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Hidden in plain sight: catatonia in pediatrics

Three reports in this number of the Acta Psychiatrica Scandinavica reflect on catatonia in children and adolescents. The medical historian Edward Shorter finds catatonia recognized in children and adolescents under many names. It appears as catalepsy and stupor in the older literature, then as schizophrenia, autism, and hysteria, and only recently as catatonia. The change in labels explains the frequent opinion that catatonia has disappeared (1). Much childhood psychopathology is ascribed to abuse and trauma. Dirk Dhossche asks whether catatonia can result from the same experiences and finds that catatonia is associated with deprivation, abuse, and trauma and that relief is obtained by applying catatonia treatment protocols (2). At an academic medical center, Neera Ghaziuddin and her colleagues examined the charts of 101 patients admitted to a pediatric psychiatry facility seeking the presence of 3 or more catatonia signs. Eighteen charts (17%) documented catatonia but in only two had the referring physicians recognized the syndrome (3). Catatonia is a motor dysregulation syndrome that is increasingly recognized among adult patients but is hardly recognized in child medicine or child psychiatry texts. Life-threatening, catatonia is often quickly treatable to remission, a rare opportunity in clinical psychiatry. It is not that the catatonia syndrome is uncommon, but it is hidden under many guises. Labeled mainly as a type of schizophrenia it often appears within bipolar and major depression, within autism spectrum disorders especially in those patients with self-injurious behaviors, and as elective mutism, persistent refusal syndrome, Tourette syndrome, or anti-N-methyl D-aspartate (NMDA) receptor encephalitis (4). Catatonia was delineated among psychiatric and medically ill patients in 1874 by Karl Kahlbaum in a small monograph of 104 pages (5). Mutism, posturing, motor rigidity, verbigeration, stupor, and excited states were its main signs. He described the condition so well that within a few years catatonia was widely recognized. In the late 1890s, Emil Kraepelin incorporated catatonia within his concept of dementia praecox. When Eugen Bleuler changed the concept to schizophrenia, catatonia lost its independence, and in succeeding decades, catatonia remained hidden within schizophrenia in evolving psychiatric classifications. The search for predictors of outcome to select treatments from among the cornucopia of new medicines found catatonia among patients with manic depression and as a neurotoxic response to the more potent neuroleptic drugs. When a neuroleptic malignant syndrome (NMS) was delineated in the 1980s, its similarity to malignant catatonia (MC) was slowly recognized. Both syndromes are marked by fever, motor rigidity, torpor or excitement, and vegetative abnormalities. Based on the belief that the neuroleptic drugs acted on brain dopamine, the recommended prescription for NMS was dopamine agonists and the muscle relaxant dantrolene. These were poorly effective, however, and when the treatments for MC were applied, resolution was prompt. Our recognition that NMS was better treated as a form of MC rather than as dysfunction in dopamine metabolism encouraged greater recognition of catatonia (6). The efficacy of known treatments fosters interest in catatonia. The report in 1930 by the American William Bleckwenn that the stupor, posturing, mutism, and rigidity of catatonia were relieved by high doses of sodium amobarbital was the first shot of the psychopharmacology era. In 1934, the Hungarian Ladislas Meduna, seeking examples of schizophrenia for his experiments with the chemical induction of grand mal seizures, selected patients with catatonia in the belief that they were bona fide examples of schizophrenia (7). Of the recognized varieties of schizophrenia, his best results were achieved with catatonia. By the 1940s, the much more facile induction of seizures by Acta Psychiatr Scand 2012: 125: 11–12 All rights reserved DOI: 10.1111/j.1600-0447.2011.01771.x 2012 John Wiley & Sons A/S