32ournal of Neurology, Neurosurgery, and Psychiatry 1996;60:326-332 Catatonia in depression: prevalence, clinical correlates, and validation of a scale Sergio E Starkstein, Gustavo Petracca, Alejandra Teson, Eran Chemerinski, Marcelo Merello, Ricardo Migliorelli, Ramon Leiguarda Abstract Objectives-To examine the clinical cor- relates of catatonia in depression, to vali- date a scale for catatonia, and to assess the validity of the DSM-IV criteria of the catatonic features specifier for mood dis- orders. Methods-A series of 79 consecutive patients with depression and 41 patients with Parkinson's disease without depres- sion were examined using the modified Rogers scale (MRS), the unified Parkinson's disease rating scale (UPDRS), and the structured clinical interview for DSM-III-R (SCID). Results-Sixteen of the 79 depressed patients (20%) had catatonia. Depressed patients with catatonia had significantly higher scores on the MRS than non-cata- tonic depressed patients matched for severity of depression, or non-depressed patients with Parkinson's disease matched for severity of motor impair- ment. Depressed patients with catatonia were older, had a significantly higher fre- quency of major depression, more severe cognitive impairments, and more severe deficits in activities of daily living than depressed non-catatonic patients. The DSM-IV criteria of catatonia separated depressed catatonic patients from patients with Parkinson's disease matched for motor impairment, with a specificity of 100%. Catatonic signs did not improve after apomorphine. Conclusions-catatonia is most prevalent among elderly patients with severe depression. The study showed the validity of the MRS for the diagnosis of catatonia in depressed patients, as well as the speci- ficity of the DSM-IV criteria of the cata- tonic features specifier. (3 Neurol Neurosurg Psychiatry 1996;60:326-332) Keywords: catatonia; depression; dopamine; Parkinson's disease In 1843 the French psychiatrist Baillarger described a delusional syndrome in alienated patients occurring in a state of stupor, with fixed gaze, a facial expression of frozen aston- ishment, muteness, and indifference.' As these patients also had suicidal ideation, Baillarger termed this state "melancholie avec stupeur". Thirty nine years later, Kahlbaum described a state "in which the patient remains completely mute and immobile, with staring expression, gaze fixed into space, with an apparent com- plete loss of will, no reaction to sensory stim- uli, sometimes with the symptom of waxy flexibility completely developed, as in catalepsy, sometimes of a mild degree, but clearly recognisable," and labelled this state "vesania katatonica".2 Stressing that catatonia was not related to "affective" melancholy sensu strictu, Wernicke suggested the term "motilitatpsychose", and suggested that this disorder may be the result of dysfunction of a "psychomotor path", producing either akine- sis, parakinesis, or hyperkinesis.3 Whereas Kahlbaum and Wernicke placed catatonia within the range of the affective disorders, Kraepelin4 considered catatonia as a type of schizophrenia, and this disorder aroused little interest until recently. In a series of studies, Taylor and Abrams' and Abrams and Taylor6 found catatonic signs such as stereotypies, posturing, catalepsy, automatic obedience, negativism, echolalia, echopraxia, or stupor in more than a quarter of a consecutive series of patients with mania. In a study that included 55 consecutive psy- chiatric admissions of patients featuring one or more catatonic signs, Abrams and Taylor found that over two thirds had an affective dis- order.6 On the other hand, motor disorders have often been reported in depressed patients. Rogers et al7 showed that patients with primary depression and newly diagnosed patients with Parkinson's disease had a slower response on a computerised task than normal control subjects. A follow up evaluation six months later showed that both in patients with Parkinson's disease and in depressed patients, improvement in mood was significantly associ- ated with improvement on the psychomotor task. Fleminger8 also showed that patients with depressive motor retardation had raised scores on a clinical rating scale of parkinsonian signs, but he also found significant differences between the movement disorder in depressed patients and that in patients with Parkinson's disease. Despite these important studies, several issues regarding catatonia still remain unsolved. Firstly, there is only one structured scale for the assessment of catatonic signs (the modified Rogers scale (MRS))9 and this scale has only been assessed with schizophrenic patients. Secondly, whether the DSM-IV"0 cri- teria of catatonia (catatonic features specifier of mood disorder) can distinguish depressed patients with catatonia from phenomenologi- cally similar disorders (for example, severe Department of Neuropsychiatry E Starkstein G Petracca A Tes6n E Chemerinski R Migliorelli R Carrea Department of Clinical Neurology, Institute of Neurological Research, Buenos Aires, Argentina S E Starkstein M Merello R Leiguarda Correspondence to: Dr Sergio E Starkstein, Raul Carrea Institute of Neurological Research, Montaineses 2325,1428 Buenos Aires, Argentina. Received 18 April 1995 and in revised form 25 September 1995 Accepted 31 October 1995 326 on 13 July 2018 by guest. Protected by copyright. http://jnnp.bmj.com/ J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.3.326 on 1 March 1996. Downloaded from
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32ournal ofNeurology, Neurosurgery, and Psychiatry 1996;60:326-332
Catatonia in depression: prevalence, clinicalcorrelates, and validation of a scale
Sergio E Starkstein, Gustavo Petracca, Alejandra Teson, Eran Chemerinski,Marcelo Merello, Ricardo Migliorelli, Ramon Leiguarda
AbstractObjectives-To examine the clinical cor-relates of catatonia in depression, to vali-date a scale for catatonia, and to assessthe validity of the DSM-IV criteria of thecatatonic features specifier for mood dis-orders.Methods-A series of 79 consecutivepatients with depression and 41 patientswith Parkinson's disease without depres-sion were examined using the modifiedRogers scale (MRS), the unifiedParkinson's disease rating scale(UPDRS), and the structured clinicalinterview for DSM-III-R (SCID).Results-Sixteen of the 79 depressedpatients (20%) had catatonia. Depressedpatients with catatonia had significantlyhigher scores on the MRS than non-cata-tonic depressed patients matched forseverity of depression, or non-depressedpatients with Parkinson's diseasematched for severity of motor impair-ment. Depressed patients with catatoniawere older, had a significantly higher fre-quency of major depression, more severecognitive impairments, and more severedeficits in activities of daily living thandepressed non-catatonic patients. TheDSM-IV criteria of catatonia separateddepressed catatonic patients frompatients with Parkinson's diseasematched for motor impairment, with aspecificity of 100%. Catatonic signs didnot improve after apomorphine.Conclusions-catatonia is most prevalentamong elderly patients with severedepression. The study showed the validityof the MRS for the diagnosis of catatoniain depressed patients, as well as the speci-ficity of the DSM-IV criteria of the cata-tonic features specifier.
In 1843 the French psychiatrist Baillargerdescribed a delusional syndrome in alienatedpatients occurring in a state of stupor, withfixed gaze, a facial expression of frozen aston-ishment, muteness, and indifference.' As thesepatients also had suicidal ideation, Baillargertermed this state "melancholie avec stupeur".Thirty nine years later, Kahlbaum described astate "in which the patient remains completely
mute and immobile, with staring expression,gaze fixed into space, with an apparent com-plete loss of will, no reaction to sensory stim-uli, sometimes with the symptom of waxyflexibility completely developed, as incatalepsy, sometimes of a mild degree, butclearly recognisable," and labelled this state"vesania katatonica".2 Stressing that catatoniawas not related to "affective" melancholysensu strictu, Wernicke suggested the term"motilitatpsychose", and suggested that thisdisorder may be the result of dysfunction of a"psychomotor path", producing either akine-sis, parakinesis, or hyperkinesis.3 WhereasKahlbaum and Wernicke placed catatoniawithin the range of the affective disorders,Kraepelin4 considered catatonia as a type ofschizophrenia, and this disorder aroused littleinterest until recently.
In a series of studies, Taylor and Abrams'and Abrams and Taylor6 found catatonic signssuch as stereotypies, posturing, catalepsy,automatic obedience, negativism, echolalia,echopraxia, or stupor in more than a quarterof a consecutive series of patients with mania.In a study that included 55 consecutive psy-chiatric admissions of patients featuring one ormore catatonic signs, Abrams and Taylorfound that over two thirds had an affective dis-order.6 On the other hand, motor disordershave often been reported in depressedpatients. Rogers et al7 showed that patientswith primary depression and newly diagnosedpatients with Parkinson's disease had a slowerresponse on a computerised task than normalcontrol subjects. A follow up evaluation sixmonths later showed that both in patients withParkinson's disease and in depressed patients,improvement in mood was significantly associ-ated with improvement on the psychomotortask. Fleminger8 also showed that patientswith depressive motor retardation had raisedscores on a clinical rating scale of parkinsoniansigns, but he also found significant differencesbetween the movement disorder in depressedpatients and that in patients with Parkinson'sdisease.
Despite these important studies, severalissues regarding catatonia still remainunsolved. Firstly, there is only one structuredscale for the assessment of catatonic signs (themodified Rogers scale (MRS))9 and this scalehas only been assessed with schizophrenicpatients. Secondly, whether the DSM-IV"0 cri-teria of catatonia (catatonic features specifierof mood disorder) can distinguish depressedpatients with catatonia from phenomenologi-cally similar disorders (for example, severe
Department ofNeuropsychiatryE StarksteinG PetraccaA Tes6nE ChemerinskiR MigliorelliR CarreaDepartment of ClinicalNeurology, Institute ofNeurological Research,Buenos Aires,ArgentinaS E StarksteinM MerelloR LeiguardaCorrespondence to:Dr Sergio E Starkstein, RaulCarrea Institute ofNeurological Research,Montaineses 2325,1428Buenos Aires, Argentina.Received 18 April 1995and in revised form25 September 1995Accepted 31 October 1995
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Catatonia in depression: prevalence, clinical correlates, and validation ofa scale
Parkinson's disease) has not been examined.Thirdly, the clinical correlates of catatonia indepressed patients have hardly been consid-ered, and the mechanism is still unknown.
In this study we examined a consecutiveseries of 79 patients with depression for thepresence of catatonia using a comprehensivepsychiatric and neurological evaluation thatincluded the MRS and the UPDRS." Todetermine the validity of the DSM-IV criteriaof catatonia we also examined a consecutiveseries of 41 non-depressed patients withParkinson's disease. Finally, we assessed theresponse to apomorphine in a sample of cata-tonic patients and patients with Parkinson'sdisease to examine the importance ofdopaminergic dysfunction in the mechanismof catatonia.
Patients and methodsPATIENTSDepression groupThis group included a consecutive series of 79patients that were examined in theDepartment of Neuropsychiatry at the RaulCarrea Institute of Neurological Researchbecause of depression. Our institute providespsychiatric care to a large section of BuenosAires and is not a tertiary care centre. Patientswith depression seen at our institute are repre-sentative of a normal psychiatric populationand are not more likely to have coexisting neu-rological disorders or other medical condi-tions. Patients included in this group had tomeet the DSM-III-R"2 criteria for either majordepression, bipolar disorder-mixed, bipolardisorder-depressed, or dysthymia. All patientsunderwent CT or MRI, and none of them hadstructural brain lesions.
Parkinson's disease groupThis group consisted of 41 consecutivepatients with Parkinson's disease and nodepression that were seen in the neurologyclinic of our institute at regular follow ups. Allpatients had positive clinical responses to lev-odopa.
PSYCHIATRIC EXAMINATIONAfter informed consent and blind to neurolog-ical findings, depressed patients and patientswith Parkinson's disease were assessed withthe following tests:
Structured clinical interview for DSM-III-R(SCID) 13
The SCID is a semistructured diagnosticinterview for major axis I DSM-III-R12 diag-noses.
Present state exam (PSE)'4The PSE is a semistructured psychiatric inter-view which was rated by a psychiatrist with thepatient and at least one first degree relative.
Research diagnostic criteria, family history(RDC-FH) 15To obtain a family history of psychiatric disor-ders for the patients' first and second degree
relatives, two first degree relatives were inter-viewed. Diagnoses of axis I disorders weremade based on the RDC-FH.
Hamilton depression and anxiety scales(HAM-D, HAM-A) 16 17The HAM-D and HAM-A are interviewerrated scales that measure symptoms of depres-sion and anxiety.
Mini mental state examination (MMSE) 18The MMSE is an 11 item examination foundto be valid and reliable in assessing global cog-nitive deficits.
Functional independence measure (FIM)'9The FIM assesses self care, sphincter control,mobility, locomotion, communication, andsocial cognition. Higher scores indicate lessimpairment in activities of daily living.
Social ties checklist (STC)'0This is a 10 item scale which assesses thequantity and quality of social supports. Scoresrange from 0 to 10, and higher scores indicatebetter social supports.
Diagnosis of catatoniaThe diagnosis of catatonia (catatonic featuresspecifier of the DSM-IV) was made by thepsychiatrist based on the PSE findings. ThePSE includes a section that rates the presenceof catatonic signs such as self neglect, bizarreappearance, slowness and underactivity, agita-tion, gross excitement and violence, dis-tractibility, mannerisms, posturing, andstereotypies. These signs are rated 0 (symptomabsent), 1 (present in fairly severe degree, orvery severe but intermittent during interview),and 2 (present in very severe degree andalmost continuous during interview). The psy-chiatric evaluation was carried out immedi-ately before or after the neurologicalexamination.
NEUROLOGICAL EXAMINATIONThe neurological evaluation was carried out bya neuropsychiatrist blind to the psychiatricdata, and consisted of the following items:
Unified Parkinson's disease rating scale(UPDRS) I I
This scale has three sections: activities of dailyliving, motor examination, and complicationsof antiparkinsonian treatment. Item scoresrange from 0 to 4, and higher scores indicatemore severe impairment. To assess patientswith Parkinson's disease with a wide variety ofextrapyramidal signs and dyskinaesiae, theneurological examination was carried outregardless of the interval since the last dose oflevodopa.
Modified Rogers scale (MRS)9This is a 36 item scale that rates clinical signsusually described in catatonic patients, such asdisorders of posture (for example, posturingand waxy flexibility), muscular and motorcompliance (for example, "gengenhalten","mitgehen"), movements of the head, face,
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trunk, and limbs (for example, mannerismsand stereotypies), ocular movements (forexample, to and fro roving movements), pur-posive movements (for example, abruptness,slowness, exaggerations, iterations, echo-praxia, blocking, ambitendence), gait (forexample, manneristic, bizarre), speech (forexample, mutism, echolalia, palilalia, speechmannerisms), behaviour during interview (forexample, automatic obedience, negativism),and reported behaviour (for example, under oroveractivity, repetitive acts, and rituals). Theseitems are rated 0 (abnormality absent), 1(abnormnality definitely present), and 2 (abnor-mality pronounced or pervasive). This scaleshows an excellent between rater and withinrater reliability, as well as good internal consis-tency.9
APOMORPHINE TEST2
This evaluation was carried out by a neurolo-gist who was blind to psychiatric data andgroup membership. A consecutive series ofseven patients with catatonia and 11 patientswith Parkinson's disease received 60 mg ofdomperidone daily for at least 48 hours beforethe test. A basal examination was carried outin the fasting state at 9 00 am. This consistedof measurements on the Webster scale22 andthe MRS. The Webster scale measures motordisabilities such as bradykinesia, rigidity, pos-ture, arm swing, gait, tremor, facial move-ments, speech, balance, dyskinesiae, anddystonias. Higher scores indicate more severeimpairment. After the basal assessment, 3 mgof apomorphine were injected subcutaneously,and the neurological assessment was repeated30 minutes after the injection. Patients withParkinson's disease were reported to show sig-nificant improvements in motor function 15minutes after the injection, with a peakresponse 30 minutes after injection.2'
STATISTICAL ANALYSISStatistical analysis was carried out on meansand SDs by multivariate analysis of variance(MANOVA), post hoc planned comparisons,and a Bonferroni correction for multiple com-parisons. Frequency distributions were com-pared using X2 with a Yates' correction for cellsizes < 5, Fisher's exact tests, and contingencytables. Regressions were calculated by a
*p < 0 05.Values are mean (SD) unless stated otherwise.
forward stepwise regression analysis, and afactor analysis was calculated using a Varimaxrotation. All P values are two tailed.
ResultsPREVALENCEBased on PSE findings, sixteen of the 79depressed patients (20%) met the DSM-IVcriteria for catatonia compared with none ofthe 41 patients with Parkinson's disease (X2Yates = 7-91, df = 1, P = 0.004). Table 1shows the demographic and psychiatric data.Patients with catatonia were significantly older(F = 15 0, df = 2,117, P < 0X0001), had sig-nificantly lower MMSE scores (F = 24-9, df= 2,117, P < 0-0001), and had significantlymore severe impairments in activities of dailyliving (F= 13-8, df= 2,117, P<0-0001)than depressed non-catatonic patients andpatients with Parkinson's disease. Depressedpatients with catatonia had significantly higherHAM-D scores than both depressed non-cata-tonic patients and patients with Parkinson'sdisease, whereas depressed non-catatonicpatients had significantly higher HAM-Dscores than patients with Parkinson's disease(F = 106-7, df= 2,117, P<0-0001). Therewere no significant differences betweendepressed-catatonic and depressed non-cata-tonic patients in HAM-A scores, but bothgroups had significantly higher scores thanpatients with Parkinson's disease (F = 27-9,df = 2,117, P < 0-0001). Finally, depressedpatients with catatonia showed a significantlyhigher frequency of familial history of affectivedisorders than depressed non-catatonicpatients and patients with Parkinson's disease(X2 = 12-4, df = 2, P = 0-001).
PHENOMENOLOGYTo examine whether age, motor impairments(as measured with the UPDRS), and severityof depression were significantly correlated withcatatonia we carried out a forward stepwiseregression analysis using the MRS total scoresas the dependent variable, and age, UPDRSmotor scores, and HAM-D scores as the inde-pendent variables. The regression analysis wassignificant (multiple R = 0-72, df = 115,P < 0-0001) and all three independentvariables accounted for a significant part ofthe variance (motor UPDRS R2 = 0 35,df = 115, P < 0000 1; HAM-D R2 = 0X16, df= 115, P < 0X0001; and age R2 = 0-02, df =115, P = 0 05). To examine the validity of thecatatonia construct while controlling for theabove variables, depressed patients with cata-tonia (n = 16) and depressed non-catatonicpatients (n = 16) were matched for age (± 5years) and HAM-D scores (±4 points), anddepressed-catatonic and patients withParkinson's disease (n = 16) were matchedfor age (± 5 years) and UPDRS motor scores(± 4 points).
Antidepressant drugs were used by sixdepressed patients with catatonia, sixdepressed non-catatonic patients, and onepatient with Parkinson's disease. Threedepressed patients with catatonia and one
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Catatonia in depression: prevalence, clinical correlates, and validation of a scale
Table 2 Mean scores for the five DSM-IV clusters of catatonic features specifier in mooddisorders, and scoring algorithm based on the Rogers catatonia scale scores
Echolalia or echopraxial 0-81 (0 75) 0.0 0.0Range 0-2
Values are means (SD) unless otherwise stated.*Score 2 points on items 3 and/or 19 (range 0-4 points) (see table 4).tScore 1 or 2 points on item 18 (range 0-2 points).jScore 2 points on items 15 and/or 20 (range 0-2 points).§Score 2 points on items 1, 2, 5, 6, and/or 8 (range 0-10 points).¶Score 1 or 2 points on items 11 and/or 17 (range 0-2 points).
depressed non-catatonic patient were takingneuroleptic drugs. Benzodiazepines were usedby six depressed patients with catatonia, 10depressed non-catatonic patients, and threepatients with Parkinson's disease. One patient(with catatonia) was taking lithium. Thirteenof the 16 patients with Parkinson's diseasewere taking levodopa (dose range: 250-1000mg/day).The DSM-IV diagnostic criteria for the
catatonic features specifier require at least twoof the following five clusters: (1) waxy flexibil-ity (rated in item 3 of the MRS) or stupor(rated in item 30 of the MRS), (2) excessivemotor activity (rated in item 29 of the MRS),extreme negativism (rated in item 33 of theMRS), or mutism (rated in item 26 of theMRS), (4) posturing (rated in item 2 of theMRS), stereotyped movements, grimacing,and mannerisms (rated in items 9 and 12 ofthe MRS), and (5) echolalia (rated in item 28of the MRS) and echopraxia (rated in item 20of the MRS). To examine whether these fiveclusters discriminate depressed patients withcatatonia (n = 16) from patients withParkinson's disease with a similar motorimpairment (n = 16) and depressed patientswith a similar severity of depression (n = 16),we carried out a MANOVA (group x DSM-IV clusters). There was a significant overalleffect (Wilks' A = 0-10, df = 12,80,
Table 3 Modified Rogers scale items that showed significant differences between depressedpatients with catatonia, depressed non-catatonic patients, and patients with Parkinson'sdisease
Aprosodic speech (F = 40-0, df = 2,45, P < 0-0001)Persistence of imposed postures (F = 28-3, df = 2,45, P < 0-0001)Simple abnormal posture (F = 20-3, df = 2,45, P < 0-0001)Simple and brief dyskinesia-like movements of face and head (F = 16-0, df = 2,45, P < 0 0001)Mutism (F = 159, df = 2,45, P < 0-0001)Indistinct/unintelligible speech (F = 15-0, df = 2,45, P < 0-0001)Reduced associated movements during gait (F = 14-0, df = 2,45, P < 0-0001)Slow/shuffling gait (F = 13-1, df = 2,45, P < 0-0001)Reported overactive behaviour (F = 12 5, df = 2,45, P < 0 0001)Simple and brief dyskinesia-like movements of trunk and limbs (F = 11 9, df = 2,45,P < 0o0001)
Slowness/feebleness of spontaneous movements (F = 11 1, df = 2,45, P < 0-0001)Mitgehen (F = 10-9, df = 2,45, P < 0-0001)Marked underactivity (F = 9-94, df = 2,45, P < 0-0001)Complex mannerisms or stereotypies of face and head (F = 9-61, df = 2,45, P < 0-001)Reported underactive behaviour (F = 8-98, df = 2,45, P < 0-0001)Echolalia (F = 7-92, df = 2,45, P < 0-001)Iterations of spontaneous movements (F = 7 90, df = 2,45, P < 0-001)Marked overactivity (F = 7 81, df = 2,45, P < 0-001)
P < 0-0001). Whereas depressed patients withcatatonia showed significantly higher scores ineach of the five clusters than non-catatonicpatients and patients with Parkinson's disease,no significant differences were found betweendepressed non-catatonic patients and patientswith Parkinson's disease in any of the five clus-ters (table 2).
Significant between group differences inindividual MRS items were analysed with atwo way ANOVA with repeated measures(group: depression and catatonia, Parkinson'sdisease, depressed non-catatonic patients;repeated measures: MRS items). There was asignificant group effect (F = 110-6, df =2,45, P < 0-000 1), and a significant group xMRS interaction (F = 3 55, df = 70,1575,P < 0-0001). Depressed patients with catato-nia had significantly higher MRS scores thanthe other two groups, but no significant differ-ences were found between patients withParkinson's disease and depressed non-cata-tonic patients. Table 3 presents those MRSitems that showed significant between groupdifferences (to adjust the a level for the numberof comparisons, a Bonferroni correction formultiple comparisons was carried out (36comparisons, threshold set at P = 0-0013)).
Based on the above findings we modifiedthe MRS, keeping those items that are neces-sary for a DSM-IV diagnosis of catatonia, andadding those items that showed significantbetween group differences. This modifiedscale (Rogers catatonia scale (RCS)) (table 4)was then examined for its reliability and valid-ity. A score > 7 separated depressed patientswith catatonia (n = 16) from patients withParkinson's disease with a similar severity ofmotor impairment (n = 16), and depressednon-catatonic patients with a similar severityof depression (n = 16), with a sensitivity andspecificity of 100% (all 16 depressed patientswith catatonia but none of the depressednon-catatonic or patients with Parkinson'sdisease had an RCS > 7). The RCS scores(mean (SD)) were: depressed-catatonic group10-8 (2 7), depressed non-catatonic group 0-6(1-3), and Parkinson's disease group 0-6 (1.3)(F = 147-6, df = 2,45, P < 0-0001).To substantiate Abrams and Taylor's sug-
gestion regarding the existence of two factorsin catatonia (hyperactive and hypoactive), wecarried out a factor analysis of the RCS whichincluded all 79 depressed patients (with orwithout catatonia). A Varimax rotation pro-duced two factors (table 5): factor 1 had aneigenvalue of 6&09 and explained 44% of thevariance. This factor loaded (> 0.70) on thefollowing items: simple abnormal postures,persistence of imposed postures, reduced asso-ciated movements during gait, aprosodicspeech, mutism, and pronounced underactiv-ity. Thus this factor can be construed as ahypoactivity factor. Factor 2 had an eigenvalueof 2-83 and explained 20% of the variance.This factor loaded (> 0 70) on the followingitems: complex mannerisms or stereotypies oftrunk, face, head, and limbs, echolalia, andpronounced hyperactivity. Thus this factorcan be construed as a hyperactivity factor.
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Unless otherwise specified, items should be rated as follows: 0 abnormality absent,1 abnormality definitely present, 2 abnormality pronounced or pervasive (see definitions andexamples in Lund et a19)
0 absent; 1 not sustained; 2 waxy flexibility4 Mitgehen5 Simple brief dyskinesia-like movements of face and head6 Complex mannerisms or stereotypies of face and head7 Simple brief, dyskinesia-like movements of trunk and limbs8 Complex mannerisms or stereotypies of trunk and limbs9 Slowness/feebleness of spontaneous movements
10 Iterations of spontaneous movements1 1 Echopraxia12 Reduced associated movements during gait13 Slow/shuffling gait14 Aprosodic speech15 Mutism:
0 normal speech; 1 less than 20 words during the interview; 2 mutism16 Verbigerations17 Echolalia18 Marked overactivity:
0 absent; 1 sits still and passive; 2 catatonic stupor20 Negativism21 Reported overactive behaviour22 Reported underactive behaviour
The reliability of the RCS was assessed bytwo neuropsychiatrists who evaluated fivedepressed non-catatonic and five depressedpatients with catatonia in separate sessions.The interrater reliability was high (intraclassr = 0-81). The intrarater reliability was
assessed by a neuropsychiatrist who examinedfive depressed non-catatonic patients and fivedepressed patients with catatonia in two ses-
sions, two to seven days apart, and was foundto be high (intraclass r = 0 89). Finally, we
also calculated the internal reliability of theRCS, which was also high (Cronbach a=0 87).We examined whether the profile of
extrapyramidal signs was different in catatonicpatients (n= 16), patients with Parkinson'sdisease (n= 16), and depressed non-cata-tonic patients (n = 16). A two way ANOVAwith repeated measures for UPDRS scores
(group: depressed-catatonic patients, depressednon-catatonic patients, and patients withParkinson's disease; repeated measures: UPDRSmotor items) showed a significant group effect(F = 15-7, df = 2,45, P < 0-0001); patientswith catatonia or Parkinson's disease showedsignificantly higher overall motor scores thandepressed non-catatonic patients. A two wayANOVA with repeated measures for patientswith catatonia or Parkinson's disease showed a
significant group x UPDRS motor item inter-action (F = 2-35, df = 13,390, P = 0 004;patients with Parkinson's disease had signifi-cantly higher tremor scores than depressed
Simple abnormal postures 0-78 0 26Persistence of imposed postures 0-72 0-27Reduced associated movements during gait 0-86 -0-06Aprosodic speech 0-82 0 33Mutism 0 95 0-12Marked underactivity 0-81 -0-12Complex mannerisms of face and head 0-14 0 79Complex mannerisms of trunk and limbs - 0-02 0-85Echolalia 0-12 0-84Marked hyperactivity -0-02 0 94
patients with catatonia (F = 4-80, df = 1,30,P < 0 05)), but no significant between groupdifferences were found on the remainingUPDRS items.
APOMORPHINE TESTA two way ANOVA with repeated measures(group: depression and catatonia (n = 7) vParkinson's disease (n = 11), repeated mea-sure: total Webster scale score before and 30minutes after apomorphine injection) showedno significant group effect (F = 0-01, df =1,16, NS; both groups showed a similar overallseverity of extrapyramidal signs), and a signifi-cant group x time interaction (F = 4-96, df =1,16, P < 0 05). Whereas patients withParkinson's disease showed a significantimprovement in Webster scale scores 30 min-utes after the apomorphine injection (pre-apomorphine score (mean (SD) 15-3 (8 8),postapomorphine score 7-2 (4.13); P =0-001), depressed patients with catatoniashowed no significant improvement (preapo-morphine score 12-8 (10-6), postapomorphinescore 10-7 (10.8), NS). Moreover, no signifi-cant changes in total RCS scores or in individ-ual RCS items were found in the depressedpatients with catatonia before and 30 minutesafter the apomorphine injection (RCS scores(mean (SD)) 12-1 (2 7) and 11-8 (1-9),respectively).
DiscussionWe examined the clinical correlates of catatoniain patients with depression, as well as thevalidity of both the Rogers catatonia scale andthe DSM-IV criteria for the catatonic featuresspecifier of mood disorders. There were sev-eral important findings. Firstly, 20% of a con-secutive series of depressed patients met theDSM-IV criteria for catatonia. Secondly, theRCS was found to be a valid instrument toassess the presence and severity of catatonia.Thirdly, the DSM-IV criteria of catatonia had ahigh specificity for this phenomenon, asdepressed patients with catatonia showed sig-nificantly higher scores in each DSM-IV clusterfor the catatonic features specifier thanpatients with Parkinson's disease and a similarmotor impairment. Fourthly, apomorphinedid not improve catatonic signs.Some limitations of our study should be
pointed out. Three patients with catatoniawere on neuroleptic drugs, which may haveproduced some of the abnormal motor signs.However, all three patients were on lowdosages of neuroleptic drugs (as also was onenon-catatonic depressed patient), and all threeshowed a significant improvement in catatonicsigns after electroconvulsive therapy. Inpatients with Parkinson's disease the psychi-atric evaluation was carried out regardless ofthe interval since levodopa intake. Althoughthis may have introduced some variability inthe psychiatric results, we only includedpatients with Parkinson's disease that were notdepressed at the time of the evaluation.Finally, the modification of the RCS wasbased on a small sample, which may have
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Catatonia in depression: prevalence, clinical correlates, and validation of a scale
resulted in an artificially high sensitivity andspecificity, and this important issue should beexamined in a separate sample.The nosological position of catatonia has
been the subject of debate ever sinceKraepelin4 included catatonia as a type ofschizophrenia. Although several anecdotalstudies suggested that patients with affectivedisorders may also show catatonia, Abramsand Taylor6 were the first to show that catato-nia was significantly more frequent among
patients with affective disorders than amongpatients with schizophrenia. This fact was
acknowledged in the DSM-IV, which includescatatonia as a modifier for mood disorders.However, several issues regarding catatoniastill remain unsolved. No structured instru-ment for the diagnosis of catatonia amongpatients with affective disorders has been vali-dated, and whether the DSM-IV criteria ofcatatonia allow the distinction betweenpatients with catatonia and similar motor dis-orders such as Parkinson's disease had notbeen previously examined.
Our study validates the Rogers catatoniascale for the diagnosis of catatonia indepressed patients. When depressed patientswith catatonia were compared with patientswith Parkinson's disease with a similar severityof motor impairments and depressed non-
catatonic patients with a similar severity ofdepression, the depressed-catatonic groupshowed significantly higher RCS scores.
Moreover, a score > 7 separated depressedpatients with catatonia from the other twogroups with a sensitivity and specificity of100%.We also examined whether the DSM-IV cri-
teria for catatonia distinguished depressedpatients with catatonia from patients withParkinson's disease. This is important,because, except for tremor, there were no
other significant differences in the severity ofextrapyramidal signs between these twogroups. We found that even after patients withcatatonia and non-depressed patients withParkinson's disease were matched for motorscores (rigidity, tremor, slowness of move-
ments, gait disturbance, posture, and bodybalance) the DSM-IV criteria for catatoniahad a high specificity (none of the patientswith Parkinson's disease were diagnosed as
having catatonia). This finding suggests thatthe mechanism causing catatonia in depressedpatients may not involve dysfunction of thenigrostriatal dopaminergic pathways, which isalso supported by the findings from the apo-
morphine test. Whereas patients withParkinson's disease showed a significantimprovement in extrapyramidal signs 30 min-utes after the subcutaneous injection of 3 mgof apomorphine, no significant changes inWebster or RCS scores were found indepressed patients with catatonia.Alternatively, the negative results after theapomorphine injection may be explained bypostsynaptic changes in dopamine receptors,and this possibility should be examined infuture studies using PET and radiolabelleddopamine ligands.
We also confirmed Abrams and Taylor'ssuggestion of two factors in catatonia (hyper-activity and hypoactivity). It is well known thatsome patients may switch from a period ofcatatonic stupor to a period of catatonicexcitement, thus reproducing in the motordomain the sequence of affective changes pre-sent in depressive-manic illness. Whether thehyperactivity and hypoactivity factors of cata-tonia share a common mechanism (for exam-ple, abnormal inhibition or release of motorbehaviours) should be further examined.The question that now arises is what is the
mechanism of catatonia in affective disorders?Although this study was not specially aimed atanswering this important question, we foundthat depressed patients with catatonia weresignificantly older, had a significantly moresevere depression, greater cognitive impair-ments, and a higher frequency of familial his-tory of affective disorders than depressedpatients without catatonia. Although age maybe a predisposing factor, it does not seem to beeither necessary or sufficient, as most elderlypatients with depression do not show catato-nia. However, a combination of age and agenetic burden may interact with stillunknown factors to produce catatonia.
In conclusion, 20% of a consecutive seriesof patients with depression met the DSM-IVcriteria of catatonia. These criteria distin-guished depressed patients with catatoniafrom non-depressed patients with Parkinson'sdisease and similar motor impairments with aspecificity of 100%. The present study alsoshowed the validity and reliability of the RCSto diagnose and rate the severity of catatonia.Finally, catatonia was significantly associatedwith age, more severe depression, and greatercognitive impairments, and it was notimproved by the use of dopaminergic agonists.Future studies should examine the neurobio-logical basis of this phenomenon.
This study was partially supported by a grant from the RauilCarrea Institute of Neurological Research and the FundacionPerez Companc. We thank Dr Robert G Robinson for his valu-able suggestions.
1 Baillarger JG. De l'etat designe chez les alienes sous le nomde stupidite. In: Recherches sur les maladies mentales. Paris:Masson, 1843.
2 Kahlbaum KL. Die Katatonie oder das Spannungsirreseins.Berlin: Hirschwald, 1874.
3 Wemicke C. Grundriss der Psychiatrie. Leipzig: Thieme,1900.
4 Kraepelin E. Die Erscheinungsformen des Irreseins.Zeitschrift fiir des gesamte Neurologie und Psychiatre 1920;62:1-30.
5 Taylor MA, Abrams. R. Catatonia: prevalence and impor-tance in the manic phase of manic-depressive illness.Arch Gen Psychiatry 1977;34:1223-5.
6 Abrams R, Taylor MA. Catatonia, a prospective clinicalstudy. Arch Gen Psychiatry 1976;33:579-581.
7 Rogers D, Lees AJ, Smith E, Trimble M, Stern GM.Bradyphrenia in Parkinson's disease and psychomotorretardation in depressive illness: an experimental study.Brain 1987;110:761-76.
8 Fleminger S. Control of simultaneous movements distin-guishes depressive motor retardation from Parkinson'sdisease and neuroleptic parkinsonism. Brain 1992;115:1459-80.
9 Lund CE, Mortimer AM, Rogers D, McKenna PJ. Motor,volitional and behavioural disorders in schizophrena: 1:assessment using the modified Rogers scale. Br JfPsychiatry 1991;158:323-7.
10 American Psychiatric Press. Diagnostic and statistical manualfor mental disorders (DSM-IV). 4th ed. Washington, DC:APA, 1994.
11 Fahn S, Elton E, UPDRS Development Committee.Unified Parkinson's disease rating scale. In: Fahn S,Marsden CD, Goldstein M, Calne CD, eds. Recent devel-
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opments in Parkinson's disease. Florham Park, NJ:Macmillan, 1987: 153-63.
12 American Psychiatric Press. Diagnostic and statistical manualfor mental disorders (DSM-III-R). 3rd ed (rev).Washington, DC: APA, 1994.
13 Spitzer RL, Williams JBW, Gibbon M, First MB. Thestructured clinical interview for DSM-III-R (SCID). I:history, rationale, and description. Arch Gen Psychiatry1992;49:624-9.
14 Wing JK, Cooper E, Sartorius N. Measurements and classifi-cation of psychiatric symptoms. Cambridge: CambridgeUniversity Press, 1974.
15 Spitzer R, Endicott J, Robins E. Research diagnostic criteria(RDC) for a group of functional disorders. New York:Biometrics Research Division, New York PsychiatricInstitute, 1975.
16 Hamilton MA. A rating scale for depression. J NeurolNeurosurg Psychiatry 1960;23:56-62.
17 Hamilton MA. The assessment of anxiety states by rating.BrJMed Psychol 1959;32:50-5.
18 Folstein MF, Folstein SE, McHugh PR. Mini-Mentalstate: a practical method for grading the cognitive stateof patients for the clinician. 7 Psychiat Res 1975;12:189-98.
19 Granger CV, Hamilton BB, Kayton R. Guide for use of theuniform data set for medical rehabilitation. Buffalo, NY:Uniform Data System for Medical Rehabilitation, 1986.
20 Starr LB, Robinson RG, Price TR. Reliability, validity andclinical utility of the Social Functioning Exam in theassessment of stroke patients. Exp Aging Res 1983;9:101-10.
21 Hughes AJ, Lees AJ, Stem GM. Apomorphine test to predictresponsiveness in parkinsonian syndromes. Lancet 1990;ii:32-4.
22 Webster DD. Critical analysis of the disability inParkinson's disease. Modern Treatment 1968;5:257-82.
Notes on tetanus (lockjaw)
Tetanus (Greek tetanos, derived from teinein to stretch)appears through the ages in military medicine.Slapping infected dung on to the newborn umbilicalcord caused tetanus neonatorum or "trismus nascen-
tium" to be rampant in the West Indies and Africa.Osler's textbook describes the "eight days sickness"caused by umbilical sepsis, which in St Kilda killed 84of 125 children within a fortnight of birth.' In the firstworld war it occurred in 1-47 per 1000 of the Britishwounded, and in 12-5 per 1000 in the Peninsular cam-paign.2
In an earlier battle, Sir Charles Bell's famous war
illustration portrays tetanus in a soldier during Sir JohnMoore's retreat to Corunna.
Risus sardonicus hails from the sneering grin thoughtto resemble the effect of a Sardinian rununculus,which on being chewed contorted the face of the eater.The anaerobic bacillus Clostridium tetani was discov-ered by Nicolaier in 1885. In 1889 Koch's pupilKitasato obtained the bacillus of tetanus in pure cul-ture and conveyed the disease to animals.
Antitoxin was quickly recognised by Thomas
Clifford Allbutt (System ofMedicine 1896;1:237): "Thediphtheria and tetanus antitoxins act directly on thetoxins." Antitetanus serum was in general use beforethe first world war, but the dose was variable. And theintrathecal, intravenous, or intramuscular routes eachhad its proponents. The mortality was still between37% and 50%.
Ancient descriptions are impressive:
Hippocrates"The master of a large ship mashed the index fingerof his right hand with the anchor. Seven days later a
somewhat foul discharge appeared; then troublewith his tongue-he complained he could not speakproperly. The presence of tetanus was diagnosed,his jaws became pressed together, his teeth were
locked, then symptoms appeared in his neck; on thethird day opisthotonos appeared with sweating. Sixdays after the diagnosis was made he died"In the Aphorisms (c 380 BC):4 section V 2, "Spasm
supervening on a wound is fatal." And section V 6,"Such persons as are seized with tetanus either diewithin four days, or if they pass these they recover".
AretaeusAn inhabitant of Cappadocia (1st century AD), an
ancient kingdom of Asia Minor, Aretaeus left this won-derful characterisation:5
"Tetanus in all its varieties, is a spasm of an exceed-ingly painful nature, very swift to prove fatal, butneither easy to be removed.... There are threeforms of the convulsions, namely in a straight line,backwards and forwards... there is tension in astraight line of the whole body, which is unbent andinflexible ....
Opisthotonos bends the patient backward, like abow, so that the reflected head is lodged between theshoulder-blades; the throat protrudes; the jaw some-times gapes, . . . respirations stertorous; the belly andchest prominent . . . the abdomen stretched, and res-onant if tapped; the arms strongly bent back in astate of extension; the legs and thighs are benttogether ....The causes of these complaints are many; for
some are apt to supervene on the wound of a mem-brane, or of muscles,... And women also sufferfrom this spasm after abortion; and in this case theyseldom recover ...
In all of these varieties then, there is pain and ten-sion of the tendons and spine, and of the musclesconnected with the jaws and cheek; for they fastenthe lower jaw to the upper, so that it cannot easily beseparated even with levers or a wedge. But if one byforcibly separating the teeth, pour in some liquid thepatients do not drink it but squirt it out ....
But if they are bent forward (Emprosthotonos),they are protuberant at the back, the loins beingextruded in a line with the back, the whole spinebeing straight; ... the lower jaw fixed on the breastbone; the hands clasped together, the lower extremi-ties extended; pains intense; the voice altogetherdolorous. Should the mischief then seize the chestand respiratory organs, it readily frees the patientfrom life ...."An inhuman calamity! an unseemly sight! ...
But neither can the physician, furnish any assistance,as regards life, relief from pain or from deformity."
J M S PEARCE304 Beverley Road,
Anlaby,Hull HUIO 7BG, UK
1 Osler W. Principles and practice of medicine. 1898.2 Official history of the war (Pathology, 1923), cited by
Wilson SAK, In: Neurology. London: Arnold, 1940:626.3 Beck T. Hippokrates Erkenntnisse. Jena: Diedrichs, 1907:132.4 Adams F. Aphorisms. In: The genuine works of Hippocrates.
Vol 2. London: The Sydenham Society 1849:737-8.5 Adams F. The extant works of Aretaeus, the Cappadocian.
Edited and translated, London: The Sydenham Society,1856:253.
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