Catatonía: revisión narrativa de su desarrollo histórico, diagnóstico, fisiopatología y terapéutica / Catatonia: A narrative review of its historical development, diagnosis, pathophysiology, and therapeutics

Inicialmente la catatonía fue un componente clínico de algunas formas de esquizofrenia, pero la evidencia básica y epidemiológica demuestra su vinculación con múltiples cuadros somáticos y psiquiátricos. Se describen y analizan conceptos clínicos, etiológicos, fisiopatológicos y terapéuticos actuales respecto a la catatonía. Se realizó una revisión narrativa amplia de artículos publicados en MEDLINE/PubMed. El diagnóstico es clínico y puede apoyarse en exámenes complementarios, pero existen instrumentos psicométricos con distinto énfasis clínico. Los subtipos más validados son el inhibido y el excitado. Se asocia mayormente a patologías somáticas, neurológicas, afectivas, psicóticas y del espectro autista. En su fisiopatología se han estudiado factores genéticos relacionados con los oligodendrocitos. Algunos hallazgos señalan un desbalance en la neurotransmisión y densidad de receptores de GABA y dopamina, hecho concordante con su función en las vías motoras y la respuesta terapéutica con benzodiacepinas. Asimismo, se ha analizado la actividad glutamatérgica, desde el modelo fisiopatológico de la encefalitis autoinmune. Las vías córtico-corticales y córtico-subcorticales tendrían un rol central, incluyendo estructuras como las cortezas orbitofrontal y temporal, núcleos basales y tronco encefálico, involucradas en la toma de decisiones, regulación emocional, almacenamiento, planificación y elaboración motora. Las principales líneas terapéuticas son las benzodiacepinas y la terapia electroconvulsiva. Otras intervenciones estudiadas son el zolpidem, antipsicóticos, estabilizadores del ánimo, moduladores glutamatérgicos y estimulación magnética transcraneal. Los nuevos hallazgos neurobiológicos discuten los preceptos nosológicos y terapéuticos, renovando el ciclo en la conceptualización de la catatonía. Se destaca el componente afectivo del síndrome psicomotor y el rol de las intervenciones que apunten a su modulación.

Catatonia was initially a clinical presentation of certain types of schizophrenia, but basic and epidemiological evidence has demonstrated its association with multiple somatic and psychiatric conditions. We describe and discuss current clinical, etiological, pathophysiological, and therapeutic concepts regarding catatonia. We conducted a broad narrative review of articles published in MEDLINE/PubMed. The diagnosis is clinical and can be supported by additional tests, but there are psychometric instruments with different clinical focus. The most validated subtypes are inhibited and excited catatonia. It is mostly associated with somatic, neurological, affective, psychotic, and autistic spectrum disorders. Genetic factors related to oligodendrocytes have been studied in its pathophysiology. Some findings point to an imbalance in neurotransmission and density of GABA and dopamine receptors, consistent with their function in motor pathways and therapeutic response with benzodiazepines. Likewise, glutamatergic activity has been analyzed from the pathophysiological model of autoimmune encephalitis. The cortico-cortical and cortico-subcortical pathways would have a central role, including structures such as the orbitofrontal and temporal cortex, basal nuclei, and brainstem, involved in decision-making, emotion regulation, storage, planning, and motor processing. The main therapeutic lines are benzodiazepines and electroconvulsive therapy. Other interventions studied are zolpidem, antipsychotics, mood stabilizers, glutamatergic modulators, and transcranial magnetic stimulation. New neurobiological findings challenge nosological and therapeutic precepts, renewing the cycle in the conceptualization of catatonia. We highlight the affective component of the psychomotor syndrome and the role of interventions aimed at its modulation.

Autismo y catatonía - Aspectos clínicos / Autism and catatonia - Clinical aspects

Resumen El autismo es un desorden del neurodesarrollo caracterizado por una alteración cualitativa en la interacción social y la comunicación, asociada a intereses restringidos y conductas estereotipadas. Puede asociarse a problemas médicos como epilepsia, disfunciones gastrointestinales, trastornos de sueño, otros trastornos del neurodesarrollo como deterioro del lenguaje, discapacidad intelectual, disfunciones sensoriales, TDA/H, torpeza motriz y/o trastornos neuropsiquiátricos como ansiedad, depresión, catatonia, esquizofrenia, trastornos obsesivo-compulsivo, trastornos de conducta e impulsividad, entre otros. La catatonía es reconocida como un síndrome neuropsiquiátrico identificado en todos los trastornos psicóticos y del estado de ánimo mayor, debido a condiciones médicas generales o como un síndrome no especificado de otra manera; esto permite codificar la catatonia en el contexto de otros trastornos psiquiátricos o del neurodesarrollo, como el trastorno obsesivo compulsivo o el autismo. Se caracteriza por síntomas motores, vocales y conductuales anormales, con alteración de la volición y la función vegetativa. Se estima que aproximadamente entre el 8 y 11 % de las personas autistas padecen catatonia. Es probable que haya un subregistro de catatonía, en especial en personas con autismo, debido a la falta de alerta sobre la misma, la heterogenicidad clínica y la similitud de muchos de sus síntomas con manifestaciones del autismo. Incluso muchas veces puede expresarse como una regresión autista tardía desde la pubertad a la vida adulta. Sus bases neurobiológicas aún no son claras y el tratamiento se basa en la administración de bensodiazepinas y la terapia electroconvulsiva, aunque es mucho el camino que aún queda por investigar en estos temas.

Abstract Autism is a neurodevelopmental disorder characterized by a qualitative alteration in social interac tion and communication, associated with restricted interests and stereotyped behaviors. It can be associated with medical problems such as epilepsy, gastrointestinal dysfunction, sleep disorders, other neurodevelopmental disorders such as language impairment, intellectual disability, sensory dysfunction, ADH/D, motor clumsiness, and/or neuropsychiatric disorders such as anxiety, depression, catatonia, schizophrenia, obsessive-compulsive disorders, behavioral and impulsive disorders, among others. Catatonia is recognized as a neuropsychiatric syn drome identified in all major mood and psychotic disorders, due to general medical conditions or as a syndrome not otherwise specified; this allows catatonia to be coded in the context of other psychiatric or neurodevelopmental disorders, such as obsessive-compulsive disorder or autism. It is characterized by abnormal motor, vocal, and behavioral symptoms, with impaired volition and vegetative function. It is estimated that approximately 8-11% of autistic people suffer from catatonia. It is probable that there is an underreporting of catatonia, especially in people with autism, due to the lack of alertness about it, the clinical heterogeneity and the similarity of many of its symptoms with manifestations of autism. Many times it can even express itself as a late autistic regression from puberty to adult life. Its neurobiological bases are still not clear and the treatment is based on the administration of bensodiazepines and electroconvulsive therapy although there is still a long way to go to investigate these issues.

Delirium, catatonía y síndrome de abstinencia manifestados como agitación psicomotora en COVID-19: una propuesta de manejo farmacológico en el hospital general

Background: Neuropsychiatric symptoms can be part of the clinical spectrum of COVID-19 infections. Aim: To devise an evidence based clinical algorithm as a guide for clinicians, to identify and treat underlying clinical syndromes of psychomotor agitation, such as delirium, catatonia or substance withdrawal in patients who are hospitalized and infected with SARS-CoV-2. Material and Methods: A review of the literature about the pharmacological management of neuropsychiatric manifestations of COVID-19 at the general hospital, to develop a clinical protocol based on a consensus from an interdisciplinary expert panel at a Clinical Hospital. Results: A consensual clinical algorithm for the management of delirium, catatonia, and substance withdrawal, manifested as psychomotor agitation in patients hospitalized with COVID-19, was developed as a clinical proposal for physicians at different levels of complexity in health services. Conclusions: Cooperation among different clinical units in the general hospital facilitated the implementation of a clinical algorithm for clinicians for the management of psychomotor agitation in COVID-19 patients.

Síndrome catatónico en una adolescente gambiana: presentación de un caso inusual / Catatonic syndrome in a gambian teenager: an unusual case presentation

RESUMEN Fundamento: la catatonía es una de las presentaciones psiquiátricas más dramáticas, es muy rara en niños y adolescentes, por lo que puede ser mal diagnosticada al confundirse con cuadros psicóticos y provocar la muerte si no es tratada de manera adecuadada. Objetivo: presentar el caso inusual de una adolescente gambiana diagnosticada como un síndrome catatónico. Presentación del caso: adolescente de 14 años de edad, gambiana, femenina, fue ingresada en el Hospital Pediátrico de Banjul; debido a negarse a ingerir alimentos, agua y hablar por una semana. El examen físico reveló aumento de la frecuencia cardíaca, signos de deshidratación moderada, nivel de conciencia estuporoso y rigidez generalizada del cuerpo. Los estudios analíticos e fonomenológicos fueron normales. Se diagnosticó como un síndrome catatónico y luego de recibir tratamiento con lorazepam durante 10 días, fue dada de alta con evolución satisfactoria. Conclusiones: a pesar de ser la catatonía una rara afección, el médico general debe conocer esta enfermedad, con el fin de poner el tratamiento adecuado, para evitar su agravamiento y así preservar la vida de estos pacientes.

ABSTRACT Background: catatonia is one of the most dramatic psychiatric presentations, it is a very rare condition in children and adolescents, it could be misdiagnosed as a psychotic disorder, and could cause death if not treated properly. Objective: to discuss an unusual case of a Gambian female teenager diagnosed of catatonic syndrome. Case report: a 14-year-old Gambian female teenager was admitted to Banjul Pediatric Hospital because she refused to eat, drink or speak for one week. On physical examination she was found to have an increased heart rate, moderate signs of dehydration, stuporous level of consciousness and generalized rigidity of the body. The analytical and phonomenological studies were normal. After being diagnosed of catatonic syndrome and treated with Lorazepam for 10 days, she improved enough and she was satisfactorily discharged. Conclusions: despite the fact that catatonia is a rare condition, the general practitioner must know this pathology, in order to impose the appropriate treatment, avoid its aggravation and thus preserve the life of these patients.

Neutrophil-lymphocyte ratio in catatonia

Abstract Background There is growing evidence of subclinical inflammation in mental disorders. Objective The aim of this study was to investigate frequency of symptoms of catatonia and the newly diagnosed subclinical inflammatory markers which are neutrophil/lymphocyte (NLR), platelet/lymphocyte (PLR), monocyte/lymphocyte (MLR) ratios in catatonia patients due to mental disorders. Methods: Patients who were admitted to psychiatry clinic with the diagnosis of catatonia according to DSM 5 in the last two years and equal number of control group were included in this retrospective study. Univariate analysis of covariance controlled for possible confounders was used to compare NLR, PLR, MLR ratios between patients and the control group. Results A total of 34 catatonia patients and 34 healthy controls were included in the study. Patients' mean age was 30.88 + 13.4. NLR value was significantly higher in the patient group than control group. There was no significant difference between the patients and control group according to PLR, MLR values. Discussion The presence of subclinical inflammation in catatonic syndrome due to mental disorders should be considered. Subclinical inflammation that was observed in numerous mental disorders continues in catatonia due to mental disorders. Large-scale studies are needed to determine the role of inflammation in catatonia.

Síndrome De Cotard Y Catatonía: Reporte De Un Caso / Cotard's Syndrome And Catatonia: A Case Report

Resumen El Síndrome de Cotard es una condición neuropsiquiátrica poco frecuente, descrito inicialmente por Jules Cotard como un delirio hipocondríaco y luego como Delirio de negación, en que el paciente niega la existencia de partes de su cuerpo, la propia existencia y/o del mundo entero. La aparición de un Síndrome Catatónico junto al Síndrome de Cotard es aún más infrecuente. Se presenta el caso de una paciente de 72 años con una Depresión psicótica, que desarrolla un Síndrome de Cotard y posteriormente Catatonía. Logra buena respuesta tras la adición de Lorazepam y Venlafaxina al esquema farmacológico en curso, por lo que se desestima el uso de Terapia Electroconvulsiva. Se constata remisión total de síntomas y posterior recuperación funcional ad integrum, siendo evaluada a través de entrevista clínica, Hamilton Depression Rating Scale, Bush-Francis Catatonia Rating Scale e Índice de Barthel. Además, se revisan otros reportes de caso sobre esta comorbilidad, y a diferencia de la mayoría de éstos, se destaca la favorable evolución de la paciente sin necesidad de Terapia Electroconvulsiva. Aún no se ha dilucidado la relación entre ambos síndromes, aunque algunos autores han planteado la hipótesis de vías neurobiológicas compartidas y otros han postulado la aparición de síntomas catatónicos como la progresión del Síndrome de Cotard. Para aclarar estas interrogantes, son necesarios más estudios al respecto que permitan conocer la etiopatogenia de esta inusual combinación.

Cotard's Syndrome is a rare neuropsychiatric condition, initially described by Jules Cotard as a hypochondriacal delusion and then as Delusion of negation, in which the patient denies the existence of parts of his body, his own existence and / or the entire world. The appearance of a Catatonic Syndrome together with Cotard Syndrome is even more infrequent. We present the case of a 72-year-old patient with a psychotic depression, who developed Cotard's Syndrome and later Catatonia. She achieves good response after the addition of Lorazepam and Venlafaxine to the current pharmacological treatment, so the use of Electroconvulsive Therapy is dismissed. Total remission of symptoms and subsequent functional recovery ad integrum was observed, being evaluated through clinical interview, Hamilton Depression Rating Scale, Bush-Francis Catatonia Rating Scale and Barthel Index. In addition, other case reports on this comorbidity are reviewed, and unlike most of these, the favorable evolution of the patient stands out without the need for Electroconvulsive Therapy. The relationship between the two syndromes has not been elucidated, although some authors have proposed the hypothesis of shared neurobiological pathways and others have postulated the appearance of catatonic symptoms such as the progression of Cotard's Syndrome. To clarify these questions, more studies are needed in order to know the etiopathogenesis of this unusual combination.

Diagnostic Variations and Treatment Responses of Catatonic Patients in the Psychiatric In-Patient Department of a Rural Tertiary Care Centre - A Clinical Study from Eastern India.

This is a cross-sectional descriptive study done in the Psychiatric indoor of North Bengal Medical College between December 2018 to December 2019. Catatonia was diagnosed using DSM-5 criteria in the patients admitted. A total 30 patients were included in the study. The patients were assessed by Bush-Francis Catatonia Rating Scale, were given oral or parenteral lorazepam as needed and observed for 2-3 weeks. Non-responders were given modified ECT as per convention. Background diagnoses were checked by thorough history taking and investigations.RESULTSMajority of the patients were Hindu males in their twenties from rural lower-middle socio-economic families, around 20% of them having family history of affective and psychotic illnesses. They were diagnosed mostly with schizophrenia and other psychotic illnesses (53%) and mood disorders (30%). The mean BFCRS score at the time admission was 20.93 ± 6.16. The commonly found symptoms were mutism, staring, negativism, rigidity, posturing/catalepsy, mannerism, and withdrawal. It was seen that 83.33% of cases responded well to lorazepam only, whereas the rest 13.33% required ECT after non-response or partial response to lorazepam. Only one case after diagnosis with catatonia following organic condition was referred to the Medicine Department. The duration of hospital stay was found to be significantly different [F= 3.58 (>3.35)] among different diagnoses groups (mood disorders, psychotic disorders and others) when the catatonic severity, lorazepam dosage and the duration of treatment response were assessed among those groups using multiple one-way ANOVA.CONCLUSIONSThis study has yielded important findings regarding the age and socio-demographic profiles of the patients, family history of psychiatric disorders, clinical features, and significance of diagnostic variations in relation to the treatment with lorazepam and ECT in catatonic patients in the psychiatric indoor in a tertiary care rural hospital of Eastern India.

Banderas rojas para sospechar encefalitis anti-NMDAr en un primer episodio psicótico: reporte de dos casos / Red flags for suspecting anti-NMDAr encephalitis in a first psychotic episode: report of two cases

RESUMEN La encefalitis asociada a anticuerpos contra el receptor de N-metil-D-Aspartato (NMDAr) es una entidad clínica recientemente descrita con un número creciente de casos reporta dos. Los síntomas psiquiátricos en etapas tempranas de la enfermedad conforman un reto diagnóstico para el médico tratante. Presentamos dos casos clínicos: el caso clínico 1, un hombre de 26 arios y el caso clínico 2, un joven de 18 arios, ambos abordados como primer episodio de psicosis y hospitalizados en instituciones psiquiátricas. Posteriormente, ambos casos fueron diagnosticados como encefalitis anti-NMDAr. La alta prevalencia de síntomas psiquiátricos en la encefalis anti-NMDAr demanda a los médicos psiquiatras y neurólogos a tener un alto índice de sospecha en presencia de síntomas atípicos en pacientes evaluados por primer episodio de psicosis.

ABSTRACT Anti-N-methyl-D-Aspartate receptor (NMDAr) encephalitis is a recently described clinical entity with an increasing number of reported cases. Psychiatric symptoms in the early stages of the disease constitute a diagnostic challenge for the treating physician. We present two clinical cases: clinical case 1, a 26-year-old man, and clinical case 2, an 18-year-old man; both presented with a first episode of psychosis and were hospitalized as psychiatric disorders. Subsequently, both cases were diagnosed as anti-NMDAr encephalitis. The high prevalence of psychiatric symptoms in anti-NMDAr encephalitis forces psychiatrists and neurologists to have a high degree of suspicion in the presence of atypical symptoms in patients evaluated for the first episode of psychosis.

A Descriptive Study on the Phenomenology of Catatonia in a Tertiary Care Hospital

Introduction: Catatonia is a complex syndrome with multiple disorders involving behavior, mood, thought process, and themotor system. About 7–15% of inpatients in psychiatry are identified with catatonia. Published literature on the phenomenologyof catatonia in India is available only as case reports.Aim: The aim of the study was to study phenomenology, clinical profile, and diagnostic break up in patients presenting withcatatonia to our hospital.Materials and Methods: A cross-sectional descriptive study including 32 catatonia patients was conducted in the PsychiatryDepartment, Chengalpattu Medical College Hospital after obtaining Institutional Ethical Committee clearance. Informed consentwas obtained from the patients caretakers. Disorders and Statistical Manual of Mental Disorders-5th Edition criteria for catatoniawere used to include patients in this study. Using a semi-structured pro forma basic sociodemographic and clinical details werecollected. Bush-Francis Catatonia Rating Scale (BFCRS) was used to assess the symptoms and severity.Results: The mean age of the study population was 33.16 ± 12.28 years (range 15–60 years) with 15 males (46.8%) and17 females (53.1%). Among the catatonia patients, schizophrenia (n = 15, 50%) was the most common diagnosis after detailedevaluation. The mean BFCRS score was 27.47 ± 3.94 (range: 18–32). The commonly observed catatonic symptoms weremutism, withdrawal, staring, immobility, and negativism (100%) followed by posturing/catalepsy (97%) and rigidity (93%).Conclusion: This study has provided us with very important insights into the phenomenology, clinical profile, and diagnosticbreak up in catatonic patients following mental disorder. Schizophrenia was the most common diagnosis with mutism, withdrawal,staring, immobility, and negativism being the more common symptoms.

Respuesta ultrarrápida a la terapia electroconvulsiva en un caso de trastorno psicótico agudo polimorfo / Ultra rapid response to electroconvulsive therapy in a case of acute polymorphic psychotic disorder

Existe la errónea percepción de que la Terapia Electroconvulsiva (TEC) debe usarse como último recurso de manejo psiquiátrico y únicamente en casos crónicos y/o refractarios. Esto, entre otras causas, ha llevado a la lamentable disminución de su empleo a lo largo de los últimos tiempos en nuestro medio y en otras latitudes. Sin embargo, las psicosis agudas con síntomas motores de tipo catatoniforme presentan tasas de respuesta de hasta 100% y la TEC debiera, por ende, hallarse en la primera línea de los recursos de tratamiento para estos cuadros, evitando o previniendo, de ese modo, connsecuencias ominosas de la catatonía. A propósito de un cuadro de trastorno psicótico agudo polimorfo sin síntomas de esquizofrenia (F23.0, CIE-10) que presentó remisión completa de síntomas catatónicos y psicóticos luego de una sola sesión de TEC (lo que es, de hecho, un resultado infrecuente), se realiza una revisión de la literatura pertinente. Se concluye que la TEC debiera retomar su relevancia en casos psicóticos agudos de buen pronóstico, en los que su postergación acarreará consecuencias innecesariamente negativas.

There is an erroneous perception that Electroconvulsive Therapy (ECT) should be used as a last resource of psychiatric management and only in chronic and refractory cases. This, among other causes, has led to an unfortunate decrement in its use during recent times both in our country and in other places. However, acute psychoses with catatoniform or motility symptoms have high favorable response rates, up to 100%, and ECT should, therefore, be a first line treatment resource for these disorders in order to prevent or avoid the occurrence of catatonia´s ominous consequences. The case of a patient with diagnosis of acute polymorphic psychotic disorder without symptoms of schizophrenia (F23.0, ICD-10) is presented. The patient achieved a complete remission of his catatonic and psychotic symptoms with a single session of ECT - an infrequent event by itself-. On this basis, e review of pertinent literature is conducted, and it is concluded that the ECT should resume its relevance in the management of acute cases with a good prognosis, as its postponement would bring up unnecessarily negative consequences.

Mediating effect of trait coping style on nurses' occupational stress and fatigue / 中国基层医药

Objective@#To investigate the fatigue status and influencing factors of nurses, and to evaluate whether trait coping styles mediate the relationship between occupational stress and fatigue.@*Methods@#A total of 167 nurses in Shaoxing Municipal Hospital were selected by cluster random sampling in April, 2018.Their fatigue status was assessed by Chinese version of multidimensional fatigue scale, occupational stress was assessed by occupational stress inventory revised edition, and trait coping style was assessed by trait coping style questionnaire.The data were analyzed by SPSS22.0.@*Results@#A total of 164 valid questionnaires were obtained, the physical fatigue score was (22.9±9.3)points, the decreased activity score was (6.7±2.7)points, the decreased motivation score was (6.6±2.6)points, the mental fatigue score was (9.0±4.0)points, the total fatigue score was (47.3±13.5)points.The total fatigue scores of nurses with different ages(F=2.520, P=0.043), nursing years(F=3.388, P=0.020), educational background(t=-2.571, P=0.011), professional title(F=3.743, P=0.026), departments(F=4.412, P=0.001) and night shift frequency(F=3.412, P=0.019) were significantly different.The total fatigue scores were positively correlated with negative coping(r=0.274, P=0.009), occupational tasks(r=0.351, P=0.007) and stress response(r=0.348, P=0.004) respectively.Negative coping styles partially mediated the relationship between occupational stress and fatigue.The total effect of occupational stress on fatigue was 0.066, the ratio of negative coping to total effect was 49.62%.@*Conclusion@#There are many factors influencing nurses' fatigue, and negative coping styles play a mediating role between occupational stress and fatigue.

Mediating effect of trait coping style on nurses' occupational stress and fatigue / 中国基层医药

Objective To investigate the fatigue status and influencing factors of nurses,and to evaluate whether trait coping styles mediate the relationship between occupational stress and fatigue.Methods A total of 167 nurses in Shaoxing Municipal Hospital were selected by cluster random sampling in April,2018.Their fatigue status was assessed by Chinese version of multidimensional fatigue scale,occupational stress was assessed by occupational stress inventory revised edition,and trait coping style was assessed by trait coping style questionnaire.The data were analyzed by SPSS22.0.Results A total of 164 valid questionnaires were obtained,the physical fatigue score was (22.9 ± 9.3) points,the decreased activity score was (6.7 ± 2.7) points,the decreased motivation score was (6.6 ± 2.6) points,the mental fatigue score was (9.0 ± 4.0) points,the total fatigue score was (47.3 ± 13.5) points.The total fatigue scores of nurses with different ages(F =2.520,P =0.043),nursing years(F =3.388,P =0.020),educational background(t =-2.571,P =0.011),professional tide (F =3.743,P =0.026),departments (F =4.412,P =0.001) and night shift frequency (F =3.412,P =0.019) were significantly different.The total fatigue scores were positively correlated with negative coping (r =0.274,P =0.009),occupational tasks (r =0.351,P =0.007) and stress response (r =0.348,P =0.004) respectively.Negative coping styles partially mediated the relationship between occupational stress and fatigue.The total effect of occupational stress on fatigue was 0.066,the ratio of negative coping to total effect was 49.62％.Conclusion There are many factors influencing nurses'fatigue,and negative coping styles play a mediating role between occupational stress and fatigue.

Viraje de fase maníaca a catatonía por noxa somática aguda / Manic phase shift to catatonia by acute somatic noxa

El síndrome catatónico como entidad neuropsiquiátrica ha sufrido cambios conceptuales a través de la historia, incluyendo tanto la clínica de su presentación como sus posibles causas. Éste último elemento cobra especial importancia, dado que la catatonía puede presentarse tanto por diversos cuadros médicos así como por patología psiquiátrica primaria. Se presenta el caso clínico de una paciente con antecedente de trastorno afectivo bipolar ingresada por un episodio maníaco con síntomas psicóticos asociados a un evento vital estresante. La paciente, durante una infección respiratoria baja, cambia su presentación clínica, objetivándose elementos propios de un estupor depresivo y síndrome catatónico. Una vez tratado el cuadro infeccioso y descartadas las causas neurológicas de la catatonía, se realizó tratamiento con benzodiacepinas, iniciándose luego fármacos para depresión bipolar, obteniéndose excelente respuesta clínica. Se pretende en este reporte dar a conocer la importancia de detectar elementos catatoniformes en pacientes psiquiátricos ingresados en unidades de corta estadía, así como buscar siempre posibles causas médicas relacionadas.

The catatonic syndrome as a neuropsychiatric entity has undergone conceptual changes throughout history, including both the clinical presentation and its possible causes. This last element is particularly important, given that catatonia can occur both in different medical situations as well as in primary psychiatric pathology. We present the clinical case of a patient with a history of bipolar affective disorder, hospitalized because of a manic episode with psychotic symptoms associated with a stressful life event. The patient, during a low respiratory infection, changes its clinical presentation, with elements of a depressive stupor and catatonic syndrome. Once the infectious symptoms were treated and the neurological causes of catatonia were ruled out, treatment with benzodiazepines was carried out, and then drugs for bipolar depression were started, obtaining an excellent clinical response. The aim of this report is to make known the importance of detecting catatoniform elements in psychiatric patients admitted to short-stay units, as well as to look for possible related medical causes.

Síndrome de Cotard, catatonía y depresión: reporte de un caso / Cotard's syndrome, catatonia and depression: A case report

El síndrome de Cotard es una condición psiquiátrica relativamente infrecuente y de características clínicas a veces dramáticas. El paciente niega la existencia de algunas partes de su cuerpo, o incluso, su propia existencia. Inicialmente descrito por Jules Cotard en 1880, este síndrome ha pasado por varias vicisitudes conceptuales a lo largo de su historia. Actualmente las delusiones de negación o nihilistas se consideran como sinónimos del síndrome de Cotard, en tanto que la presencia de síntomas catatónicos ha sido generalmente descrita como poco frecuente. Se presenta el caso de un paciente varón de 47 años con trastorno depresivo mayor que desarrolló un síndrome de Cotard y catatonía; el paciente mejoró consistentemente con venlafaxina 150 mg/día, aripiprazol 15 mg/día y diazepam 40 mg/día después de cuatro semanas. El artículo se complementa con una revisión de la literatura en torno al síndrome.

Cotard's syndrome is a relatively rare psychiatric condition, with sometimes dramatic clinical characteristics. The patient so diagnosed denies the existence of some parts of his body, or even, his or her own existence. Initially described by Jules Cotard in 1880, the history of this syndrome has gone through a variety of conceptual vicissitudes. Nowadays, denying or nihilist delusions are considered as a synonym of Cotard's syndrome, while the presence of catatonic symptoms has been described as fairly infrequent. The case of a 47-year-old male patient with major depressive disorder who developed Cotard's syndrome and catatonia is presented; he was treated with venlafaxine 150 mg/day, aripiprazole 15 mg/day and diazepam 40 mg/day, showing a consistent improvement after four weeks. A literature review about Cotard syndrome complements the case discussion.

Catatonia y delirium: síndromes que pueden confluir en el paciente neuropsiquiátrico / Catatonia and Delirium: Syndromes that may Converge in the Neuropsychiatrie Patient

Resumen Introducción: La catatonia y el delírium son 2 síndromes diferentes e independientes. La catatonia es un síndrome psicomotor asociado a una variedad de enfermedades de diferentes causas médicas y está caracterizado por ausencia de actividad, inducción de posturas pasivas contra gravedad, la oposición o ausencia de respuesta ante estímulos externos, flexibilidad cérea, estereotipias, manierismos y ecofenómenos, entre otros. El delirium se caracteriza por alteraciones de la conciencia y cognitivas, principalmente atención y orientación, habitualmente de aparición aguda, que tiende a fluctuar durante el día y con evidencia de que la alteración es una consecuencia fisiológica directa de una enfermedad, una intoxicación o la abstinencia de alguna sustancia. A pesar de las diferencias y que las clasificaciones excluyen la posibilidad de que estos síndromes puedan presentarse juntos, varios reportes de casos y estudios en grupos de pacientes han planteado que pueden darse las 2 condiciones conjuntamente. Material y métodos: En el presente estudio se detectó a 16 pacientes hospitalizados en quienes concomitaban ambos síndromes, identificados mediante la escala Delirium rating scale-R (DRS-98) y la escala de Bush y Francis de Catatonia (BFCRS). Resultados: Se siguió el desenlace durante la hospitalización y su condición clínica al egreso. Estos pacientes en su mayoría tenían diagnósticos neurológicos, tuvieron una hospitalización larga, requirieron tratamiento con antipsicóticos y benzodiacepinas y sufrieron frecuentes complicaciones. Conclusiones: Catatonia y delirium son síndromes que pueden presentarse al mismo tiempo, lo que lleva a que los pacientes tengan peor desenlace y mayor riesgo de complicaciones.

Abstract Introduction: Catatonia and delirium are two different and independent syndromes. Catatonia is a psychomotor syndrome associated with a variety of diseases of different medical causes and is characterised by lack of activity, induction of passive postures against gravity, opposition or absence of response to external stimuli, waxy flexibility, stereotypies, mannerisms and echophenomena. Delirium is characterised by consciousness and cognitive alterations, mainly attention and orientation and usually of acute onset, which tend to fluctuate during the day and with evidence that the alteration is a direct physiological consequence of a disease, intoxication or substance withdrawal. Despite the differences and the fact that the classifications exclude the possibility that these syndromes may manifest together, several case reports and studies in groups of patients have postulated that the two conditions can occur together. Material and methods: In this study we identified 16 hospitalised patients who experienced both syndromes at the same time as confirmed by the Delirium Rating Scale-Revised (DRS-98) and the Bush-Francis Catatonia Rating Scale (BFCRS). Results: Patient outcome was followed during hospitalisation and the patients' clinical condition upon discharge. These patients had mostly neurological diagnoses, long hospital stays, required treatment with antipsychotics and benzodiazepines and had frequent complications. Conclusions: Catatonia and delirium are syndromes that can present at the same time, resulting in worse patient outcome and an increased risk of complications.

Encefalitis por anticuerpos contra receptores de N-metil-D-aspartato y síndrome de DRESS secundario a fenitoína: Reporte de un caso / Encephalitis by anti-N-Methyl-D-Aspartate receptor antibodies and DRESS syndrome secondary to phenytoin: A case report

La encefalitis debida a anticuerpos contra receptores N-metil-D-aspartato (NMDA)es una entidad potencialmente tratable, caracterizada por síntomas neuropsiquiátricos que incluyen crisis epilépticas, alteración de conciencia, catatonía y trastornos autonómicos, y desencadenada por una respuesta inmunológica mediada por antígenos. A su vez, el síndrome DRESS (sigla en inglés de Reacción a drogas con eosinofília y síntomas sistémicos) es un cuadro de hipersensibilidad retardada mediada por células, frecuentemente asociada a fármacos antiepilépticos aromáticos. Se presenta el caso de una paciente joven que debutó con crisis epilépticas inicialmente fármaco-sensibles, desarrolló luego el síndrome de DRESS secundario a fenitoína. Cursó posteriormente con trastornos de memoria y lenguaje, alteraciones conductuales y estado catatónico y presentó anticuerpos contra receptores NMDA en el líquido cefalorraquídeo. Ambas entidades respondieron a inmunoterapia con corticoides, lo cual contribuiría a explicar una asociación fisiopatogénica entre estas dos entidades inmunomediadas.

N-Methyl-D-Aspartate receptor encephalitis is a potentially treatable entity characterized by neuropsychiatric symptoms including epileptic seizures, disruption of consciousness, catatonia, and autonomic disorders, and triggered by an immunological response mediated by an antigen. In turn, the DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a delayed cell-mediated hypersensitivity reaction, frequently associated with antiepileptic aromatic drugs. The case is presented of a young patient who debuted with epileptic seizures initially drug-sensitive, developedthen DRESS syndrome secondary to the use of phenytoin, and later presented disorders of memory and language, behavioral alterations and catatonic state, and presented anti- NMDA receptor antibodies in CSF. Both entities responded to corticoid immuno-therapy, which could contribute to explain a pathogenic association between these two immunomediated entities.

Catatonia, beyond a psychiatric syndrome / Catatonia, além de uma síndrome psiquiátrica

ABSTRACT Although catatonia is a well-known psychiatric syndrome, there are many possible systemic and neurological etiologies. The aim of this case report was to present a case of a patient with cerebral venous sinus thrombosis and infarction in which catatonia was the clinical manifestation of a possible nonconvulsive status epilepticus. To our knowledge, only one such case has been reported in the literature, which had a simplified diagnostic investigation. It is important to correctly recognize the organic cause underlying catatonia in order to treat the patient as soon as possible thereby improving outcome. Therefore, physicians need to update their knowledge on catatonia, recognizing that it can be part of a psychiatric or neurologic condition.

RESUMO Embora a catatonia seja uma síndrome psiquiátrica bem conhecida, existem várias etiologias possíveis, tanto sistêmicas quanto neurológicas. O objetivo deste relato de caso é apresentar um quadro de trombose venosa central com infarto venoso em que a catatonia foi a manifestação clínica de um possível status não convulsivo. Na concepção dos autores, apenas um caso é encontrado na literatura, porém com uma propedêutica simplificada. É importante o correto reconhecimento das causas orgânicas que podem estar causando a catatonia para que sejam corrigidas assim que possível, melhorando o prognóstico do paciente. Além disso, os médicos precisam atualizar seus conhecimentos sobre a catatonia, uma vez que ela pode ser parte tanto de uma condição psiquiátrica quanto neurológica.

Catatonia ictal en el Servicio de Urgencia: una rara forma de presentación del estado epiléptico no convulsivo / Ictal catatonia presentation as a non-convulsive status epilepticus: a case report

The differential diagnosis of non-convulsive status epilepticus (NCSE) is often complex due to a wide clinical variability of its presentation, including psychiatric manifestations. We report a 68 years old male with a history of depression treated with venlafaxine, mirtazapine, quetiapine and risperidone, presenting in the emergency room with confusion and generalized rigidity. A brain CT scan did not show lesions. A neuroleptic syndrome was initially suspected. At the third day the obtundation worsened and an electroencephalogram (EEG) was performed, which showed epileptiform abnormalities. Treatment with valproic acid resulted in disappearance of such abnormalities. After three weeks of mechanical ventilation, the patient was extubated and remained lucid and partially orientated in time and space.

Development and validation of the Bush-Francis Catatonia Rating Scale - Brazilian version / Desenvolvimento e validação da versão brasileira da escala de classificação de Bush-Francis para catatonia

ABSTRACT Objective: This article aims to describe the adaptation and translation process of the Bush-Francis Catatonia Rating Scale (BFCRS) and its reduced version, the Bush-Francis Catatonia Screening Instrument (BFCSI) for Brazilian Portuguese, as well as its validation. Methods: Semantic equivalence processes included four steps: translation, back translation, evaluation of semantic equivalence and a pilot-study. Validation consisted of simultaneous applications of the instrument in Portuguese by two examiners in 30 catatonic and 30 non-catatonic patients. Results: Total scores averaged 20.07 for the complete scale and 7.80 for its reduced version among catatonic patients, compared with 0.47 and 0.20 among non-catatonic patients, respectively. Overall values of inter-rater reliability of the instruments were 0.97 for the BFCSI and 0.96 for the BFCRS. Conclusion: The scale's version in Portuguese proved to be valid and was able to distinguish between catatonic and non-catatonic patients. It was also reliable, with inter-evaluator reliability indexes as high as those of the original instrument.

RESUMO Objetivo: O artigo tem como objetivo descrever o processo de tradução e adaptação da Escala de Catatonia Bush-Francis (ECBF) e de sua versão reduzida (ICBF) para o Português, bem como sua validação. Métodos: O processo de equivalência semântica foi realizado em quatro passos: tradução, retro-tradução, avaliação da equivalência semântica e estudo-piloto. A validação consistiu em aplicações dos instrumentos em português simultâneas por dois avaliadores em 30 pacientes com catatonia e 30 pacientes sem catatonia. Resultados: Média dos escores totais em pacientes catatônicos foi de 20,07 para a versão completa e 7,80 para versão reduzida, contra 0,47 e 0,20 em pacientes não-catatônicos respectivamente. Valores gerais para confiabilidade inter-observador dos instrumentos foi de 0,97 para ICBF e 0,96 para ECBF. Conclusão: A versão em Português da escala provou ser válida e capaz de diferenciar pacientes catatônicos daqueles sem catatonia. Também mostrou ser confiável, com índices inter-avaliadores tão altos quanto no instrumento original.

A Case of Catatonia Later Diagnosed with NMDA Receptor Encephalitis / 대한정신분열병학회지

We report a case of a young female patient with catatonic features who later turned out to be suffering from an anti-NMDA (N-methyl-D-aspartate)-receptor-antibody encephalitis. A previously healthy 21-year-old woman was admitted to psychiatric inpatient care presenting with acute psychotic behavior with catatonic features. Laboratory tests of serum and CSF (Cerebrospinal fluid), EEG (Electroencephalogram), brain MRI (Magnetic Resonance Imaging) were unremarkable except vague slow wave on EEG. However, subtle cognitive impairment at the bedside examination suggested further imaging studies to rule out possible organic etiology like autoimmune encephalitis. Brain PET (Positron Emission Tomography) and SPECT (Single Photon Emission Computed Tomography) suggested probable inflammation in the brain. In case of autoimmune encephalitis, given the severity of symptoms and worsening course, steroid pulse therapy was initiated promptly even though the diagnosis was not confirmed but presumed at that time. She recovered completely with steroid therapy. Later her disease turned out to be anti-NMDA-receptor-antibody encephalitis by the antibody test which was not available at the time of admission. Psychiatrists need to be aware of autoimmune encephalitis like anti-NMDA-receptor-antibody encephalitis in the differential diagnosis of acute psychosis with catatonic features. Subtle cognitive impairment which tends to be overlooked due to catatonic features might be a clue to suspect the organic etiology.