Catatonia is a psychomotor dysregulation syndrome seen in several illnesses. Uncertainties exist regarding its prevalence and causes. While some research shows a strong association with mood disorders, other data show catatonia to be strongly associated with schizophrenia. Data from low- and middle-income countries are required.
To determine the clinical and demographic profile of patients with catatonia that received electroconvulsive therapy (ECT) between 01 January 2012 and 31 December 2014.
The study was conducted at Elizabeth Donkin Psychiatric Hospital in Port Elizabeth, Eastern Cape. The hospital has mostly patients admitted under the
A retrospective chart review was conducted. Using the hospital ECT database, all files of patients who received ECT for catatonia were identified. Demographics, psychiatric and medical diagnoses, signs of catatonia and other data were abstracted from these files.
Forty-two patients received ECT for catatonia, of whom 34 (80.95%) were diagnosed with a psychotic illness. Schizophrenia was the most common diagnosis (
Psychotic disorders were more frequent than mood disorders in the sample. Schizophrenia was the most common diagnosis, followed by psychotic disorder owing to a general medical condition.
Catatonia is a psychomotor dysregulation syndrome seen in several illnesses.
The 3 principal subtypes of catatonia are retarded catatonia, excited catatonia and malignant catatonia.
Clinical features which may be present in patients with catatonia include those listed in
Clinical features of catatonia.
Excitement
Immobility or stupor
Mutism
Staring
Posturing
Catalepsy
Grimacing
Stereotypies
Mannerisms
Verbigeration
Rigidity
Negativism
Waxy flexibility
Echolalia
Echopraxia
Withdrawal
Impulsivity
Automatic obedience
Perseveration
Combativeness
Autonomic changes
Catatonia may be associated with neurodevelopmental disorders, psychotic illnesses, bipolar disorders, depressive disorders and medical illnesses.
Management of catatonia itself includes supportive care, pharmacological treatments and electroconvulsive therapy (ECT).
Investigation of the distribution and features of catatonia locally will aid in understanding the causes and associations of the syndrome in this setting. This is important, as early identification will allow for timely initiation of treatment for both the catatonia and the underlying cause.
To determine the clinical and demographic profile of patients with catatonia who received ECT at Elizabeth Donkin Hospital, Port Elizabeth, between 01 January 2012 and 31 December 2014.
This study was a retrospective descriptive chart review. It was a cross-sectional survey and was non-experimental in nature.
The study was conducted in Port Elizabeth at Elizabeth Donkin Hospital, which is a designated psychiatric hospital providing care, treatment and rehabilitation services for patients with mental illness.
Electroconvulsive therapy services at the hospital are provided when clinically indicated. All the relevant Mental Health Care Act forms are completed when the ECT is administered. Patients with possible catatonia are presented by medical officers or registrars at a consultant-driven multidisciplinary team ward round. Those diagnosed with catatonia are administered a trial of lorazepam; ECT is initiated if there is a response to lorazepam. The dose of lorazepam is reduced while the patient receives ECT, and definitive management is initiated before completion of ECT. Electroconvulsive therapy is stopped once the signs of catatonia have resolved, and this is based on clinical evaluation. A consultant report and hospital ECT document are completed for all patients receiving ECT; this includes information on clinical findings, whether or not the patient meets DSM criteria for catatonia, diagnostic information, a recommended management plan, the indication for ECT, medical comorbidities and results of special investigations. Both the consultant report and the ECT document are filed in the relevant patient folders.
Names and folder numbers of patients who receive ECT at Elizabeth Donkin Hospital are recorded in an electronic database which was used to identify all patients who received ECT during the study period. The hospital folders of these patients were retrieved and reviewed. All patients who were administered ECT for catatonia were included in the study.
Information from the consultant psychiatrist’s reports and the medical officer’s clinical notes was recorded on a data collection sheet. Each data collection sheet was numbered.
Demographic variables, including age, sex, and race, were abstracted. The clinical signs of catatonia were categorised into the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) categories:
Motoric immobility, including catalepsy or stupor.
Excessive motor activity that is purposeless and not influenced by external stimuli.
Extreme negativism or mutism.
Peculiarity of voluntary movements such as posturing, stereotyped movements, mannerisms or grimacing.
Echolalia or echopraxia.
Signs of catatonia which did not fall into one of these categories were recorded separately. The final DSM-IV-TR psychiatric diagnosis, medical morbidities, information regarding illicit substance use and the number of ECTs received were also abstracted.
Analysis was carried out using SAS Version 9.2. Descriptive statistics, namely, frequencies and percentages, were calculated for categorical data; means or medians were calculated for numerical data. Analysis focused on the description of demographic and clinical profiles as well as the profile of catatonic signs. Comparative analyses focused on comparing the prevalence of different catatonic signs with the underlying diagnoses, and on comparing demographic characteristics, diagnostic factors and substance use with the number of ECTs received and the length of hospital stay. Analytical statistics, namely, the chi-square test (or Fisher’s exact test) for nominal data and the Kruskal-Wallis test for ordinal data, was used. A significance level of 0.05 was used.
The data were recorded on a data collection sheet by the researcher. Each data collection sheet was numbered; names were not recorded to ensure anonymity. The approval of the Faculty of Health Ethics was obtained from the Biosafety and Ethics Committee of Walter Sisulu University. Written permission to conduct research at the hospital was obtained from the chief executive officer of the hospital.
For the 36-month period considered, 42 patients received ECT for catatonia.
The median age was 23.5 (interquartile range [IQR] 20.1–27.0) years. Participants were predominantly male (
Thirty-four (80.95%) of the total 42 patients presented with an underlying psychotic illness. Among patients with a psychotic illness, schizophrenia was the most common diagnosis (
Distribution of primary psychiatric diagnoses (
Distribution of medical comorbidities (
A total of 12 (28.57%) patients were diagnosed with a medical comorbidity. Eight (19.05%) patients were found to be HIV infected (
Substance use prior to admission was identified in 20 (47.62%) patients (
Frequency of substances used (
The majority of patients in the sample showed features of decreased motor activity, with extreme negativism or mutism documented in 38 (90.47%) individuals and motoric immobility, including catalepsy or stupor, identified in 36 (85.71%) individuals (
Clinical features of catatonia (
The median number of ECTs received was 8 (IQR 6–12). No statistically significant associations were found between demographic characteristics (age, sex or race), underlying diagnosis, or substance use, and the number of ECTs received.
The median length of hospital stay was 15 (IQR 10–26) weeks. Demographic characteristics (age, sex or race), underlying diagnosis and substance use were not associated with length of hospital stay.
In this sample, psychotic disorders were more common than mood disorders: 34 (80.95%) of the total 42 patients were diagnosed with an underlying psychotic illness. Only 7 (16.67%) patients were diagnosed with mood disorders. These findings differ from those which have shown that catatonic patients frequently receive a mood disorder diagnosis,
GMCs were determined to underlie the psychiatric presentation in 19.05% of the sample. All of these patients were identified with a psychotic syndrome and received the final DSM-IV-TR diagnosis of psychotic disorder owing to a GMC. No patients in the sample were identified with catatonia caused by a medical condition. It is worth mentioning that medical causes of catatonia should be considered, even when a psychiatric cause is identified, as there may be multiple causes for the catatonia.
The majority of patients in this sample showed features of decreased motor activity with only 4 patients demonstrating excessive motor activity. No cases of malignant catatonia were identified. Negativism or mutism was identified in 90.47% of patients and features of immobility were detected in 85.71% of the sample. Peculiar voluntary movements were seen in 47.61% of patients and echophenomena in 38.10%. These findings are similar to those of Rosebush et al. who investigated 180 episodes of catatonia, at an acute facility in Canada, and found the retarded subtype to be present in the majority of cases. They also noted that close to the entire sample displayed immobility, mutism and withdrawal. Other features such as waxy flexibility and echophenomena were seen in less than 50.0% of cases.
Identified limitations include the retrospective study design and small sample size. Rating scales were not used to support the diagnosis of catatonia or to monitor the response to ECT. It is possible that cases were missed by the treating clinicians, and it is also possible that cases were not captured on the electronic database. Although DSM-IV-TR diagnoses were recorded for the purpose of this study, clinical notes did not always contain detailed information concerning the specific criteria that the patients met for each diagnosis.
In this retrospective review, we identified 42 patients who received ECT for catatonia between 01 January 2012 and 31 December 2014 at Elizabeth Donkin Hospital in Port Elizabeth, in the Eastern Cape of South Africa. The majority of patients were young adult males, aged 20–24 years. Psychotic disorders were more frequently diagnosed than mood disorders; schizophrenia was the most common diagnosis in the sample.
The findings of this study show that the diagnosis of catatonia in the Eastern Cape of South Africa is not negligible, and demonstrate the need for further local research on this topic, including the prevalence and causes. These data are required to develop clear guidelines for the management of catatonia in South Africa.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
K.O. was the project leader and the main author. Both W.E. and I.E. made conceptual contributions and co-wrote the manuscript.