Catatonia in an Outpatient Clinic: A Clinical Study

 

 

Abstract


Introduction: Catatonia is a well-known entity in psychiatry. Its presentation is widely variable and conflicting. The objective is to study the presentation of Catatonic Symptoms among patients of four selected categories attending an adult psychiatric outpatient clinic.
Method: Over a period of eleven months (August 2003 and June 2004), 771 newly registered patients belonging to selected categories of DSM-IV were screened on Stony Brook Catatonia Screening Instrument. Subjects positive on at-least 2 items of the instrument during the past 48 hours were included in the catatonia group while rest were included in the non-catatonia group.
Results: Out of the total patients screened, 22 could be included in catatonia and 749 in non-catatonia group. The patients with catatonia had significantly earlier mean age of presentation (p=0.0005), with significant presentation with diagnostic category of Mental Disorders due to General Medical Conditions (p=0.005) and Schizophrenia & Other Psychotic Disorders (p=0.01). Patients without catatonia were significantly associated with Mood Disorders (p=0.003). The risk ratio (relative risk) of catatonia was 9.2 with Mental Disorders due to General Medical Conditions, 2.96 with Schizophrenia & Other Psychotic Disorders and 0.25 with Mood Disorders.
Conclusion: Catatonia is a commonly diagnosed condition among young patients suffering from Schizophrenia and Other Psychotic Disorders.
Key Words: Catatonia, Schizophrenia, Psychotic disorder, Mood Disorder, General Medical Conditions

 

INTRODUCTION:


Catatonia as a disorder of movement is known to exist since many centuries. The credible task of defining this syndrome in patients with psychiatric disorder goes to Karl Ludwig Kahlbaum in 1874 (Fink and Taylor, 2003). The prevalence of these symptoms among psychiatric population is a matter of debate. It is suggested that the prevalence of catatonia has decreased over time in developed countries (Mahendra, 1981; Banerjee and Sharma, 1995), while other studies (Carpenter et al., 1976; Banerjee and Sharma, 1995; Fink and Taylor, 2003) recognize catatonia to be a widely recognized syndrome. Initially catatonic symptoms were recognized to be mainly associated with schizophrenia but recent studies have shown that these symptoms are more prevalent with mood disorders especially with mania (Abrams and Taylor, 1997).
This paper aims at studying the presentation of Catatonic Symptoms in terms of clinical and socio-demographic profile among patients of four selected categories attending an adult psychiatric outpatient clinic in India.

METHOD:


The study was conducted between August 2003 and July 2004 in the outpatient clinic of a tertiary care hospital, King George’s Medical University, Lucknow, India. All the consecutively first-time registered patients who were clinically diagnosed by the Senior Consultants (MS, BS), with Schizophrenia and Other Psychotic Disorders (295, 297, 298.9), Mood Disorders (296), Mental Disorders due to General Medical Conditions (293.81, 293.82, 293.83, 293.89) and Substance Related Disorders (291, 292, 303, 304, 305) using DSM-IV (APA, 1994) fulfilling the selection criteria were included and assessed in detail. Clinical Global Impression (Guy, 1976) was used to rate the severity of illness. Simultaneously they were screened on Stony Brook Catatonia Screening Instrument (Bush et al., 1996), a part of the Stony Brook Catatonia Rating Scale (Bush et al., 1996), in which the first fourteen items are used as screening instrument. Presence of any two or more items in last twenty-four hours is said to be screen positive.
The selection criteria were age above 18 years, willingness to give informed consent and stable physical condition of the patient, permitting examination for catatonic symptoms. The informed consent for participation in the study of uncooperative patients was obtained from their relatives.
Statistical analysis was done on SPSS using SPSS 11.5 version (SPSS Inc., Chicago, IL). The continuous samples were analyzed using independent sample t-test and discrete variables using Chi-square and Fisher exact test. The discrete factors, which were found to be significant in univariate analysis, were analyzed for risk using odds ratio and relative risk.


RESULTS:


A total of 771 patients were diagnosed under the selected categories and screened for catatonia during the study period. Out of these, 22 patients were found to be screen positive and 749 to be negative for catatonia. All the screened patients could be included. Since only first-time registered patients were studied, only 28 (3.6%) patients were found to be taking some medications. These were antipyretics of non-steroidal anti-inflammatory drugs category (16 patients), antibiotics (4 patients) and both (8 patients). Two of the patients who screened positive for catatonia were taking antipyretics and antibiotics (Paracetamol, Ampicillin and Ofloxacin). These medications were either given as over the counter medications or were prescribed by the primary care physicians.


Socio-demographic profile (Table 1) of patients in either category revealed that majority of patients belonged to young adult age group (18-45 years). The mean age at presentation was found to be significantly earlier among the catatonic patients than non-catatonic patients (p=0.0005). Both the catatonic and non-catatonic groups did not differ in terms of gender, duration of illness, domicile, marital status, number of episodes and severity of illness on clinical global impression. The patients with catatonia were significantly associated with negative family history (p=0.0001), while the patients without catatonia were significantly associated with mood disorder (p=0.001).

 

Table 1

Socio-Demographic and Clinical Profile of the patients attending the out-patient clinic

Categories

N (%) Pts. without Catatonia (Total=749)

N (%) Catatonia

Pts (Total=22)

X2 / t-value

Significance (p-value)

Age at presentation (in years)

   

6.45

0.039

  • 18-45

447(59.7)

19(86.4)

-2.9

0.1

  • 46-65

279(37.2)

3(13.6)

5.3

0.02*

  • >65

23(3.1)

0

0.48

0.5

Mean (Years + S.D.)

36.4+14.8

25.3+9.6

3.5

0.0005

Gender

   

0.002

1

Male

421(56.2)

12(54.5)

   

Female

328(43.8)

10(45.5)

   

Marital Status

   

0.055

0.82

Married

461(61.5)

13 (59.1)

   

Unmarried

288(38.5)

9(40.9)

   

Domicile

   

0.019

1

Rural

656(87.6)

20 (90.9)

   

Urban

93(12.4)

2 (9.1)

   

Duration of presenting illness (days)

   

1.93

0.38

  • <30

366(48.8)

11(50)

-0.001

1

  • 31 – 180

309(41.3)

7(31.8)

0.787

0.5

  • >180

74(9.9)

4(18.2)

-1.836

0.15

Mean (Days + S.D.)

232.4+663.7

282.8+624.6

-0.3

0.72

Number of episodes

   

0.79

0.67

  • 1

652(87.1)

18(81.8)

0.57

0.5

  • 2

81(10.8)

3(13.6)

-0.15

0.7

  • >2

16(2.1)

1(4.5)

-0.85

0.4

Mean  + S.D.

1.1+0.5

1.2+0.5

- 0.9

0.35

F/ H for psychiatric illness

   

19.8

0.00005

  • Negative

323(43.1)

20(90.9)

-15.873

0.0001†

  • +ve for Mood Disorders

282(37.6)

1(4.5)

6.707

0.001‡

  • +ve for Schizophrenia

144(19.2)

1(4.5)

3.2

0.098

CGI-SI score + S.D.

3.92 + 2.12

4.16 + 1.92

-0.54

0.59

* Odds ratio = 0.27, Relative Risk = 0.27

† Odds ratio = 13.2, Relative Risk = 12.5:   ‡ Odds Ratio = 0.08, Relative Risk = 0.08:

S.D. = Standard deviation: X2 =Chi-square:  F/H= family history

CGI-SI: Clinical Global Impressions- Severity of Illness


The frequency of identification of catatonic symptoms among total patients screened was 2.8% (Table 2). The maximum frequency of non-catatonic patients was in Mood Disorder (60.5%) while catatonia was mostly associated with Schizophrenia and Other Psychotic Disorders (59.1%). Out of the total catatonic patients, 13.7% had physical cause for catatonia. Schizophrenia and Other Psychotic Disorders and Mental Disorders due to General Medical Conditions were found to be significantly associated with catatonia while the category of Mood Disorder was found to be more significantly associated to non-catatonic patients.

Table 2

Frequency of Catatonia among patients of Selected Diagnostic Categories

 

 

Diagnostic Categories

(DSM-IV)

Number(%) of pts. without Catatonia  (Total=749)

Number (%) of Catatonic pts.

(Total=22)

X2

value

Significance

(p-value)

O/R

(R/R)

1

Schizophrenia &

Other Psychotic Disorders

240(32.1)

13(59.1)

-7.1

0.01

3.1(2.96)

a

Schizophrenia

47(6.3)

5(22.7)

-6.7

0.01

4.39(4.07)

b

Schizophreniform Disorder

68(9.1)

3(13.7)

-0.12

0.4

-

c

Brief Psychotic Disorder

108(14.4)

5(22.7)

-0.6

0.3

-

d

Other Psychotic Disorders

17(2.2)

0

-

1

-

2

Mood Disorders

453(60.5)

6(27.3)

9.8

0.003

0.24(0.25)

a

Major Depressive Disorder

217(29)

1(4.5)

5.1

0.008

0.12(0.12)

 
  • Single Episode

180(24)

1(4.5)

3.5

0.04

0.15(0.15)

 
  • Recurrent

37(4.8)

0

0.3

0.62

-

b

Bipolar Disorder

236(31.5)

5(22.7)

0.4

0.49

-

 
  • Manic Episode

209(27.5)

3(13.7)

1.5

0.22

 
 
  • Depressive Episode

27(3.8)

2(9)

0.5

0.2

-

3

Substance Related Disorders

46(6.1)

0

0.5

0.63

-

4

Mental Disorders due to GMC

10(1.3)

3(13.7)

-12.8

0.005

11.67(9.2)

 

Total (771)

749 (97.2)

22 (2.8)

     

O/R = Odds ratio: R/R = Relative Risk: GMC= General Medical Condition


The estimation of risk revealed that the highest risk of association of catatonia in socio-demographic factors was with negative family history and the least was with family history of Mood Disorder. Among the various diagnostic categories the risk ratio of catatonia was highest with Mental Disorders due to General Medical Conditions (9.2), followed by Schizophrenia and Other Psychotic Disorders (2.96) and least with Mood Disorder (0.25). Schizophrenia had risk ratio of 4.39.


Discussion


To the best of our knowledge, most of the studies on catatonia have been done on psychiatric inpatients. It was thought that not all patients with catatonia would be hospitalized hence to nullify this factor this study was carried out among outpatients. In this aspect, our study gives a more representative data of psychiatric patients. The study was restricted to four diagnostic categories commonly associated with catatonia (Fink and Taylor, 2003). We recognize that catatonia has been reported with other psychiatric conditions as well (Salam and Kilzieh, 1988), but including total patient group would have made our time limited study unwieldy and hence the decision to exclude such a group.


Researchers report catatonia in 6-15% of adult in-patients (Fink and Taylor, 2003) while an Indian study found it in 37.2% of in-patients (Banerjee and Sharma, 1995). A Recent study (Chalasani et al., 2005) comparing the rates of catatonia among inpatients in India and Wales (U.K.), found the rates to be similar in both the places (13.5% in India and 9.6% in Wales). The difference of percentage, in comparison to our rate of 2.8%, could be due to difference in diagnostic criteria, rating scales and the population studied. Inpatients also tend to have a much more severe and chronic illness as compared to an outpatient sample. It is reported that catatonia is a disease of the young, having onset in early twenties (Wilcox and Nasrallah, 1986), with nearly equal distribution between males and females (Banerjee and Sharma, 1995; Fink & and Taylor, 2003) and our findings seem to match with this.


The significant association of catatonia patients with category of Schizophrenia and Other Psychotic disorders than Mood disorder is a comparatively contradictory finding. Multiple studies (Abrams and Taylor 1997; Fink and Taylor, 2003) had revealed catatonic symptoms to be present most commonly among manic patients, followed by depression and schizophrenia (Fink and Taylor, 2003).


A multi-centric study on Schizophrenia (Carpenter et al., 1976) had found the highest frequency of diagnosis of catatonic schizophrenia in India (21.8%) while the worldwide average was of 8.2%. Another study in India (Banerjee and Sharma, 1995) revealed similar presentation, reporting more frequency of catatonic patients among psychotic disorders than in mood disorders. This strengthens our finding of stronger association between Schizophrenia and catatonia among Indian patients, although another study reveals no difference (Chalasani et al., 2005).


The patients with catatonia had strongest risk with general medical conditions. Few patients in our study were taking antipyretics and antibiotics, which are not known to have any effect on catatonia. Association between catatonia, physical disorder and medications is well known (Ahuja N, 2000; Fink and Taylor, 2003) and underlies the need to exclude physical causes of catatonia prior to labeling it as purely psychiatric.
There were certain limitations of our study. Firstly, since our study was an outpatient-based and assessment was done at one point of time so there is a possibility that some of the catatonic patients might have been missed as it has been reported in literature that catatonia is known to have a waxing and waning presentation (Fink and Taylor, 2003). Secondly, a follow up study (Fein and McGrath, 1990) had pointed out that some of the catatonic patients who were earlier diagnosed as schizophrenia were re-diagnosed as mood disorder. The validation of this diagnostic shift needs a follow up study. Thirdly, despite a sufficient sample of patients screened, small numbers of catatonic patients were found, which limited the statistical analysis in the study. Fourthly, since catatonia was searched in particular diagnostic categories hence our findings could not be generalized to all psychiatric patients but our results may be considered as a representative data of the studied diagnostic categories.


Our study has given some important directions. Firstly, that catatonia is frequently diagnosable condition in our setup. Secondly, the catatonia continues to be more likely associated with Schizophrenia and Other Psychotic Disorders than Mood disorders in this part of the world. Thirdly, the catatonia tends to appear early in age. It is described that catatonia indicates a better prognosis for schizophrenia (Abrams and Taylor, 1997) but the commonly observed association of early onset with a poor prognosis emphasizes a needs for a long-term follow-up study to clarify this issue.

 

Authors:


1. Arvind Kendurkar, M.D. (Psychiatry), Assistant Professor
E-mail:akendurkar@gmail.com
2. Mukul Sharma, M.D. (Psychiatry), CCST (General Adult Psychiatry), Consultant Psychiatrist, Lancashire Care NHS Trust and Hony. Lecturer in Psychiatry, University of Manchester
3. Bharat Saluja, M.D. (Psychiatry), CCST (General Adult Psychiatry),Consultant Psychiatrist, Devon Partnership NHS Trust
Institution of Study: Department of Psychiatry, King George’s Medical University,
Lucknow, (U.P.) India- 226003

Correspondence to:
Arvind Kendurkar
Mailing Address: House no. 3, Mahaveer Nagar, New Purena, In front of Anmol Super Market, Raipur (C.G.), India

 

Acknowledgment:
Prof. Max Fink (Emeritus Professor, SUNY at Stony Brook, New York) for clarification of pertinent issues regarding Catatonia
Dr.Vivek Agarwal (Assistant Professor, Department of Psychiatry, King George’s Medical University, Lucknow, India) for his valuable help in preparation of draft.

 

REFERENCES:


1. Abrams R and Taylor MA., 1997. Catatonia: Prediction of response to somatic treatments. American Journal of Psychiatry, 134, 78-80.
2. Ahuja N., 2000.Organic Catatonia: A Review. Indian Journal of Psychiatry, 42(4), 327-346.
3. Banerjee A and Sharma LN., 1995.Catatonia Incidence in acute psychiatric admissions. Indian Journal of Psychiatry, 37(1), 35-40.
4. Bush G, Fink M, Petrides G, Dowling F and Francis A., 1996.Catatonia: I: Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93, 129-136.
5. Carpenter WW, Bartko JJ, Carpenter CL and Strauss JS., 1976. Another view of schizophrenic subtypes: A report from the international pilot study of schizophrenia. Archives of General Psychiatry, 33, 508-516.
6. Chalasani P, Healy D. and Morriss R., 2005. Presentation and frequency of catatonia in new admissions to two acute psychiatric admission units in India and Wales: Cross-cultural comparison of catatonia in new admissions. Psychological Medicine, 35(11), 1667-1675.
7. Fein S and McGrath MG., 1990. Problems in diagnosing bipolar disorder in catatonic patients. Journal of Clinical Psychiatry, 51, 203-250.
8. Fink M and Taylor MA., 2003. Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge U.K., Cambridge University Press.
9. Guy W., 1976. “Clinical Global Impressions”, ECDEU Assessment Manual for Psychopharmacology. U.S. Department of Health, Education and Welfare, DHEW Publication No. (ADM) 76-338.
10. Mahendra B., 1981.Editorial: Where have all the catatonics gone? Psychological Medicine, 11, 669-671.
11. Salam SA and Kilzieh N., 1988.Lorazepam treatment of psychogenic catatonia: an Update. Journal of Clinical Psychiatry; 49, 16-21.
12. Wilcox JA and Nasrallah HA., 1986. Organic factors in catatonia. British Journal of Psychiatry, 149, 782-789.

 

Copyright Priory Lodge Education Limited 2007

First Published September 2007

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