Catatonia in the medically ill: Differences and parallels in etiology, phenomenology and management.

OBJECTIVE: Catatonia is a disorder characterized by psychomotor symptoms. The etiology, symptomatology, response and outcome of catatonia in the medically ill has not been vigorously studied. Those who have catatonia associated with another mental disorder versus. catatonic disorder due to another medical condition may differ. The aim of this study is to study the causes, phenomenology and outcomes of medically ill patients with catatonia and explore differences among those who have catatonia associated with psychiatric illness vs. systemic medical illness. METHOD: We studied the incidence of catatonic symptoms in medically hospitalized patients to identify any apparent differences in clinical manifestations due to distinctive etiologies. Specifically, we assessed if there are differences between those who had catatonia associated with another mental disorder versus those with catatonic disorder due to another medical condition in their phenomenology, management and likelihood of response to treatment. RESULTS: Of our 40 patients, 18 patients (45%) had catatonia associated with another mental disorder, 17 (42.5%) had catatonic disorder due to another medical condition, and in 5 patients (12.5%) the cause of catatonia was not identified. The most common catatonic symptoms regardless of etiology in our medically ill were mutism, followed by rigidity, and immobility. Bipolar disorder, schizophrenia, major depressive disorder, metabolic abnormalities, anti NMDAR encephalitis were the most frequent causes of catatonia in our medically ill patients. Compared to subjects with catatonic disorder due to another medical condition, those with catatonia associated with another mental disorder had more frequent mannerisms (Chi-square = 4.27; p = 0.039), waxy flexibility (Chi-square = 11.0; p < 0.01), and impulsivity (Chi-square = 4.12, p = 0.042). Nonsignificant trends were noted for posturing (Chi-square = 3.74, p = 0.053), perseveration (Chi-square = 3.37, p = 0.067), and stereotypy (Chi-square = 2.91, p = 0.088) also being more frequent in catatonia associated with a psychiatric cause. DISCUSSION: Our data supports phenomenological differences between medical and psychiatric causes of catatonia in the medically ill.

OPQRST(U): Integrating substance use disorders or "Use" into the medical history.

Substance use disorders (SUDs) are pervasive in the United States, with 20.1 million cases in 2016, of which only 19% receive treatment. SUDs permeate all medical specialties and should be considered in the differential diagnosis of every chief complaint. Acknowledging the salience of SUDs provides a unique opportunity for early identification and intervention. Thus, SUDs should be reflected prominently in the history of the present illness rather than in the social history. To this effect, we propose the inclusion of Use (U) in the history of present illness and incorporating "U" into the pedagogical mnemonic of OPQRST that is commonly used in medical training. Obtaining this history will help determine if and which abused substances may be contributing to the chief complaint. We also suggest the incorporation of an additional acronym, SORTED, to account for the various domains of Use, including Street (illicit drugs), OTCs (over-the-counter medications), Rx (prescriptions, including nonmedicinal use of pharmaceutical drugs), Tobacco (including e-cigarettes), EtOH (alcohol), and Dietary (caffeine, vitamins, and herbal supplements) agents. We discuss how utilizing OPQRSTU will help reshape the way medical students think about SUDs and will facilitate detection and diagnosis of all domains of SUDs.