Priya Gopalan, MDPierre N. Azzam, MD

Diagnosis and Treatment of Catatonia

• Overview of Catatonia– Typical Features of Catatonia– Historical Evolution of the Diagnosis– Diagnosis from DSM-IV to DSM-5– Epidemiology– Clinical Evaluation of Catatonia

• Prototypes of Catatonia– Distant Mute– Waxy Stiff– Stubborn Grouch– Broken Record

Agenda

• Catatonia and its Underpinnings– Differential Diagnosis– Precipitating Conditions– Pathophysiologic Theories

• Management of Catatonia– Essential of Management– Mainstays of Therapy– Benzodiazepines in Challenge and Maintenance Therapy– Electroconvulsive Therapy (ECT) and Alternate Options– Management and Prevention of Complications

• Questions

Agenda

Pierre N. Azzam, MD

Overview of Catatonia

Clinical Case #1: Pt. S.

• Demographic:– 42y/o single white man

• Medical History: – diabetes, HTN, strokes (R cerebellar, R temporal, R basal ganglia)

• Psychiatric History: – schizophrenia, undifferentiated type

• Clinical Presentation: – admitted with infectious eneterocolitis– multi-system organ failure intubation– upon extubation, quetiapine 400mg po QHS– altered mental status and QT prolongation on EKG

Clinical Case #1: Pt. S.

• Mental Status:– lying in bed, eyes closed, motionless– resisted opening his eyelids, then kept them shut– no spontaneous speech– no rigidity, catalepsy, waxy flexibility

• Evaluation/Management:– initial primary diagnosis: multifactorial delirium– EEG: slowing, MRI: multiple infarcts, age undetermined– recommendations: PRN olanzapine (no improvement)

Clinical Case #1: Pt. S.

• Follow-up Visit:– stupor, intermittent alertness– mutism, intermittent repetition: “I’m scared”– mild rigidity and waxy flexibility– purposeless blanket-bunching– frequent head movements (side-to-side)

• Management:– lorazepam 1.5 mg trial– perked up and requested to listen to Nat King Cole– lorazepam 0.5 mg TID started as maintenance therapy

Clinical Case #1: Pt. S.

“I felt like I was stuck betweentwo planes in space… Like therewere pins in me everywhereholding me in place… Iremember you asking questions,and I knew some answers butcouldn’t say… I was scared.”

• Syndrome (not a disease)

• Motor and behavioral disturbances

• Various medical and psychiatric precipitants

• Fluctuating time course

• Most common features:– Mutism– Interpersonal withdrawal– Negativism (resistance to

instruction)– Stupor/immobility– Staring– Catalepsy (posturing)– Rigidity– Stereotypy (repetitive behaviors)– Mannerisms (odd behaviors)– Excitement/combativeness– Echophenomena– Ambitendency (“stuck”)

Catatonia at a Glance

History of Catatonia: Kahlbaum (Fink 2003)

• Coined the term catatonia• Stages of the condition:

– Melancholia, apathy– Mania, hyperactivity– Stupor, confusion– Dementia

• Credited with unifying motoric and behavioral features, outlining temporal course of catatonia.

Karl Ludwig Kahlbaum. Psychiatrische Wochenschrift. Public domain image. Wikimedia Commons

History of Catatonia: Taking Root in Schizophrenia (Fink 2003)

• Late 1800s: Emil Kraepelin folded catatonia into dementia praecox, conceptualized catatonia as a more chronic disordered state.

• Early 1900s: Eugen Bleuler included catatonia as a (marginal) feature of schizophrenia, focused on psychodynamic theories.

Emil Kraepelin. Credit: Wellcome Library, London. Used with Permission. Wikimedia CommonsE. Bleuler. Beilage sur Munchener medizinischen Wochenschrift. Public domain image. Wikimedia Commons

• 1950s – 1970s: – Catatonia identified in patients

with mania, depression, medical and neurologic conditions

– Up to 10% of psychiatric inpatients

– “Lethal catatonia” identified, along with neuroleptic malignant syndrome (NMS)

• 1980s – 2010s:– Catatonia first treated with

lorazepam

– DSM III as subtype of schizophrenia

– DSM IV as subtype of schizophrenia and specifier to depression or mania

– DSM-5: Catatonia as a separate syndromal entity

History of Catatonia: Modern Progression

Catatonia and the DSM IV-TR (APA 2000)

• Classifications– Schizophrenia (subtype)– Depressive, manic, mixed

episodes (specifier)– Catatonia secondary to

general medical condition (stand-alone diagnosis)

• Diagnostic Criteria (2+)– Motoric immobility– Excessive motor activity– Extreme mutism or

negativism– Peculiar voluntary

movements– Echolalia or echopraxia

Catatonia and the DSM-5 (APA 2013)

• Classifications– Catatonia associated with

another mental disorder (specifier)

– Catatonic disorder due to another medical condition

– Unspecified catatonia• Distressing or functionally

impairing symptoms• Contributing condition

unclear or full criteria not met

• Diagnostic Criteria (3+)– Stupor– Catalepsy– Waxy Flexibility– Mutism– Negativism– Posturing– Mannerism– Stereotypy– Agitation– Grimacing– Echolalia– Echopraxia

• General Hospital Setting– Prevalence: Unknown– Believed to be under-recognized and -treated

• Inpatient Psychiatric Setting– Prevalence: 7-20%– Due to general medical condition: 20-25%

• Sex: 1.1–1.3 : 1 (female : male)

• Age: affects all ages, rare in childhood

Epidemiology

1. Excitement2. Immobility/Stupor3. Mutism4. Staring5. Posturing/Catalepsy6. Grimacing7. Echophenomena8. Stereotypy9. Mannerisms10. Verbigeration11. Rigidity12. Negativism13. Waxy Flexibility14. Withdrawal

15. Impulsivity16. Automatic Obedience17. Mitgehen18. Gegenhalten19. Ambitendency20. Grasp Reflex21. Perseveration22. Combativeness23. Autonomic Abnormality

• Screening: First 14 items (2+ positive)

• Monitoring: All 23 items (each measured for serial tracking)

Bush-Francis Catatonia Rating Scale (Bush 1997)

• Observe patient engaging in conversationLook for: mutism, echolalia, verbigeration

• Scratch your head in exaggerated manner Look for: echopraxia

• Check chart for 24-hour oral intake, vital signs, behaviorsLook for: autonomic instability, withdrawal

• Observe directly and indirectly at different times of the dayLook for: fluctuations in clinical presentation

Clinical Evaluation (Fricchione 2011)

• Extend hand: “Do NOT shake my hand”Look for: ambitendence

• Reach in pocket, and say: “Show me your tongue. I want to stick a pin in it.”Look for: automatic obedience

• Check for grasp reflexLook for: frontal release signs

• Examine arms for toneLook for: rigidity, waxy flexibility, gegenhalten

Clinical Evaluation (Fricchione 2011)

Priya Gopalan, MD

Prototypes of Catatonia

• Demographic: – 55 y/o widowed African American female

• Medical History: – Breast cancer

• Psychiatric History: – Remote episode postpartum depression

• Present Illness: – Begins course of chemotherapy, receives one dose of intramuscular

(IM) steroid, dexamethasone– Three days later, family notes that Ms. C is pacing around the house,

“fidgety,” talking to herself, and seeing people that are not present

Clinical Case #2: Pt. C.

• In the ED: – Physical exams by emergency medicine and neurology note

audiovisual hallucinations, loose associations, and echolalia, but no other abnormal findings

– Ms. C is admitted to the general medical floor

• During Admission: – Primary team withholds chemotherapy and starts antipsychotics for

delirium– She receives 10mg PO olanzapine and 7.5mg IV haloperidol– Medical work up, including: basic labs, CPK, UDS, MRI, and EEG

reveal no abnormalities

Clinical Case #2: Pt. C.

• Psychiatry is consulted for evaluation of “altered mental status”

• Family confirms lack of prior psychiatric symptoms or substance abuse

• Ms. C is observed watching TV in her room, repeating the words on commercials

• She is minimally interactive with the examiner and mumbles nonsensically throughout the exam.

Clinical Case #2: Pt. C.

• No fevers, diaphoresis, or flushing

• Rigidity noted in upper extremities, but no cog-wheeling

• Catalepsy in upper extremities

• No echopraxia, automatic obedience, or ambitendency

• Positive (abnormal) grasp, glabellar, and snout reflexes

• Normal deep tendon reflexes

• No clonus or tremors

Clinical Case #2: Pt. C.

• Would you call this catatonia?

• What features of catatonia does this person exhibit?– Echo-phenomena– Verbigeration– Rigidity– Catalepsy– Grasp reflex

• What factors predispose this patient to catatonia?– History of a mood disorder– Medical illness– Steroid exposure– Antipsychotic exposure

Clinical Case #2: Pt. C.

• Ms. C is diagnosed with catatonia, likely due to steroids

• The psychiatry consultation service recommends stopping all anti-dopaminergic agents

• Ms. C is given 1mg IV lorazepam x 1 and re-examined one hour later.

• At that time, she responds to questions, but is confused and gives inappropriate answers

Clinical Case #2: Pt. C.

• Psychiatry team starts lorazepam 1mg IV three times daily (TID)– The next day she is interactive, but still has echolalia– She continues to have intermittent agitation and motor exam is

limited by restraints

• Lorazepam is increased to 2mg IV four times daily (QID)– Catatonia symptoms resolve– Hallucinations resolve– She continues to have tangential thoughts and delusions that the

physicians are other people

Clinical Case #2: Pt. C.

• Aripiprazole is initiated for psychosis, and she is transferred to inpatient psychiatry for further management

• Psychiatric symptoms resolve on a regimen of aripiprazole 20mg daily and lorazepam 2mg QID, and Ms. C is discharged to home

• Aripiprazole and lorazepam are both tapered off as an outpatient with no return of symptoms

Clinical Case #2: Pt. C.

• Carl Jung: Archetypes

• Kahana and Bibring: Personality types

• Groves: “Hateful Patient”

• Prototype models exist for numerous psychiatric conditions (e.g., bipolar disorder, personality disorders)

Prototypes in Psychiatry

Prototype Models

• Advantages:– Effective

– Practical

– Matches natural clinical reasoning

– Facilitates teaching and pattern-guided recognition

• Disadvantages:– Oversimplified

– Risk of stereotyping

– Risk of symptom exclusion

– Associated with high false-positive rates

Retarded Catatonia (Kahlbaum Syndrome)

• Clinical features:– Stupor– Mutism– Rigidity– Withdrawal– Waxen Flexibility

• Typical associations: depression, psychosis, neurologic disease

A Woman Diagnosed as Suffering from Melancholia. Credit: Wellcome Library, London. Adapted with Permission.

Excited Catatonia (Delirious Mania)

• Clinical features:– Nightmarish derealization– Excessive activity/agitation– Disorganized speech– Confusion, disorientation– Stereotypy, echophenomena

• Typical associations: mania, mixed states, toxidromes

A Woman Diagnosed as Suffering from Mania. Credit: Wellcome Library, London. Adapted with Permission.

• Malignant Catatonia– Clinical features:

• Posturing, rigidity• Confusion• Intermittent excitement• Fever, dysautonomia

– Course: sudden; rapid progression; fluctuation

– Mortality: 10-30%

• Neuroleptic Malignant Syndrome– Clinical features:

• Severe rigidity• Altered mental status• Fever, dysautonomia• Recent neuroleptic use

– NMS and MC clinically indistinguishable

– Two sides of a coin?–Vancaester 2007

Malignant Catatonia

The Distant Mute

• ID: 57y/o man

• PMH: epilepsy, on phenytoin

• PPH: major depression, alcohol dependence

• Admission: seizures one week prior to admission, followed by dehydration and FTT

• Presentation– No speech– Averted gaze; when finally made

eye contact, no blink for > 2 mins– Refused to interact, engage in

care, eat or drink– Did opposite of most commands

The Distant Mute

• Presentation: Abnormal eye contact, prominent mutism, uncommunicative

• Key Point: Mutism may be the most frequently observed sign in an acute care setting

The Waxy Stiff

• ID: 45y/o man

• PMH: none

• PPH: alcohol and opioiddependence

• Admission: found by parents kneeling in fixed position; three days of comments about being the Antichrist; two weeks of depression

• Presentation:– Minimal speech. Intermittent

eye contact– Maintenance of unusual

postures in UE, rigidity in LE

The Waxy Stiff

• Presentation: Sole presence of motor findings (catalepsy, waxy flexibility)

• Key Point: Classic catatonia presentation is not necessarily the most common

The Stubborn Grouch

• ID: 62y/o woman

• PMH: DM, kidney disease, HTN

• PPH: MDD, alcohol dependence

• Admission: intra-abdominal abscess after nephrectomy

• Presentation:– Pulled off anything placed on her

(clothes, lines, tape, blankets)– Laying in her own urine– “Get out! I want you out!”– Doesn’t look at the interviewer– Later: fists clenched, eyes shut– Oppositional paratonia

The Stubborn Grouch

• Presentation: Prominent negativism

• Key Points: Negativism is often mistaken for volitional behavior, and may be more common in the general medical setting

The Broken Record

• ID: 31y/o man

• PPH: bipolar disorder; PCP and dextromethorphan dependence

• Admission: punched in the face

• Injuries: multiple facial fractures and head injury

• Presentation:– Intermittently pulled at lines– Shrugged shoulders repeatedly– Parroted snapping fingers, hands

up, scratching head– “I don’t know,” “That’s okay”– Automatic obedience

The Broken Record

• Presentation: Purposeless agitation, hyperactivity, echophenomena

• Key Points: Challenges traditional images of catatonia, can be confused with delirium

Prototypes in Catatonia: Summary

Distant Mute Waxy Stiff Broken Record Stubborn Grouch

Overarching Theme

Disconnection Inertia Perseveration Obstinance

Diagnostic Features

Mutism

Immobility

Interpersonal withdrawal

Catalepsy

Waxy flexibility

Rigidity

Echophenomena

Verbigeration

Hyperactivity

Negativism

Repetitive movements

Excitement

Challenges in the General Hospital

Distinguishing sedation from catatonic stupor

Accusations of volitional symptom production

Reflexive misattribution to psychopathology

Risk of medical and surgical complications due to immobility

Management of patient safety by unit staff

Misdiagnosis leading to neuroleptic administration

Incomplete medical evaluation due to negativism

Consideration of medical decision-making capacity with refusal of care

Pierre N. Azzam, MD

Catatonia and its Underpinnings

Differential Diagnosis

• Mutism (akinetic, elective, post-ictal)• Parkinson’s disease-related akinesia• Gilles de la Tourette’s disorder• Hyperactive delirium• Hypoactive delirium• Locked-in syndrome• Abulia• Coma

Precipitating Conditions (Fricchione 1997, 2011)

• Psychiatric Illness– Affective disorders *– Schizophrenia *– Autistic spectrum

disorders*– Conversion disorder– Obsessive compulsive

disorder (OCD)

• Neurologic Insults– Epilepsy *– Encephalopathy *– Encephalitis*– Infarct (cingulate,

temporal, parietal) *– CJD– Hemorrhage– Meningitis– Traumatic Brain Injury

Precipitating Conditions (Fricchione 1997, 2011)

• Medical Conditions– Acute intermittent

porphyria *– Systemic lupus

erythematosis*– Addison’s disease– AIDS– Cushing’s disease– Hepatitis– Hyperparathyroidism– Tuberculosis– Uremia

• Medications/Drugs– Corticosteroids *– Metoclopramide *– Neuroleptics *– Phencyclidine (PCP) *– Disulfiram– MDMA (ecstasy)– Stimulants– Withdrawal states:

benzodiazepines *, dopaminergic drugs

Pathophysiologic Theories

“Similar symptomatology in neuroleptic catatonia (including NMS) and psychogenic catatonia may reflect a common pathophysiology involving dopamine and GABA neurons in mesostriatal, mesolimbic, and hypothalamic pathways.”

– Fricchione 1997

Proposed Neural Networks (Daniels 2009, Fricchione 2011)

• Diffuse rather than focal lesions

• Striatal-thalamocortical tracts– Basal Ganglia

motor regulation– Orbitofrontal Cortex

motivation; perseveration

• Other proposed involvement– Hypothalamus

hyperthermia, dysautonomia– Limbic System

subjective fear– Parietal Cortex

visuospatial processing

• Dopamine HYPOactivity– Mesolimbic– Nigrostriatal– Hypothalamic

• GABAA HYPOactivity– Orbitofrontal– Limbic connections– Striatal DA inhibition

• Glutamate HYPERactivity– Posterior parietal– Frontal GABAA inhibition

• 5-HT and possible link to serotonin syndrome?

Proposed Neurochemistry (Daniels 2009)

Priya Gopalan, MD

Management of Catatonia

Essentials of Management

• Observe closely and monitor vital signs

• Manage precipitating conditions

• Discontinue offending medications

• Restart recently withdrawn dopaminergic agents

• Monitor for medical complications

• Involve health care proxy

Additional Workup(Fink 2003, Daniels 2009)

• Collateral Information: history of drug use or psychiatric illness, presentation course

• Vital Signs: ↑HR, BP, RR

• Serum Labs: ↑CPK, WBC ↓Na, Fe

• Head imaging

• EEG: no consistent findings; may wax and wane with frontal slowing

Potential Medical Complications (Gross 2008)

• Aspiration• Burn• Cardiac failure• Dehydration• DIC• DVT/PE• GI bleed/obstruction• Pneumonia• Renal failure

• Respiratory distress• Rhabdomyolysis• Seizures• Sepsis• Urinary retention• Urinary tract infection

Death: up to 25% in malignant catatonia

Preventive Measures

• DVT precautions (anticoagulation)

• Aspiration precautions

• Hydration

• Nutrition (parenteral)

• Stretching (PT/OT)

• Wound Care

• Mobilization

Mainstays of Catatonia Treatment

• Barbiturates: historical first-line treatment

• Benzodiazepines: current first-line treatment

• Dopamine Agonists: adjunctive agents– Amantadine: pre-synaptic DA agonist– Bromocriptine: post-synaptic DA agonist

• Dantrolene: used in cases of MC (rigidity)

• Electroconvulsive Therapy: treatment in BZD non-responsive patients, malignant catatonia

Benzodiazepines in Catatonia

• BZD Challenge– Lorazepam 1-2mg IV x 1, monitor response– Lorazepam 1mg IV Q30min until response (up to 4-6mg)

• BZD Maintenance– Response to challenge predicts response to maintenance treatment

(~90%)– Dosing based on response to challenge– Typical start dose: lorazepam 1-2mg po/IV TID– Daily adjustment based on response

• If inadequate response within 5 days of med trial (sooner if malignant catatonia), seek ECT or alternative treatment

• Prospective study (n=28): 4 patients who did not improve with benzodiazepines after 5 days improved with ECT treatment (Bush 1996)

• Case series: delay in ECT for malignant catatonia, by 5 days death for 14 patients; versus 16 of 19 patients who survived when they received ECT within 5 days of diagnosis (Philbrick 1994)

• Pennsylvania: Court order for ECT when patient is unable to consent

ECT in the Treatment of Catatonia

Case-Reported Treatments

• Antiepileptic Drugs– Carbamazepine– Topiramate– Valproic Acid

• Atypical antipsychotics– Aripiprazole– Olanzapine

• Levodopa• Lithium• Methylphenidate• NMDA-antagonists

– Memantine– Amantadine

• Zolpidem

(Babington 2007; Bastiampillai 2008; Bowers 2007; Carroll 2007; Chang 2009; Munoz 2008; Prowler 2010)

Misconceptions in the Medical Setting

• Catatonia must be “psychiatric”Catatonia presents in the setting of medical and psychiatric conditions (additive effects?).

• “The patient is just playing possum”Many behaviors are not ones people typically choose when they are being “problematic.”

• Unresponsive = AsleepBZDs remain the treatment of choice.

• Response to Ativan proves it’s psychiatricBZDs treat catatonia, often not the precipitating condition.

• Non-Malignant Catatonia– BZD response: 70%

– ECT response: 85%

– AP response: 7.5%

• Malignant Catatonia– BZD response: 40%

– ECT response: 89%

– AP response: 0%

Treatment Outcomes (Hawkins 1995)

• Less Likely to Relapse– Rapid, dramatic response

to BZD

– Episodic course

– High inter-episode functioning

– Primary mood disorder

– If ECT: adequate seizures, easily induced

• More Likely to Relapse– High-dose BZD required

– Coarse neurologic disease

– Oneiroid state

– Chronic mania

– Alcohol dependence

– Substance-induced mood disorder with catatonia

When to Maintain Treatment (Daniels 2009; Carroll 2004)

Summary

• Catatonia is a heterogeneous syndrome of motor and behavioral disturbances

• Various neurologic, medical, psychiatric etiologies (affective disorders, general medical conditions, psychotic disorders)

• Pathophysiology related to DA and GABA depletion• Rapid identification, supportive measures, somatic treatments are

life-saving– BZD – first line– ECT – gold standard, use if BZD ineffective/contraindicated – Dopaminergic agents – use adjunctively

• Prolonged and malignant cases require aggressive management

Questions?

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed – Text Revision. Washington, DC: American Psychiatric Association, 2000.

Babington PW, Spiegel DR. Treatment of catatonia with olanzapine and amantadine. Psychosomatics48:534-536, 2007.

Bastiampillai T, Dhillon R. Catatonia resolution and aripiprazole. Australian & New Zealand Journal of Psychiatry 42:907, 2008.

Bowers R, Ajit SS. Is there a role for valproic acid in the treatment of catatonia? Journal of Neuropsychiatry and Clinical Neuroscience 19:197-198, 2007.

Bush G, et al. Catatonia and other motor syndromes in a chronically hospitalized psychiatric hospitalization. Schizophrenia Research 27:83-92, 1997.

Carroff SN, et al. Catatonia: From Psychopathology to Neurobiology. Arlington, VA: American Psychiatric Press, 2004.

Carroll BT, et al. Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes. Journal of Neuropsychiatry and Clinical Neuroscience 19:406-412, 2007.

Chang CH, et al. Treatment of catatonia with olanzapine: A case report. Progress in Neuro-Psychopharmacology & Biological Psychiatry 33:1559-1560, 2009.

Daniels J. Catatonia: Clinical aspects and neurobiological correlates. Journal of Neuropsychiatry and Clinical Neuroscience 21:371-380, 2009.

References

Fink M. Convulsive therapy: a review of the first 55 years. Journal of Affective Disorders 63:1-15, 2001.Fink M, Taylor MA. The catatonia syndrome: forgotten but not gone. Archives of General Psychiatry

66:1173-1177, 2009.Fink M. Taylor MA. Catatonia: A Clinician’s Guide to Diagnosis and Treatment. Cambrdige, UK: Cambridge

University Press, 2003.Fink M. Catatonia: A syndrome appears, disappears, and is rediscovered. The Canadian Journal of

Psychiatry 54:437-444, 2009.Fricchione G, et al. Recognition and treatment of the catatonic syndrome. Journal of Intensive Care

Medicine 12:135-147, 1997.Gross AF, et al. Dread complications of catatonia: A case discussion and review of the literature. Primary

Care Companion 10:153-155, 2008.Hawkins JM, et al. Somatic treatment of catatonia. International Journal of Psychiatry in Medicine 25:345-

369, 1995.Kitabayashi Y, et al. Postpartum catatonia associated with atypical posterior reversible encephalopathy

syndrome. Journal of Neuropsychiatry and Clinical Neuroscience 19:91-92, 2007.Lim J, et al. Ictal catatonia as a manifestation of nonconvulsive status epilepticus. Journal of Neurology,

Neurosurgery, and Psychiatry 49:833-836, 1986.

References

Mahendra B. Where have all the catatonics gone? Psychological Medicine 11:669-671, 1981.Mann SC, et al. Electroconvulsive therapy of the lethal catatonia syndrome. Convulsive Therapy 6:239-247,

1990.Munoz C, et al. Memantine in major depression with catatonic features. Journal of Neuropsychiatry and

Clinical Neuroscience 20:119-120, 2008.Philbrick KL, Rummans TA. Malignant catatonia. Journal of Neuropsychiatry and Clinical Neuroscience 6:1-

13, 1994.Prowler ML, et al. Treatment of catatonia with methylphenidate in an elderly patient with depression.

Psychosomatics 51:74-76, 2010.Smith SM. EEG in neurological conditions other than epilepsy: when does it help, what does it add? Journal

of Neurology, Neurosurgery, and Psychiatry 76:ii8-12, 2005.Taylor MA, Fink M. Catatonia in psychiatric classification: A home of its own. American Journal of Psychiatry

160:1233-1241, 2003.Vancaester E, Santens P. Catatonia and neuroleptic malignant syndrome: two sides of a coin? Acta

Neurologica Belgica 107:47-50, 2007.Van der Jeijden, et al. Catatonia: disappeared or under-diagnosed? Psychopathology 38:3-8, 2005.