What is the approach to screening for retarded catatonia?

Screening for Retarded Catatonia

Use the Bush-Francis Catatonia Rating Scale (BFCRS) as your primary screening tool, which guides you through a systematic neuropsychiatric examination to identify the motor and behavioral signs of retarded catatonia. 1

Initial Recognition and Clinical Examination

Maintain a high index of suspicion for catatonia in any patient presenting with acute psychiatric illness, as it occurs in more than 10% of these cases and is frequently underdiagnosed. 2

Essential Physical Examination Components

• Observe for immobility and decreased motor activity - patients may remain motionless for prolonged periods 2
• Assess for mutism - complete absence of verbal output or severely reduced speech 2
• Check for staring - fixed gaze without normal eye contact or tracking 2
• Test for rigidity - resistance to passive movement of limbs 2
• Evaluate for catalepsy - maintenance of imposed postures 2
• Look for waxy flexibility - limbs remain in positions where they are placed 2
• Assess for negativism - resistance or opposite response to instructions 2

Critical Non-Verbal Signs to Document

Perform thorough and repeated observations, as catatonic signs may fluctuate or be subtle initially. 3 Look specifically for:

• Posturing - spontaneous maintenance of unusual body positions 2
• Mannerisms - odd, purposeless movements 2
• Stereotypies - repetitive, non-goal-directed movements 2
• Grimacing - maintenance of odd facial expressions 2
• Echopraxia - mimicking examiner's movements 2

Structured Screening Approach

Step 1: Use the Bush-Francis Catatonia Rating Scale

Apply the BFCRS systematically during your examination, as this validated screening instrument guides you through the complete neuropsychiatric assessment needed to identify catatonia. 1

The scale assesses 23 catatonic signs and provides both screening (first 14 items) and severity rating components 1

Step 2: Differentiate from Baseline in Neurodevelopmental Disorders

In patients with autism spectrum disorder or other neurodevelopmental conditions, you must establish their "personalized score at baseline" - documenting their premorbid neurobehavioral and motor symptoms - before attributing new signs to catatonia. 4

• Document the patient's baseline motor patterns, functional abilities, and behavioral symptoms before the current presentation 4
• Identify "catatonic deterioration from baseline" - new features that represent a change from the patient's usual neurodevelopmental presentation 4
• This distinction is critical because underlying neurodevelopmental disorders can mimic catatonic signs, leading to both over- and under-diagnosis 4

Essential Diagnostic Workup After Positive Screen

When to Pursue Medical Evaluation

If you suspect comorbid delirium, perform a comprehensive general medical workup, as this clinical suspicion is the strongest predictor of identifying underlying medical causes. 5

Do not attribute catatonia solely to psychiatric etiology without medical evaluation, as this approach is associated with significantly less thorough diagnostic workup and missed medical causes. 5

Medical Conditions to Exclude

Screen for the following medical etiologies, as catatonia occurs with a broad spectrum of medical illnesses beyond psychiatric disorders: 2

• Neuroleptic malignant syndrome - check for recent antipsychotic exposure, fever, and autonomic instability 3
• Encephalitis - assess for fever, altered consciousness, and neurological signs 3
• Systemic diseases - evaluate for metabolic derangements, infections, and autoimmune conditions 3
• Affective disorders - catatonia is particularly common with mood disorders 2

Common Pitfalls to Avoid

Catatonia is associated with significant morbidity and mortality if left untreated, making early recognition essential. 2

• Do not assume catatonia only occurs in schizophrenia - this outdated concept leads to missed diagnoses, as catatonia occurs across many psychiatric and medical conditions 2
• Do not rely on a single examination - repeated observations are necessary as signs may be intermittent 3
• Do not skip the physical examination - underdiagnosis often results from inadequate physical assessment 3
• Consider psychiatric consultation in general hospital settings where catatonia is frequently overlooked 3

When Screening is Positive

Once catatonia is identified, it must be treated before any underlying conditions can be accurately diagnosed. 2

• Most patients respond rapidly to low-dose benzodiazepines (such as lorazepam), with overwhelming clinical evidence supporting this first-line treatment 1
• Electroconvulsive therapy is occasionally required for treatment-resistant cases 1
• Patients with longstanding catatonia or schizophrenia may be less likely to respond to initial benzodiazepine treatment 2