Journal of Affective Disorders 74 (2003) 279–285www.elsevier.com/ locate/ jad

Research report

R elevance of the catatonic syndrome to the mixed manic episode

a a a b ,*¨ ¨Stephanie Kruger , Robert G. Cooke , Cathy C. Spegg , Peter BraunigaCentre for Addiction and Mental Health, Clarke Institute of Psychiatry, Mood Disorders Program, University of Toronto, Toronto,

Canadab ¨Klinik f ur Psychiatrie, Verhaltensmedizin und Psychosomatik am Klinikum Chemnitz, Dresdner Strasse 178, 09131Chemnitz, Germany

Received 23 October 2000; received in revised form 20 February 2002; accepted 8 March 2002

Abstract

Background: Catatonic symptoms have been associated with mixed mania in the older psychiatric literature, however, todate no systematic studies have been performed to assess their frequency in these patients.Method: Ninety-nine patientswith bipolar disorder manic or mixed episode were assessed for the presence of catatonia.Results: Thirty-nine patientsfulfilled criteria for mixed mania of whom 24 were catatonic. Among the patients with pure mania, only three were catatonic.Eighteen catatonic patients with mixed mania required admission to the acute care unit (ACU).Limitations: Our findingsonly apply to severely ill patients with mixed mania who require ACU admission. Nevertheless, it is important to know, thatthe likelihood of overlooking catatonia in less severely ill patients with mixed mania is low and that it does not need to beroutinely assessed on a general ward.Conclusions: Catatonia is frequent in mania and linked to the mixed episode. Catatoniain mixed mania is likely to be found among the severely ill group of patients with mixed mania, who require emergencytreatment. 2003 Elsevier Science B.V. All rights reserved.

Keywords: Catatonia; Mania; Mixed mania; Bipolar disorder

1 . Introduction pure mania, the course and outcome of mixed maniaare reported to be more severe (McElroy et al.,

Manic-depressive mixed states have been de- 1992).scribed in the traditional psychiatric literature since The association of catatonic symptoms with manic1854 (Falret, 1851) and account for up to 60% of episodes has a long tradition. In the French literature,

´manic episodes (Specht, 1908; Kraepelin, 1913; the term ‘manie choreatique’ was coined for manicLange, 1922; McElroy et al., 1992). Compared with states with predominant motor symptoms. Wernicke

and Kleist (Wernicke, 1900; Kleist, 1912) observedthat catatonic symptoms occurred more frequently in*Corresponding author. Tel.:1 49-371-333-10501; fax:1 49-cyloid psychoses in pure mania. Lange (1922)371-10502.

¨E-mail address: p.braeunig@skc.de(P. Braunig). examined 700 manic patients for the presence of

0165-0327/03/$ – see front matter 2003 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 02 )00088-5

¨280 S. Kruger et al. / Journal of Affective Disorders 74 (2003) 279–285

catatonia and found that 28% of the patients with which severely ill patients are placed under closemixed mania had multiple catatonic symptoms as observation and monitoring. Patients on this unitopposed to 13% of the patients with pure mania. usually are brought in by police or ambulance andOther authors observed that mixed affective states their status is often involuntary. The remaining 75were characterized by motor excitement alternating patients were admitted to the General Inpatient Unitrapidly with inhibition, verbigerations, stereotypies, (GPU). For the purpose of data analysis, the twoposturing and iterations (Kraepelin, 1916; Neele, groups were combined.1949; Leonhard, 1957; Gjessing, 1960, 1975; Men- None of the patients had evidence of currenttzos, 1995). Kahlbaum described a form of catatonia schizoaffective disorder, neurological disorders orwhich he termedcatatonia gravis and which corre- illicit drug abuse/dependence. Treatment was with-sponds to today’s understanding of the manic-depres- held until rating scale assessments had been per-sive mixed state with catatonic symptoms (Kah- formed by one of the authors.lbaum, 1884). We used the criteria proposed by McElroy et al.

There is agreement in the contemporary literature (1995) to make distinctions between mixed and purethat catatonia frequently occurs in mania at preval- mania. Patients with mixed mania met full DSM-IVence rates ranging between 28 and 37% (Abrams and (American Psychiatric Association, 1996) criteria for

¨Taylor, 1977; Francis et al., 1997; Braunig et al., a bipolar-I manic episode and had two or more1998). In a previous study we found that catatonic prominent depressive features. Symptoms such asmania is characterized by more severe manic symp- insomnia, lack of concentration or weight loss, whichtoms, more comorbidity, more general psycho- could be either related to depression or to mania,pathology (anxiety, hostility, anergia) and poorer when ambiguous, were excluded from the definition

¨outcome than non-catatonic mania (Braunig et al., of mixed mania. The severity of the depressive1998). However, little is known about the association symptoms was quantified with the 17-item Hamiltonof the catatonic syndrome to episode type. The Depression Rating Scale (HAM-D 17) (Hamilton,clinical features of the mixed episode and previous 1960).observations suggest that catatonic symptoms mayoccur more frequently in mixed than in pure mania.Thus, the current study is a further step towards 2 .2. Assessment of catatoniacharacterizing catatonic mania and the significanceof the catatonic syndrome for the mixed episode. Catatonia was assessed with the Catatonia Rating

¨Scale (CRS) (Braunig et al., 1998, 2000) a sys-tematic rating instrument designed to measure

2 . Method catatonic symptoms and behaviours across a range ofdimensions (type, frequency and severity). The scale

2 .1. Patients and diapnosis contains 21 individually defined items consisting of16 catatonic motor symptoms and five catatonic

One-hundred and eleven consecutive admissions behavioural symptoms and has been validated in¨ ¨to the Zentrum fur Psychiatrie und Psychotherapie of different patient populations (Braunig et al., 2000;

¨the University of Bochum with mania according to Kruger et al., 2000). Ratings range from 0 (absent) toDSM-IV (American Psychiatric Association, 1996) 1 (minimal), 2 (moderate), 3 (marked) and 4 (severe),were approached for participation in the current with detailed rating instructions for each item orstudy. Twelve patients refused consent. Among the group of items. The diagnostic threshold forremaining 99 patients, 66 gave informed consent and catatonia is the presence of at least four symptomsin 33 patients consent was obtained from a legal rated at least 2 (moderate). The CRS is administeredrepresentative. All were assessed for the presence of during an examination lasting 45 minutes at thecatatonia. In 24 of these 99 patients the severity of most. Rating scale assessment was performed withinthe manic episode required admission to the Acute 3 days of admission (T ) and again within 3 days of1

Care Unit (ACU). This Unit is a secured ward on discharge (T ).2

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Table 22 .3. Statistical analysisFrequencies of catatonic symptoms in catatonic patients withmixed mania (N 5 24)

Dichotomous variables were analysed by chi-Catatonic symptoms Catatonic mixedsquare analysis or Fisher’s exact test using SPSS for

manicsWindows (Version 7.0). Group mean differencesNo. %were compared by using the two-tailedt-test. A

cluster analysis was performed using Ward’s linkage Motor excitement 24 100Verbigerations 23 96and squared Euclidian distance as the measure, toStereotypes 23 96assess if on the basis of the scale’s items, a differen-Motor inhibition 23 96tiation could be made between patients who requiredIterations 22 92

admission to the ACU and those who were admitted Groping 19 79to the GPU. A stepwise discriminant function analy- Impulsivity 19 79

Mutism 19 79sis was performed to optimize differences betweenGrimacing 18 75the ACU and the GPU groups with regard to theirExaggerated responsiveness/copying 17 71CRS symptom scores.Blinking 13 54Mannerism 13 54Jerky movements 11 46Gegenhalten 9 373 . ResultsRigidity 8 33Negativism 7 293 .1. Frequency of mixed mania, demographics andParakinesias 5 21

course parameters Posturing 3 12Waxy flexibility 3 12Rituals 2 8Thirty-nine patients (39.4%) of the total sample ofAutomatic obedience 1 499 patients with mania were diagnosed with mixed

mania and 60 (60.6%) with pure mania. The meanage for all patients with mixed mania was 38.8612.3years; 23 (58.9%) were women, the mean age of in the pure mania group. Nineteen (48.7%) patientsonset of the bipolar illness was 26.6 years, and the with mixed mania were admitted to the ACU, ofmean number of previous episodes was 9.3618.0. whom 18 were patients with catatonia. The remain-The mean hospitalization length for the index admis- ing six (25%) catatonic patients with mixed maniasion was 40.0621.7 days, which is a typical length were admitted to the GPU. The three patients withof stay for patients with mixed states at this facility. pure mania who were catatonic were admitted to the

GPU.3 .2. Frequency of catatonia The number of catatonic symptoms rated moderate

or higher ranged from 5 to 18, and 13 patientsTable 1 shows the distribution of catatonic symp- exhibited more than 10 symptoms. Table 2 shows the

toms among subjects. Twenty seven (27.3%) patients sequential order of catatonic symptoms ranked byfulfilled criteria for a catatonic syndrome (at least frequency of occurrence atT in patients with1

four items rated moderate or higher). Of these, 24 catatonic mixed mania. The total CRS score for bothwere in the mixed mania group and only three were T and T in patients with catatonic mixed mania1 2

Table 1Distribution of catatonic symptoms among subjects with pure and mixed mania based on admission modality

ACU GPU Total df Fisher’s exact test

N % N % N %

Pure mania 0/5 0 3/55 5 3/60 5 1 0.767Mixed mania 18/19 95 6/20 30 24/39 62 1 0.000

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Table 3Differences in severity of selected catatonic symptoms atT between subjects with mixed mania admitted to the ACU (N 5 18) and subjects1

admitted to the GPU (N 5 6)

Item ACU GPU t df P

Mean score S.D. Mean score S.D.

Motor excitement 3.67 0.49 2.83 0.75 3.17 22 0.004Blinking 2.17 1.69 1.00 0.62 2.22 22 0.037

aMotor inhibition 2.78 0.81 0.00 0.00 2.32 22 0.027Iterations 3.33 0.91 2.17 1.17 2.54 22 0.019Grimacing 2.98 0.44 1.98 0.53 2.47 22 0.022Jerky movements 1.94 1.70 1.46 1.49 2.76 22 0.000

aRigidity 1.11 1.18 0.00 0.00 2.27 22 0.047Verbigerations 3.61 0.70 2.67 1.03 2.55 22 0.018

aNegativism 1.17 1.34 0.00 0.00 2.10 22 0.047a Mann–Whitney-U test used due to zero variance in one cell.

independent of admission to the GPU or to the ACU patients with mixed mania who required ACUwas 35.5 (S.D.: 11.71) and 1.50 (S.D.: 2.06), respec- admission, 18 of whom were catatonic. By contrast,tively. This indicates significant remission of the proportion of catatonia among the group ofcatatonia after successful treatment. The three pa- patients with mixed mania who received voluntarytients with pure mania who were catatonic exhibited inpatient treatment on a general ward was only 6/20the following catatonic symptoms: motor excitement, (30%). Most studies on mixed mania did not includeverbigerations, stereotypies, impulsivity, exaggerated an ACU subgroup and others did not specificallyresponsiveness/copying and grimacing. clarify the status of their inpatient population (Sup-

Catatonic patients with mixed mania requiring pes et al., 1992; Dilsaver et al., 1994; McElroy et al.,ACU admission scored significantly higher than 1995; Strakowski et al., 1996; Perugi et al., 1997;those admitted to the GPU on several CRS items Goldberg et al., 1998). This subject selection may in(Table 3). part explain why the presence of catatonia was not

Three items on the CRS (mutism, motor excite- reported.ment and iterations) were selected by discriminate The distribution of catatonic symptoms in the totalfunction analysis to correctly place catatonic subjects sample of subjects with mixed mania suggests thatwith mixed mania in the ACU or the GPU group. these are mainly restricted to those associated withSimilarly, the cluster analysis revealed that except motor arousal or inhibition (e.g. iterations, verbigera-for one patient, all catatonic subjects with mixed tions, jerky movements, mutism), whereas symptomsmania were classified correctly based on their ratings of catalepsy (e.g. waxy flexibility, posturing) andon the CRS as belonging either to the ACU or to the with the exception of exaggerated responsiveness,GPU group. These results were significant at the symptoms of disturbance of volition (e.g. gegenhal-,0.05 level. ten, automatic obedience) did not occur to a signifi-

cant degree. In fact, based on the severity ratings ofmutism, motor excitement and verbigerations alone,

4 . Discussion catatonic mixed manics were classified into thosewho would need ACU admission and those who

The frequency of 27.3% (N 5 27) of catatonia in would not. Verbigerations and other symptoms ofthe total (N 5 99) sample of patients with pure and speech disturbance are considered one of the hall-mixed mania is consistent with other reports in the marks of catatonia and are reported to be neglectedliterature (Abrams and Taylor, 1977; Bush et al., in modern catatonia research (Ungvari et al., 1995)

¨1996; Braunig et al., 1998). The high frequency and our findings confirm this observation.¨(N 5 24, 61.5%) of catatonia in the group of patients In a previous paper (Braunig et al., 1998), we

with mixed mania may reflect our inclusion of 19 reported that catatonic mania is also associated with

¨S. Kruger et al. / Journal of Affective Disorders 74 (2003) 279–285 283

more severe manic and depressive symptoms as well typical neuroleptic agents (Wetzel et al., 1988;as with more general psychopathology (anxiety, Menza and Harris, 1989; Fricchione, 1989; Rosebushanergia, hostility, thought disorder). This is in ac- et al., 1992; Ungvari et al., 1994a,b; Hawkins et al.,cordance with the current finding of catatonic pa- 1995; Petrides et al., 1997; Blumer, 1997; Huang ettients requiring admission to the ACU. Thus, the al., 1999).presence of catatonia in mania seems to be a marker The generalizability of our findings is limited,of the severity of the acute episode and it can be since they only apply to severely ill patients withconcluded that catatonia is more likely to occur in mixed mania who require ACU admission. Neverthe-patients whose acute symptoms are severe and less, it is important to know, that the likelihood ofcomplex. overlooking catatonia in less severely ill patients

None of our patients was treated with high with mixed mania is low and that it does not need topotency neuroleptic drugs. Thus, the occurrence of be routinely assessed on a general ward.catatonic symptoms in our patients cannot be linked The frequency of catatonic mixed mania will varyto treatment with these drugs. In addition, neurolep- with the instrument used to establish the diagnosis.tics primarily induce pseudoparkinsonism (motor We used a detailed rating instrument, which coversinhibition, rigor) and akathisia. Our catatonic patients the whole spectrum of catatonic motor and behav-exhibited a minimum of five catatonic symptoms, the ioural symptoms and with which even subtle mani-majoritiy of which were unrelated to present or past festations of these symptoms can be detected. Clear-use of neuroleptic drugs. ly, without a systematic rating tool, fewer and only

There is evidence in the literature that catatonic severe cases of catatonia would have been identified,symptoms may occur in neurological disorders and explaining why catatonia in mixed mania often goesare associated with neuropsychological deficits (Akil unrecognized and is clearly underdiagnosed. Weet al., 1991; Saver et al., 1993; Northoff et al., 1999, propose the use of a rating scale (Bush et al., 1996;

¨2000; Mendez, 1999; Chen et al., 2000; Shill and Braunig et al., 2000) rather than a checklist (e.g.Stacy, 2000). The assessment of neurological soft DSM-IV) for catatonia, to facilitate recognition andsigns or any other indicators of neurological dysfunc- proper assessment and to detect subtle manifestationstion was not the objective of this study, however, it of the complex catatonic syndrome.is a clinically relevant issue and future studies shoulduse clinical assessment and brain imaging to sub-stantiate these observations. 5 . Conclusions

Our findings are of diagnostic and therapeuticsignificance. Catatonic symptoms in bipolar disorder Catatonic symptoms in mania are closely linked toare often overlooked if subtle, or misinterpreted, the mixed episode. The frequency of catatonic mixedbecause of the misconception that they are generally mania can be expected to be relatively low on ainfrequent (Ries, 1985; Fein and McGrath, 1990). general inpatient unit, whereas it is likely to increaseOur findings show that catatonic symptoms are likely dramatically in an acute care setting. This finding isto occur in patients with mixed episodes, and that of clinical importance as catatonia in patients withthey occur along a severity continuum. Because of mixed states yields the risk of misdiagnosis and oncethe strong association of catatonic symptoms with recognized, requires specific therapeutic interven-psychotic symptoms (Blumer, 1997) and because of tions.the general difficulties in diagnosing a severe mixedstate, these patients are at risk of being misdiagnosedas schizophrenic. This risk is increased because the

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