The Use of Physical Exam in Assessment for Catatonia: Has COVID-19 Impacted Diagnosis Rates?

ABSTRACT

Background: Catatonia is a syndrome comprised of motor and behavioral symptoms that can have many different etiologies including psychiatric and neuromedical1. The modified Bush-Francis Catatonia Rating Scale (BFCRS) is a widely used screening instrument used for both diagnostic and symptom-severity tracking purposes. BFCRS items can be assessed through observation (patient or chart), verbal interactions, and physical exam. The COVID-19 pandemic has introduced limitations in hands-on evaluation due to infection control measures. We conducted a literature review to assess how often physical exam findings are used in diagnosing catatonia and hypothesize whether the pandemic is increasing under-diagnosis of catatonia. Method: We conducted a search of PubMed, Medline, and psycINFO of case reports from 1996 (when the BFCRS was published2) to present day for each individual item on the BFCRS that appeared in the title and/or and excluded publications that did not use the search terms to describe patient symptoms or did not describe catatonia. We then compared the relative appearances of the physical exam items to the non-physical exam items over the past 25 years. Finally, we compared the number of reports collected June 2020 – May 2021 (to approximate cases occurring from March 2020 – February 2021 during the height of COVID) to the average over the previous 25 years and previous 10 years, to determine if there were less reported cases of catatonia during COVID compared to previous years. Results: The most commonly reported symptoms were mutism (19.4%, z=20.1), immobility/stupor (19.1%, z=19.7), posturing/catalepsy (12.2%, z=10.5), and rigidity (9.3%, z=6.6), chi2=88.2, p < 0.0001. Physical exam symptoms were reported less frequently (14.8% of cases) compared to observed (55.1%) and interviewed symptoms (30.1%), chi2=115.19, p < 0.0001. Physical exam symptoms occurred less frequently than expected (14.8% vs 21.7%) based on number of criteria, chi2=21.34, p < 0.0001. There was no decrease in case reports in June 2020 – May 2021;case reports during COVID made up 8.9% of reports in the last 25 years, and 15.9% of reports in the last 10 years, chi2=13.56, p = 0.0002. Discussion: Our data suggests that physical exam items in the BFCRS are used less frequently than non-physical exam items when diagnosing catatonia. Despite a pandemic with increased isolation precautions, the collected data from case reports suggests that there was not a significant increase in missed catatonia diagnoses. However, catatonia is an under-diagnosed condition generally and physical exam of a suspected catatonic patient by a psychiatrist can be a key element to accurate diagnosis.3 Conclusion: While our literature review has limitations (e.g. searching for terms available only in the title and , not in the body of the paper), we feel confident in saying that physical-exam findings are not used as frequently as non-physical exam findings in diagnosing catatonia. While the physical exam should always be done when possible and can lead to more accurate diagnoses, we do not feel that any potential reduction in physical exams during the pandemic has lead to a significant increase in missed catatonia diagnoses. References 1. Rosebush PI, Mazurek MF. Catatonia and its treatment. Schizophr Bull. 2010 Mar;36(2) 239-42. 2. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2) 129-136. 3. Walther S, Stegmayer K, Wilson JE, Heckers S. Structure and neural mechanisms of catatonia. Lancet Psychiatry. 2019 Jul;6(7)610-619.