SAN FRANCISCO— An investigation into the most commonly observed signs of catatonia has researchers reconsidering the minimum clinical requirements for such a diagnosis. Findings presented at the 156th Annual Meeting of the American Psychiatric Association suggest that the established criteria may need to be re-evaluated and reorganized.

The current diagnostic criteria for catatonia, according to the DSM-IV-TR, require “the presence of catatonia as manifested by motoric immobility, excessive motor activity (that is apparently purposeless and not influenced by external stimuli), extreme negativism or mutism, peculiarities of voluntary movements, or echolalia or echopraxia,” cited Antonio Lopez-Canino, MD. He and Bogdan Paul Sasaran, MD, investigated 117 literature-reported cases of drug-induced catatonia, to which the DSM-IV-TR, Bush-Francis Catatonia Rating Scale (BFCRS), and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria had been applied. Their hope was to “decrease catatonia’s heterogeneity and increase diagnostic confidence,” Dr. Lopez-Canino noted. He is currently a resident in the Menninger Department of Psychiatry at Baylor College of Medicine in Houston but completed this study while in training in the Department of Psychiatry at Stony Brook University Hospital, Stony Brook, New York.

SIGNS

Patients with catatonia were divided into two categories: an excited group and a stuporous group. Drs. Lopez-Canino and Sasaran then designed the 13-item Sign Inventory for Catatonia (SIC) according to the rate of occurrence of individual signs in the 117 patients in their review. “SIC may be used as a screening tool in medicine and psychiatry, and by nonpsychiatrists who often come into contact with catatonia before we do, while BFCRS is mainly a primary comprehensive research tool,” they noted.

The SIC was then compared to the DSM-IV-TR, ICD-10, and BFCRS criteria—with some striking results. “Mutism (90.6%), negativism (84.6%), staring (78.6%), and autonomic abnormalities (59.8%) were the most elicited signs,” they reported.

For patients in the excited group, verbigeration and combativeness—signs present in 18% and 41% of stuporous patients with catatonia, respectively—were absent, the investigators noted. Likewise, there was no waxy flexibility in the excited group (47% in the stuporous group). There were no reports of echophenomena or grasp reflex in either group. Dr. Sasaran, who is an Assistant Professor of Psychiatry at Elmhurst Hospital Center, New York, explained that in a retrospective study, one reports only what is recorded and not necessarily the entire gamut of signs and symptoms the patient could have presented with. Nevertheless, “echophenomena,” he added, “are thought to be fairly common signs encountered in catatonia, and the fact that there was not a single report of them in 117 patients is puzzling.”

CONTRADICTORY CATATONIC CONCLUSIONS

Though both the DSM-IV-TR and the SIC found mutism and negativism to be the most prevalent signs of catatonia, five of the DSM-IV-TR’s 11 criteria for catatonia (stereotypy, mannerisms, grimacing, echopraxia, and echolalia) did not appear at all on the SIC, the investigators reported. Excitement and stupor, the primary BFCRS criteria (before mutism and staring) were present on the SIC in less than 1% and 23% of patients, respectively. An additional 11 of the 23 BFCRS criteria were present in less than 12% of patients on the SIC. Autonomic abnormalities—the lowest-prevalence sign of catatonia on the BFCRS—were ranked fourth on the SIC, present in nearly 60% of patients, they noted.

Drs. Lopez-Canino and Sasaran concluded that “the core catatonic syndrome was established by high rates of mutism, negativism, and staring, which are in contradiction with the sign hierarchy in the DSM-IV-TR, ICD, and BFCRS.” The investigators suggest that “further prospective studies taking into consideration both the clinical and statistical significance of these findings are highly needed.”

—C. Justin Romano

Suggested Reading
Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93:129-136.
Lopez-Canino A, Francis A. Drug-induced catatonia. In: Caroff SN, Mann SC, Francis A, Fricchione GL, eds. Catatonia: From Psychopathology to Neurobiology. Washington, DC: American Psychiatric Press. In press.
Peralta V, Cuesta MJ. Motor features in psychotic disorders. II. Development of diagnostic criteria for catatonia. Schizophr Res. 2001;47:117-126.

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