Psychiatry - December 2008 - (Page 46)

In view of the variety of neuropsychiatric and general medical conditions that can manifest with catatonic features, a generic catatonia rating instrument would be insufficient to capture catatonia in specific patient populations and consequently would need modification.6 Wong et al28 tested the BFCRS in a sample of patients with chronic schizophrenia where catatonic features are frequently encountered. Using Rasch analysis, the authors constructed a 20-item scale from the BFCRS that was useful in their population of chronic catatonics. They suggested that rigidity, grasp reflex, and autonomic abnormality (and perhaps impulsivity) do not measure the same construct as other BFCRS signs in chronically ill patients with schizophrenia.28 The BFCRS Revised version was shorter and simpler that the original BFCRS and better suited to identifying catatonic signs in patients with chronic schizophrenia.28 that failure to diagnose katatonia or provide effective psychiatric treatment may result in a poor outcome.30 DIRECTIONS FOR FUTURE RESEARCH The KANNER scale should be compared against a gold standard. We propose testing the KANNER rating scale against the BFCRS. While other scales have merit, there is limited experience with these scales in North America. The KANNER scale has three components; each should be tested separately (Appendices 2–4). It may be useful to call together a consensus panel to propose criteria, evaluate rating scales, and identify treatment standards. This has been done for other neuropsychiatric illnesses, such as Lewy body dementia. Furthermore, since the KANNER is a neuromotor examination, a training video or DVD with patients or simulation actors might be helpful to achieve improved understanding of katatonia and create a core standardization in the rating of katatonia (Table 1). specificity of this scale cannot be easily ascertained. Because the KANNER scale is based on an exhaustive and comprehensive review, we propose that it be adopted and tested prospectively for its clinical utility, sensitivity, and specificity. ACKNOWLEDGMENT This work is dedicated to the late Tressa D. Carroll who provided conceptual input. APPENDIX 1. KANNER scale acronym KANNER scale Katatonia Autism Neuropsychiatric and Neuromovement Examination Rating APPENDIX 2, PART 1. KANNER scale screening TREATMENT RESPONSE IN KATATONIA Peralta et al29 and Barnes et al30 remind us that catatonia is found across a wide range of psychiatric, neurological, and medical disorders, and this generally supports Kahlbaum’s idea of a unitary phenomenology and pathology. The response to lorazepam or electroconvulsive therapy (ECT) does not follow the primary psychiatric diagnosis. In fact, it is katatonia that responds to these treatments. While some authors have noted a trend toward less favorable improvement for catatonic symptoms in schizophrenia as compared to mood disorders, this has not been consistently or conclusively demonstrated. Nonetheless, the presence of katatonia predicts a favorable response of these signs to interventions like intravenous amobarbital, lorazepam (and other benzodiazepines), and ECT. Katatonia seems to be associated with a favorable prognosis, when diagnosed and treated promptly. There is clinical evidence to suggest 46 Psychiatry 2008 [ V O L U M E 5, NUMBER WIRED `N MIRED: mnemonic for screening for katatonia22,31 Waxy flexibility/catalepsy Immobility Refusal to eat or drink Excitement Deadpan staring Negativism Mutism Impulsivity Rigidity Echolalia/echopraxia Direct observation of catatonic features in nursing notes in the past day to past week Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No Yes/ No PROPOSAL We propose the KANNER scale as a unifying instrument for quantifying katatonic core features (a) across the broad range of neuropsychiatric illnesses and (b) in the specific contexts of autism and pervasive developmental disorders. The KANNER scale is named after Leo Kanner (1894–1981), who described the neuromotor and neurodevelopmental features of autism, which are also features of katatonia.13–15 We feel it is necessary to identify katatonia in patients with other neuropsychiatric illnesses, including schizophrenia and mood disorders, and due to general medical conditions (Table 1). Based on our review and analysis from a large body of literature, the clinical signs for a possible and a probable diagnosis of catatonia are contained within the KANNER scale. Since there is no true gold standard for diagnosis, the sensitivity and 12, DECEMBER] Yes/ No These catatonic signs cannot be discounted nor removed unless recorded in error. These are observations only. Medical and psychiatric etiologies cannot be used to exclude any signs. If there are two or more signs detected, then perform Part 2 of the KANNER scale

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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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