — In spite of ap-

parent wakefulness, our patient stares straight ahead. She fails to respond to questions and commands, and does not recoil from toenail pressure.

Ambitendency — Patient appears stuck in an indecisive, hesitant movement, resulting from verbal contradiction of strong non-verbal signal.

SPATIAL POSTURING SYMPTOMS OF CATATONIA

Posturing — Spontaneous and active maintenance of body positions by the patient against gravity for long periods. Postures held may be bizarre or mundane. Catalepsy — Patient passively allows induction of a posture by examiner which is then held against gravity. • Posturing and Catalepsy — This man has axial and

right arm posturing. Catalepsy is also demonstrated with the maintenance of cervical extension and his left arm in the raised position.

• Posturing and Catalepsy — This man displays spon- taneous axial and left arm posturing. The examiner then shows that catalepsy in both arms.

Grimacing — A specific type of posturing – maintaining an odd facial expression. • Grimacing — This man maintains his lips in an exag-

gerated pucker (classically called schnauzkrampf). Waxy-Flexibility — Offering initial resistance before al- lowing repositioning of body into other postures (which, if then held against gravity, count as catalepsy). Feels like bending a warm candle stick or a 1980’s Gumby doll. • Waxy Flexibility and Catalepsy — Waxy flexibility and

catalepsy often occur together, as seen in this video. The examiner’s efforts to reposition the right arm are initially met with resistance but ultimately allowed to proceed. The examiner senses slowly dissipating resistance along a range of motion to a new posi- tion, which is then maintained against gravity. Here significant mirror movements are seen in the left arm. Mirror movements are considered a soft neuro- logic sign seen in a wide variety of neuropsychiatric disorders. Mirror movements are NOT considered a specific catatonic sign.

Rigidity — maintenance of stiff/hypertonic position, de- spite efforts to be moved. Mitgehen — Anglepoise lamp. Despite being given con- trary instructions, patient is unable to resist light pressure of examiner to lift a limb. Once limb is raised, the new posture may be maintained or arm may be lowered slowly.

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PERSEVERATIVE AND HYPERKINETIC MOTOR SYMPTOMS OF CATATONIA

Perseveration — Repeatedly returns to the same topic or persists with movement. Stereotypy — A non-goal directed, apparently purposeless, repetitive motor behavior. The movement itself is odd. • Stereotypy 1 — Here, the rotating motion of the right

forearm is a stereotypy. • Stereotypy 2 — Here, the fingerplay in the right hand

is a stereotypy. Mannerisms - Repetitive purposeful movements, such as holding hands as if they were handguns, saluting people, or exaggerations of mundane movements. The movements are not atypical, but the context or ways in which they are carried out are odd. • Mannerism — This patient exhibits motor perse-

veration and mannerism in his right arm and hand. Notice the animated and exaggerated quality of his expression.

• Mannerisms 1 — The patient carries out a mannerism resembling stirring and pouring of a beverage. He carried out this mannerism 3 times in a span of 4-5 minutes. He would walk around the room, then return to the same spot and perform this same behavior.

• Mannerisms 2 — Here, he keeps his eyes closed, shuffles backwards and forwards while rhythmically bobbing his head. He would spontaneously and re- petitively go from walking with a normal gait, into this gait, and back again.

• Mannerisms 3 — Here, with eyes closed, he repeti- tively scoots a chair with his knees. This behavior was not random, nor was it convenient to get where he was needing to go. Rather, the mannerism was stimulus bound in that he seemed magnetically drawn to chairs.

Echopraxia — Patient spontaneously copies others’ move- ments. In extreme forms the patient may be unable to re- frain from copying others’ movements, despite instructions not to. Echolalia — Repeating of others’ statements, phrases or questions. • Echolalia —Family member asks “do you know what?”

and the patient replies the partial echo: “what?” Verbigeration — A verbal type of stereotypy. Repetition of phrases and sentences in an automatic fashion. Essentially synonymous with the term palilalia. • Echolalia with Verbigeration — Family member says

“you should try to eat” and the patient replies and then repeats the partial echo “try try try.”

• Verbigeration — The word “yeah yeah yeah” is re- peated in an automatic fashion, as if a broken record.

Excitement — Apparently non-purposeful constant motor unrest or extreme hyperactivity. Automatic Obedience — Exaggerated cooperation with requests, often prompted by motor cues. Also can refer to

spontaneous continuation of movement induced by exam- iner (which combines the concept of perseveration). Agitation — Striking out violently in an undirected manner or otherwise engaging in inappropriate, typically suddenly hyperactive behavior, often without provocation.

RETURN TO RICKY'S CASE & REVIEW FINDINGS

Verbigeration with echolalia — he was not answering coherently. He was repetitively yelling, “Is everything OK, Mr. Rothstein?” “Here we are! Here we are!” and “let me in! let me in! let me in!” Excitement, agitation, negativism — He was covered in fe- ces and urine. When the police attempted to talk to him, he threw a soiled shirt at an officer and was tazed. Initially in ED he was awake, but uncooperative. Without provocation, Mr. R became agitated, pacing, and gesticulating wildly around the room. He refused to allow staff to clean him of feces. Posturing, negativism, mutism — He stands stiffly and motionless for several minutes at a time, not making any eye-contact, nor answering any questions. Possible psychotic thought content suggestive of manic or mixed mood episode — He then becomes spontane- ously verbal and, though difficult to understand, makes grandiose statements as to his wealth and power to help others through his music. Perseveration, verbigeration — At times, mid-sentence, his speech unravels into perseverative, but logically-discon- nected phrases. Excitement, negativism — After several minutes he sud- denly stands, and walks over to the corner, turning his back to you for 2-3 minutes. Mannerism — He then turns three times to the left and three times to the right and tiptoes out of the room. Perseveration, staring, stupor — he grabs a tech by the arm and will not let go, staring ahead blankly Posturing, “psychological pillow” — You notice now his head is raised off the pillow. He appears to be in a fetal posi- tion but with his arms in the same position as they were in the chair. Mannerism, staring — He repetitively taps his fingers. He continues to stare straight ahead without blinking. Waxy-flexibility, catalepsy — he displays initial resistance to any attempts to move his arms. On being asked to relax he ultimately does somewhat but keeps his arms fixed in the position you leave them. Mutism, verbigeration, echolalia — His speech continues to be significantly decreased and impoverished with the exception of a few repetitive utterances, “bothering you, bothering you.” At least intermittent awareness, orientation and possible negativism - After significant latency, he does demonstrate orientation to month, year, place, and city. He won’t engage in further cognitive assessment or history gathering.

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PROGRESSIVE CASE CONFERENCE: PART 4

Post-Test

1. Match the following symptoms to their definition (Definitions may be for more than one symptom):

Mutism Gegenhalten Negativism Verbigeration Stupor Posturing Ambitendency Catalepsy Echopraxia Waxy-flexibility Mannerism Psychological Pillow Echolalia Automatic obedience Stereotypy Grimacing

a. Despite instructions to the contrary, patient permits the examiner’s light pressure to move the patient’s limbs into a new position (posture), which then may be maintained by the patient.

b. Patient is verbally unresponsive. c. Patient appears “stuck” in an indecisive, hesitant movement, resulting from the examiner verbally

contradicting his or her strong non-verbal signal. d. Patient spontaneously copies examiner’s movements or unable to refrain from copying exam-

iner’s test movements despite instructions to contrary. e. Patient resists examiner’s manipulations whether light or vigorous with strength equal to that

applied, as if bound to the stimulus of the examiner’s actions. f. Maintaining odd or uncomfortable body postures for long periods such as lying in jackknifed

position, sitting with upper and lower portions of body twisted at right angles, holding arms above head or raised in prayer-like manner, or holding fingers/hands in odd positions.

g. Patient initially resists examiner’s manipulations before gradually allowing him/herself to be postured.

h. Odd, purposeful movements, exaggerations or stilted caricatures of mundane movements. Odd in context or way it’s carried out. (e.g. holding hands as if they were handguns, saluting passersby)

i. Odd, non-goal-directed, repetitive motor behavior. Often awkward or stiff and apparently sense- less. May be complex and take form of rituals or compulsive behaviors. Odd in the frequency of behavior. (e.g. Rocking, shoulder shrugging, sniffing, making clicking noises before/after speak- ing, tapping or touching automatically, squeezing eyes shut or opening eyes wide).

j. Patient automatically repeats examiner’s utterances or parts of them. k. Unresponsiveness, hypoactivity, and reduced or altered arousal; when severe patient exhibits

pathologic analgesia.

2. How many symptoms meet threshold for DSM-5 diagnosis of catatonia? ______________________________________ 3. Name 1 standardized rating scale for screening and assessment of catatonia __________________________________