Psychiatry - December 2008 - (Page 43)

“catatonia is schizophrenia” and improve the detection of katatonia in patients. Specifically, katatonia is also observed in mood disorders, general medical conditions, and pervasive developmental disorders. The literature also supports the view of Dr. Leo Kanner and his description for neuromotor and neuropsychiatric signs in autistic disorder. This scale is named in honor of Dr. Kanner. It was developed by the authors and includes some of Dr. Kanner’s core concepts. This paper will identify the clinical features of katatonia and introduce the KANNER scale (see Appendix 1) to improve conceptualization, detection, and measurement of this important clinical syndrome. INTRODUCTION Karl Ludwig Kahlbaum is best known for his description of catatonia. He presented his first description of catatonia in Innsbruck in 1869 and later wrote his monograph entitled Katatonia in 1873.1 Since then, the presence of catatonic signs has always held diagnostic, therapeutic, and prognostic value.2 Kahlbaum's description of this syndrome in his monograph included careful documentation of phenomenology. He selected the term katatonia to describe “tension insanity” and held that the neuromotor signs (e.g., waxy flexibility) were more important than the content of delusions (e.g., megalomania). While he was convinced that he was describing a unitary illness, he did identify mood disturbances, psychosis, and medical factors in this new illness.2 Kahlbaum described katatonia as a syndrome of motor abnormalities including mutism, negativism, stereotypies, catalepsy (waxy flexibility), and verbigeration.1 Kraepelin included catatonia as belonging to the group of dementia praecox, but acknowledged that “catatonic morbid phenomena” occurred in different psychiatric disorders.3 43 In modern times the terms catatonic and catatonia have unfortunately become limited to describe specifiers for neuropsychiatric illnesses. The clinical term catatonia therefore holds minimal conceptual importance in clinical practice. For instance, Larner defines catatonia as a state of unresponsiveness with maintained immobility, posturing, mutism, and refusal to eat or drink. He lists several signs that may or may not be present (including incontinence).4 Meanwhile Rogers has argued that catatonia is an extrapyramidal disorder.5 Fink and Taylor point out that in the two centuries since catatonia was first described, psychiatric terminology has changed many times.6 The authors propose that the term katatonia (with a “k”) be used to describe this crosssectional clinical syndrome to avoid continuation of the more recent nosological confusion. In the published literature, katatonia has staged a remarkable comeback over the past 15 to 20 years, with several rating scales, brain imaging and genetic studies, and neurochemical theories that underscore the importance of this clinical entity.6,7 However, research on katatonia has been limited by the lack of a psychopathological definition and clear conceptual understanding of the subject. This may explain why the existing catatonia rating instruments differ from each other in terms of the definition and number of individual symptoms.7–11 There is some variability of katatonia across various psychiatric disorders.11 Thus, reexamination of the reliability and validity of catatonia rating scales across the various neuropsychiatric illnesses is recommended. Furthermore, the need for a new conceptual understanding of katatonia has been suggested because of the fluidity of the boundaries of the concept.12 This review addresses the clinical concepts and attempts to describe katatonia over the past few decades. A new rating scale [VOLUME 5, and a conceptual outline for this important clinical entity will be presented. RESEARCH CRITERIA DEFINING KATATONIA Kanner’s autism. Kanner identified autism in 11 children between 2 and 8 years of age.13–15 He described stereotypy, echolalia, and other neuromotor and neurodevelopmental signs. His classification was quickly adopted into the psychiatric nomenclature. Currently, autism (autistic disorder) has been placed as a subcategory of pervasive developmental disorders. Consequently, more emphasis has been placed on the social and emotional domains than the motor signs. There are several observations suggesting that catatonia and autism may have common underlying pathophysiology and treatment response.16 The Autism Behavioral Checklist (ABC) does not define catatonic signs to the extent of detecting catatonic symptomatology in patients with autism. The autism rating scales fail to quantify items to show treatment response to the catatonic features. Consequently, we feel that there is a need for a new rating scale to assess katatonia in autism and pervasive developmental disorders. To date, there have been no studies of systematic ratings of catatonia in autism. Lohr and Wisniewski (1987). Lohr and Wisniewski17 proposed criteria for the catatonic syndrome, requiring one cardinal feature and two secondary features.1 Northoff found that all patients who met this criteria scored at least 8 (>7) on the Northoff Catatonia Scale (NCS).9 Catalepsy, positivism, or negativism (1 of these 3) must be present to meet Lohr and Wisniewski’s criteria.17 Their criteria may not take into account immobility, excitement, and withdrawal (refusal to eat and drink) and may exclude a number 12, DECEMBER] NUMBER Psychiatry 2008 43

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

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