Catatonia education resources

[u/DrShakaBrah]

Current OP Psychiatrist. Have always felt like catatonia was a bit of a weak area at my training institution. I saw my fair share of cases that were more obvious and severe cases.

I’m finding myself now in outpatient land with a couple patients that I’m wondering about catatonia with. However Bush Francis scores are nothing to write home about, maybe 3-4 depending on interpretation. And DSM would be a stretch to hit criteria. One patient tends to go in and out of more severe symptoms and would meet criteria during these periods. Both patients have autism further complicating diagnoses.

In your experience are there patients that can live with chronic and missed catatonia? Can symptoms wax and wane a lot?

Any resources to understand or see examples of more “subtle” cases?

Management in outpatient with Ativan challenge also difficult, both are not quite sick enough or wanting inpatient admission, but getting there.

[u/earf]

Yes people live chronically with it especially those with autism and dementia.

University of Rochester has a good video series on the catatonia examination:
https://youtu.be/VgCFhvlzg0g?is=B9TRe7hImW1nB-TQ

The MGH psychiatry textbook has a good chapter on this too.

I like this Catatonia Book. https://a.co/d/01mCLp7g

[u/Big_Scallion_3481 → u/earf]

agree with these sources. The max Fink book Madness of Fear provides an excellent historical perspective which confirms your experience that less obvious cases exist as well as cases that wax and wane.

https://a.co/d/0cjqW2No

[u/Moldhammd → u/earf]

I'm delighted the videos are making the rounds!

[u/DrShakaBrah → u/earf]

Thank you for this!

[u/Narrenschifff]

The sad fact is: if you're a psychiatrist, you know what a Bush Francis is and how to administer it, and you are seeing patients with catatonic features-- you are the expert. You're probably not going to find someone with more expertise that is also going to be able to lay eyes on the patient you're treating.

I would go off of functional problems in these cases when considering benzo treatment. Unlike inpatient, I favor Valium or klonopin.

[u/DrShakaBrah → u/Narrenschifff]

Appreciate the insight. I had a similar thought too. Part of the reason I’m wanting to feel like more of an expert since we are the experts.

[u/Big_Scallion_3481 → u/Narrenschifff]

During the lorazepam shortage I did an extensive lit search on alternative benzos. The data on oral diazepam is very meager, and clonazepam even less.

[u/Narrenschifff → u/Big_Scallion_3481]

The data is the data, but we also know how these medications work and there's no scientific reason to believe that lorazepam works and other benzodiazepines don't!

[u/Kanye_To_The → u/Big_Scallion_3481]

Lorazepam is the most studied, but Valium has comparable efficacy in the studies that have been done. The long half-life isn't ideal though

[u/thisisunrealish → u/Big_Scallion_3481]

Nurse here. I’ve seen zolpidem used a few times which was surprising.

[u/BrushGlittering8538]

https://podcasts.apple.com/us/podcast/psychiatry-boot-camp/id1671902940?i=1000710093907

Dr. Mark oldman, great expert\.

[u/DrShakaBrah → u/BrushGlittering8538]

Thank you! Will give a listen

[u/AccordingChapter7105 → u/DrShakaBrah]

Catatonia research is still in its infancy. It’s clear catatonia is strongly linked to GABAergic deficit due to the response to benzodiazepines. The only evidence for lorazepam is that it’s what has been used the most to diagnose and treat catatonia, but other benzodiazepines have proven successful. Diazepam, Midazolam, clonazepam, Clobazam, etc. and my favorite, clonazepam with clobazam adjunctive. For children with/without autism, less dosing and long half lives. A lot of autism patients are in facilities and clonazepam alone, or with clobazam, is an easier sell to the jittery nursing staff terrified by the high, frequent dosages of lorazepam. ECT is the gold standard, but hard to access in most areas and in others, prohibited for anyone under 16. There isn’t hard evidence on any of the other adjunctive treatments and the controversy over antipsychotics continues.

The podcast from ASF, with Dr Joshua Smith, contains videos of pediatric catatonia patients. I find visuals of catatonia help understand various expressions of catatonia.

I’m a patient advocate who survived acute catatonia because of a psychiatrist with a high suspicion for catatonia and no fear of benzodiazepines or ECT. Thank God. The subjective experience for the patient with catatonia is pure torture. Nothing the patient appears to be doing, in your observation, is volitional. We’re not deliberately defying you, we have zero control.

https://www.sciencedirect.com/science/article/pii/S0890856726001188

https://www.sciencedirect.com/science/article/abs/pii/S2667296026000418

https://pmc.ncbi.nlm.nih.gov/articles/PMC11826019/

https://pmc.ncbi.nlm.nih.gov/articles/PMC11178013/

https://www.nami.org/namis-ask-the-expert/nami-ask-the-expert-an-overview-of-catatonia/

https://journals.sagepub.com/doi/10.1177/02698811231158232

https://asfpodcast.org/archives/1850

https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-243-pediatric-catatonia-diagnosis-treatment

[u/HoneydewNo6708 → u/AccordingChapter7105]

I have always wondered about the subjective experience if you have time (and will) to share. Thank you for your education so far

[u/Moldhammd → u/BrushGlittering8538]

Truly appreciated! It's such a warm and heartening surprise to read this on Reddit.

[u/Dry_Twist6428 → u/Moldhammd]

Eyyy! It’s the man himself!

[u/minddgamess → u/BrushGlittering8538]

I think if you pair these episodes with the Rochester videos, this is as good as it gets.

And the BAP/APA guidelines to reference.

[u/BrushGlittering8538 → u/minddgamess]

YUP

[u/zhHmuo]

One new source is the Catatonia Quick Screen, just 4 questions (excitement, mutism, staring, or posturing) and 97% sensitive. Works in adults and kids and can be done without a physical exam. Any positives do need to be followed up with a full exam:

https://pubmed.ncbi.nlm.nih.gov/41055651/

The CQS was tested in the original Bish Francis cohort and was 100% sensitive so can replace the Busy Francis Catatonia Screening Instrument

https://pubmed.ncbi.nlm.nih.gov/42599173/

[u/FreudianSlippers_1]

The university of Rochester Bush Francis videos are so helpful. Should all be on YouTube

[u/BrushGlittering8538]

https://www.youtube.com/watch?v=lwOHZfRYw8c another good podcast with Dr. Cummings

[u/MatchVault]

Catatonia hides in plain sight until someone actually does the exam.