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Objective: The clinical management of catatonia has always been a focus of psychiatric nursing. Unfortunately, there is still limited research on the risk factors and nursing methods for patients with catatonia and bacterial pneumonia. Few studies have identified and analyzed the clinical risk factors for catatonia patients with bacterial pneumonia. This study aims to explore the risk factors and preventive nursing measures for pneumonia in patients with catatonia. Methods: A total of 88 patients with catatonia treated in the emergency department of a psychiatric hospital from January 2019 to October 2021 were selected. They were divided into bacterial pneumonia group (n=17) and nonpneumonia group (n=71) based on whether they had pneumonia. The demographic data and clinical characteristics of the two groups were compared. Logistic regression analysis and point-biserial correlation were used to analyze the risk factors for developing pneumonia in patients with catatonia. Results: The incidence of pneumonia in patients with catatonia was 19.32%. Correlation analysis showed that age (r=0.216, p=0.043), The Activities of Daily Living Scale (ADL) score (r=0.265, p=0.013), cell count of white blood (r=0.591, p<0.001), neutrophil count (r=0.599, p<0.001), percentage of neutrophils (r=0.311, p=0.003), C-reactive protein (r=0.558, p<0.001), bedridden days (r=0.470, p<0.001), and albumin level (r=-0.288, p=0.007) were significantly associated with pneumonia. Multivariate logistic regression analysis showed that smoking, bedridden days, family support, and nutritional status were risk factors for pneumonia in patients with catatonia. Conclusion: Reducing smoking and bedridden days, improving nutrition, and providing timely preventive nursing care by family members can reduce the occurrence of pneumonia in patients with catatonia. [ABSTRACT FROM AUTHOR]

Objective: Catatonia is a neuropsychiatric disorder that can occur in patients of any age, but it is uncertain whether patient demographics or underlying diagnoses differ between pediatric and adult patients. This study investigates patients of all ages diagnosed with catatonia during acute care hospitalizations in the United States over a 5‐year period. Method: The National Inpatient Sample, an all‐payors database of acute care hospital discharges, was queried for patients with a discharge diagnosis of catatonia between 2016 and 2020 with patients stratified by age as pediatric (≤18 years) or adult (>18 years). Results: Among 174,776,205 hospitalizations recorded in the NIS from 2016 to 2020, 61,990 (95% CI: 60,257 to 63,723; 0.035%) involved a diagnosis of catatonia. Of these, 3255 were for pediatric patients and 58,735 were for adult patients. Compared with adult patients, pediatric catatonia patients were more likely to be male and non‐White. Diagnostically, psychotic disorders, encephalitis, and neurodevelopmental disorders were more common primary discharge diagnoses in pediatric patients, while adult patients more frequently were diagnosed with mood disorders. Length of stay was not significantly different between pediatric and adult catatonia hospitalizations. Physical restraints were commonly applied for patients with catatonia. Conclusion: Pediatric and adult catatonia patients differed in sex, race, and diagnosis, although hospital length of stay was not different between pediatric and adult catatonia hospitalizations. These results may inform catatonia diagnosis in the hospital setting and point to disparities that could be targets of quality improvement efforts. [ABSTRACT FROM AUTHOR]

Background: Catatonia is a complex syndrome with prominent psychomotor, cognitive, and affective manifestations. Among the commonly described manifestations of catatonia are mannerisms and stereotypies. Kahlbaum, who coined the term catatonia, described several presentations of mannerisms and stereotypies as complex behaviors in his monograph. However, most of the subsequent psychiatric literature has described both phenomena in the context of simple motor movements or actions. Study design or method: We identified complex behavioral presentations of mannerisms and stereotypies described by Kahlbaum in his monograph. We summarize the development and use of mannerisms and stereotypies as psychiatric terminology since Kahlbaum, emphasizing the spectrum of behavior captured early in this usage. We list the inconsistent and interchangeable use of these terms in subsequent literature and describe recent examples of complex behavioral manifestations of mannerisms and stereotypies in the context of catatonia. Study results: We propose a new framework for mannerisms and stereotypies that utilizes descriptive psychopathology factors in various normative references, the context of the behavior examined, and critical pathological processes identified in mannerisms and stereotypies to identify and describe complex manifestations of these phenomena. Conclusion: Catatonia continues to remain under-recognized and undertreated. Our current diagnostic tools can make mannerisms and stereotypies complex and challenging to recognize. We suggest defining stereotypies as noncontextual repetitive activities while mannerisms as non-contextual peculiarities of activities. Utilizing our proposed framework and definitions can improve the description, recognition, and treatment of catatonia. [ABSTRACT FROM AUTHOR]

Catatonia, documented since the 19th century, remains a significant challenge in terms of recognition and treatment. Over the last two decades, ketamine has brought new perspectives to psychiatry, sparking widespread interest. Concurrently, catatonia has attracted heightened scientific attention. Preliminary evidence suggests the therapeutic potential of ketamine for catatonia. We systematically searched Medline/PubMed, Embase, PsycINFO, Lilacs, and Cochrane Library databases, as well as Google Scholar, for studies with ketamine or its enantiomers as intervention for catatonia, with no restrictions to underlying diagnosis, date, language, or study design. Twenty articles were included, encompassing a total of 25 catatonic patients receiving ketamine or esketamine. Predominantly female (61.9 %), with a mean age of 44.4 years, patients mostly exhibited manifestations compatible with the retarded subtype of catatonia. Mood disorders were the most prevalent underlying diagnoses. Ketamine was primarily administered intravenously over a 40-minute period and in multiple-dosing schemes. Mean response and remission rates of catatonic manifestations for the whole sample were 80 % and 44 %, respectively, with no reports of worsening catatonic features or psychotic symptoms. Only one patient discontinued treatment due to intolerable dissociative effects. Challenging the conventional contraindication of ketamine in psychotic disorders, current evidence highlights its potential efficacy, particularly in treating catatonia. Pending further research, we advocate reevaluating this contraindication, as it may offer a promising therapeutic option, especially for challenging cases. Preliminary evidence suggests potentially greater benefits for catatonic patients with underlying mood disorders compared to primary psychotic disorders. [ABSTRACT FROM AUTHOR]

Personalized functional connectivity mapping has been demonstrated to be promising in identifying underlying neurophysiological basis for brain disorders and treatment effects. Electroconvulsive therapy (ECT) has been proved to be an effective treatment for major depressive disorder (MDD) while its active mechanisms remain unclear. Here, 46 MDD patients before and after ECT as well as 46 demographically matched healthy controls (HC) underwent resting-state functional magnetic resonance imaging (rs-fMRI) scans. A spatially regularized form of non-negative matrix factorization (NMF) was used to accurately identify functional networks (FNs) in individuals to map individual-level static and dynamic functional network connectivity (FNC) to reveal the underlying neurophysiological basis of therepetical effects of ECT for MDD. Moreover, these static and dynamic FNCs were used as features to predict the clinical treatment outcomes for MDD patients. We found that ECT could modulate both static and dynamic large-scale FNCs at individual level in MDD patients, and dynamic FNCs were closely associated with depression and anxiety symptoms. Importantly, we found that individual FNCs, particularly the individual dynamic FNCs could better predict the treatment outcomes of ECT suggesting that dynamic functional connectivity analysis may be better to link brain functional characteristics with clinical symptoms and treatment outcomes. Taken together, our findings provide new evidence for the active mechanisms and biomarkers for ECT to improve diagnostic accuracy and to guide individual treatment selection for MDD patients. • The longitudinal MRI data for MDD patients before and after ECT were acquired. • Individual large-scale functional network for each subject was mapped. • Static and dynamic large-scale functional network connectivity analyses were employed. • Machine learning based prediction model for treatment outcome was established. [ABSTRACT FROM AUTHOR]

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Background: Major Depressive Disorder (MDD) represents a significant global health concern, often complicated by comorbidities such as catatonia and autism spectrum disorder (ASD). Recognizing the interplay among these conditions and their impact on suicidal tendencies is crucial for effective clinical management. Methods: A total sample of 147 subjects with MDD was divided into Significant Catatonia (SC) and Non-Significant Catatonia (NSC) groups based on Catatonia Spectrum (CS) scores. Participants were evaluated through the Structured Clinical Interview for DSM-5, Research Version (SCID-5-RV), the Adult Autism Subtreshold Spectrum (AdAS Spectrum), and the Mood Spectrum—Self Report questionnaires. Statistical analyses included Mann–Whitney U test, Chi-square test, logistic regression analyses, and a decision tree model. Results: The SC group exhibited higher CS, AdAS Spectrum, and MOODS-SR total and domain scores compared to the NSC group. Individuals with significant autistic traits were over-represented in the SC group, as well as participants with higher suicidality, suicidal ideation, and a history of suicide attempts. The total AdAS Spectrum and MOOD-SR score, the AdAS domain "Hyper-hypo reactivity to sensory input", and the "Cognitive depressive" MOOD-SR domain were predictive of belonging to the SC group. Suicidality levels appeared to be higher in clinically significant ASD, intermediate in subjects with autistic traits (AT), and low in the absence of AT. Conclusions: the study suggests the existence of a specific phenotype of MDD associated with catatonia, characterized by elevated autistic traits and suicide risk. [ABSTRACT FROM AUTHOR]

Electroconvulsive therapy (ECT) is considered one of the most effective treatments for psychiatric disorders. ECT has proven effective in the treatment of depression, mania, catatonia and psychosis. It is presumed that seizures induced during ECT administration cause toxicity and potentially neuronal and glial cell death. A broad range of neurological disorders increase cerebrospinal fluid and serum levels of neuron-specific enolase (NSE) and S-100b protein. This study aims to investigate the effect of ECT on NSE and S-100b levels, which, together, serve as a proxy for neuronal cell damage. Serum concentrations of S-100b and NSE of adult patients who received ECT were measured by immunoluminometric analysis before and after treatment. A two-way ANOVA test was used to estimate the statistical differences in marker concentrations between the subgroups of the study population. Results: A total of 55 patients were included in the analysis: 52.73% (n = 29) were diagnosed with depression, 21.82% (n = 12) with schizophrenia or other psychosis, 16.36% (n = 9) with mania and 9.09% (n = 5) with catatonia. There were no statistically significant changes in NSE (p = 0.288) and S-100b (p = 0.243) levels. We found no evidence that ECT induced neuronal damage based on NSE and S-100b protein levels measured in the serum of patients before and after treatment. [ABSTRACT FROM AUTHOR]

Electroconvulsive therapy (ECT) is an effective, safe, and mostly well-tolerated treatment for patients with severe or difficult to treat depression or psychotic disorders. However, a relevant number of patients experience subjective and/or objective cognitive side-effects. The mechanism of these transient deficits is not yet clear. Thus, our study prospectively investigated neurofilament light chain (NfL) concentrations as a highly sensitive biomarker for neuroaxonal damage along with cognitive performance during a course of ECT. Serum NfL concentrations from 15 patients with major depressive disorder receiving ECT were analyzed (1) 24 h before the first ECT, (2) 24 h and (3) 7 days after the last ECT (45 measurements in total). Neuropsychological testing including memory, executive functions and attention was performed at each time-point. NfL concentrations did not change between the three time-points, while a temporary cognitive impairment was found. Even in the subset of patients with the strongest impairment, NfL concentrations remained unchanged. Neuropsychological testing revealed the common pattern of transient cognitive side-effects with reduced performance 24 h post-ECT (global cognition score: p < 0.001; memory: p = 0.043; executive functions: p = 0.002) and return to baseline after 7 days (all p < 0.001). Our study adds to the evidence that neither ECT per se nor the transient cognitive side-effects seem to be associated with an increase of NfL as a marker of neuroaxonal damage. In contrast, we discuss cognitive side effects to be potentially interpreted as a byproduct of ECT's neuroplastic effects. [ABSTRACT FROM AUTHOR]

Catatonia is a neuropsychiatric disorder associated with changes in behavior and affect. In adults, catatonia can respond rapidly to treatment with benzodiazepines as part of the "lorazepam challenge test." The acute effectiveness of benzodiazepine treatment in pediatric catatonia, however, has received less study. This study reports catatonia severity as measured by the Bush Francis Catatonia Rating Scale (BFCRS) in pediatric patients before and after treatment with lorazepam. Multicenter retrospective cohort study from 1/1/2018 to 6/1/2023 of patients aged 18 and younger with a clinical diagnosis of catatonia and assessment using the BFCRS before and after treatment with lorazepam. Among 54 patients, median age was 16, and 26 (48.1 %) were female. Neurodevelopmental disabilities were present in 24 (44.4 %) of patients. Prior to treatment, patients had a mean BFCRS score of 16.6 ± 6.1, which significantly reduced to 9.5 ± 5.3 following treatment with lorazepam (mean paired difference 7.1; t = 9.0, df = 53, p < 0.001), representing a large effect size (Hedges's g = 1.20; 95 % CI: 0.85 to 1.55). No significant association was found between lorazepam dose or route of administration and clinical response, nor were age, sex, study site, the presence of a neurodevelopmental disorder, the presence of hyperactive catatonic features, or the time between treatment and reassessment associated with post-treatment BFCRS. Lorazepam resulted in a rapid improvement in BFCRS score in pediatric patients, with a large effect size. Further research is needed into optimal dosing and route of administration of the lorazepam challenge test in pediatric patients. [ABSTRACT FROM AUTHOR]

Background. Currently, researchers are aiming to establish the relationship between neurocognitive disorder and other clinical manifestations of endogenous diseases and functional indicators of the patient’s adaptation to social life. According to some data, the development of cognitive disorders is associated with the severity of catatonic disorders in the clinical picture of various diseases, in particular the presence of catatonic symptoms determines the worst indicators of cognitive functioning in the case of schizophrenia.The aim. To study the clinical and psychopathological features of catatonic syndrome in connection with schizophrenia spectrum disorders, as well as its connection with neurocognitive disorder manifestations among patients with endogenous disorders.Methods. From September 2022 to March 2024, we conducted a prospective, multicenter study of patients (n = 69) suffering from paroxysmal schizophrenia with primary catatonic symptoms in the structure of attacks. Mental status, the severity of catatonic symptoms using Bush – Francis Catatonia Rating Scale, neurocognitive profile using a number of validated scales (Montreal Cognitive Scale, Brief Assessment of Cognition in Schizophrenia, Frontal Assessment Battery) were assessed.Results. Neurocognitive disorder was revealed in all cases studied. It has been noted that, depending on the presence/absence of affective symptoms, various domains of the neurocognitive profile are affected. Thus, in patients without severe affective symptoms, auditory and verbal memory, attention, processing speed, and motor skills are impaired. In patients with pronounced affective disorders, processing speed, motor skills, and problem-solving behavior are affected.Conclusion. Based on the results of processing the material, it was revealed that the most pronounced neurocognitive disorders were found in case of the manifestation of paroxysmal paranoid schizophrenia in male patients with a relatively early onset of the disease and hypokinetic catatonic disorders. In the future, we are planning to compare these results with the results of control group of patients with endogenous diseases and without catatonia.

Disorders manifested by both neurological and mental disorders belong to the neuropsychiatric diseases. This category includes Alzheimer's disease, Parkinson's disease, Wernicke–Korsakoff syndrome, delirium tremens, catatonia and anti-NMDA receptor encephalitis. The etiology of psychotic disorders in neuropsychiatric diseases probably differs from that in schizophrenia and other psychoses, which causes both inefficiency and adverse events when using antipsychotics in neuropsychiatry. In the absence of a therapeutic alternative, antipsychotics can be prescribed with caution for neurodegenerative disorders, whereas catatonia is a relative, and anti-NMDA receptor encephalitis is an absolute contraindication to their use.

• What is the primary question addressed by this study? What are the clinical features of catatonia in patients with dementia? • What is the main finding of this study? Catatonia in dementia does not have a different syndromic presentation. However, the diagnosis of dementia leads to varying preferences regarding the choice of symptomatic therapy and seems to be a predictor of a poorer therapeutic response. • What is the meaning of the finding? Actively treating catatonia, particularly in patients with dementia, addressing the characteristics of these patients is of paramount importance and may contribute to a better overall prognosis. • Twitter This systematic review investigates catatonia in the elderly. Dementia influences treatment choices for catatonia and seems to be a predictor of a poorer therapeutic response. Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral, and autonomic abnormalities. It is often underdiagnosed in geriatric patients with dementia despite established diagnostic criteria and treatment options. This systematic review investigates catatonia in the elderly, particularly those with dementia, to examine their clinical presentation, treatment response, and prognosis compared to elderly patients without dementia. We comprehensively searched MEDLINE and EMBASE, including case reports and series on catatonia in elderly patients. Reviewers independently performed data extraction and quality assessments. Statistical significance was set at a p value ≤0.05, and a multivariate logistic regression model was used to analyze differences between patients with and without dementia. Our review included 182 articles with 225 cases. We found no significant differences in the clinical presentation of catatonia between patients with and without dementia, with both groups commonly exhibiting the hypokinetic variant. However, patients with dementia were more frequently treated with NMDA receptor antagonists (OR: 3.27; CI: 1.05–10.11; p = 0.040) and had a lower complete response rate to treatment (OR: 0.37; CI: 0.19–0.75; p = 0.006). Patients with dementia also exhibited fewer acute medical conditions (OR: 0.17; CI: 0.05–0.65; p = 0.009). Catatonia in dementia does not have a different syndromic presentation. However, the diagnosis of dementia leads to varying preferences regarding the choice of symptomatic therapy and seems to be a predictor of a poorer therapeutic response. Actively treating catatonia, particularly in patients with dementia, addressing the characteristics of these patients is of paramount importance. [ABSTRACT FROM AUTHOR]

Background: There is limited data on the prevalence, symptom profile, and etiology of catatonia among the elderly. Aim: This study aimed to evaluate the prevalence, symptom profile, and primary etiology of catatonia among elderly patients (≥60 years) admitted to an indoor acute care psychiatric unit of a general hospital setting. Methodology: For this retrospective study, the inpatient psychiatry registry of the department for the period of January 2016 and June 2023 was screened to identify elderly patients (aged ≥60 years). The treatment records of these patients were screened for the presence of catatonia. The symptom profile of those with catatonia as per the rating on the Bush Francis Catatonia Rating Scale (BFCRS) and the psychiatric diagnosis made as per the International Classification of Diseases, Tenth Revision was extracted and compared with those without catatonia. Results: Out of the 298 elderly patients admitted to the inpatient unit during the study period, 33 (11.1%) had catatonia at the time of admission. As per BFCRS, the most common catatonic symptoms were mutism (100%), followed by staring (93.9%), immobility (84.8%) and rigidity (84.8%), posturing/catalepsy (69.7%), negativism (66.7%), withdrawal (60.6%), and autonomic abnormality (42.2%). No significant difference was noted among those with and without catatonia in terms of sociodemographic variables. In terms of the etiology of catatonia, in the majority of the patients, catatonia is associated with affective disorder (unipolar > bipolar disorder) (28 out of the 33 patients), followed by dementia (n = 3) and psychotic disorder (n = 2). In terms of management, compared to those without catatonia, those with catatonia more often received benzodiazepines and electroconvulsive therapy. Conclusion: About one-tenth of the elderly admitted to the acute psychiatry inpatient units have catatonia, most of them have retarded catatonia, and the majority of the catatonia among the elderly is associated with affective disorders.

Background: Catatonia has been reported with withdrawal of medications. Among the various psychotropics, clozapine has been implicated to cause catatonia when abruptly withdrawn. The data regarding clozapine withdrawal catatonia are scarce and are mostly available in the form of case reports and series. Aim: In this case series, we present three cases of clozapine withdrawal catatonia and review the available literature on clozapine withdrawal clozapine. Results: All the three patients developed catatonia within 48 h to 14 days of stoppage of clozapine in the doses of 100–350 mg/day. Two of the patients experiencing clozapine withdrawal improved with reinstitution of clozapine in the previous doses along with benzodiazepines. However, one patient additionally required electroconvulsive therapy (ECT) for the management of withdrawal catatonia. A review of literature showed that clozapine withdrawal catatonia has male preponderance and has been reported with withdrawal of clozapine doses of 50–550 mg/day. The catatonia usually starts in 48 h to 2 weeks of stopping clozapine. Available literature suggests that most of the patients have been managed with restarting of clozapine, along with lorazepam and occasional patients require ECT. Conclusions: To conclude our case series and the available review of literature suggests that sudden discontinuation of clozapine can lead to withdrawal catatonia. Our cases also highlight the importance of reviewing treatment history, especially of abrupt discontinuation of clozapine when a patient on clozapine present with catatonia. This can be very helpful in deciding about further management.

Abstract Introduction Catatonia, a psychomotor disorder characterized by diverse clinical signs, including stupor and mutism, remains elusive in its causes and a challenge to diagnose. Moreover, it is often underrecognized due to its resemblance to disorders of consciousness. However, when diagnosing catatonia, an antipsychotic medication may exacerbate the condition. The first‐line treatment typically includes benzodiazepines and/or electroconvulsive therapy (ECT). Case Report A 60‐year‐old woman with systemic lupus erythematosus (SLE) and epilepsy presented with catatonic stupor. Despite stable treatment, she experienced an acute deterioration in consciousness, requiring hospitalization. Her condition improved markedly following a benzodiazepine challenge, as documented on EEG. This improvement was short‐lived, but a second benzodiazepine challenge restored her from E1V1M1 (stupor) to E4V5M6 within minutes, as documented by a video recording. The patient was treated with lorazepam 1.5 mg/day orally and did not experience further relapses. Discussion The diagnosis of catatonia had been based on her scores on the Bush‐Francis Catatonia Rating Scale (BFCRS; Screening, 6/14; Severity, 19), despite meeting only two DSM‐5 criteria for catatonia (stupor and mutism). The diagnosis was supported by EEG and video documentation, excluding other potential differential diagnoses such as nonconvulsive status epilepticus and encephalopathy. Additional quantitative EEG analyses indicated that benzodiazepine administration increased brainwide alpha and beta band power significantly, suggesting that the benzodiazepine normalized attention, consciousness, and long‐range synchronization. This report additionally emphasizes the significance of video recordings in managing catatonia, and it helps in accurately tracking symptoms, documenting comprehensively, and improving patient understanding, which is crucial for treatment adherence.

Introduction Catatonia is a syndrome characterized by psychomotor and behavioral disturbances and is associated with a substantially increased mortality risk in adolescent patients. There is a dearth of published literature describing treatment strategies for pediatric patients with catatonia. This dual-case series will describe the treatment course of 2 adolescent patients with catatonia at our pediatric inpatient psychiatric facility. Case Series This case series presents 2 adolescent patients (a 17-year-old male and a 16-year-old female) who initially presented with worsening agitation and paranoia, later developing catatonia. Both patients required long durations of hospitalization and were treated with high-dose lorazepam before requiring the addition of electroconvulsive therapy (ECT). Discussion Treatment of pediatric patients with catatonia creates a significant burden on patients, families, and the healthcare system. Treatment with high-dose benzodiazepines is high risk, while ECT is both difficult to access and comes with its own risks. Both patients discussed are transitional age, meaning they will soon be young adults who will continue to require high-level psychiatric care. Psychiatric pharmacists have a large role to play in ensuring safe medication management for these complex patients. Conclusions This case series of 2 adolescent patients with catatonia demonstrates marginal reduction in symptoms with high-dose lorazepam in conjunction with ECT, with minimal side effects. This case series adds to the limited available literature regarding treatment of catatonia in pediatric patients and highlights the need for further study into effective treatment alternatives.

Objectives: Electroconvulsive therapy (ECT) is one of the most effective treatments in mood disorders, mainly in major depressive episode (MDE) in the context of either unipolar (MDD) or bipolar disorder (BD). However, ECT remains a neglected and underused treatment. Older people are at high risk patients for the development of adverse drug reactions. In this context, we sought to determine the duration of MDEs and the number of lines of treatment before the initiation of ECT in patients aged 65 years or over according to the presence or absence of first-line indications for using ECT from international guidelines. Methods: In this multicenter, retrospective study including patients aged 65 years or over with MDEs in MDD or BD who have been treated with ECT for MDEs, data on the duration of MDEs and the number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests. Results: We identified 335 patients. The mean duration of MDEs before ECT was about 9 months. It was significantly shorter in BD than in MDD- about 7 and 10 months, respectively. The co-occurrence of chronic medical disease increased the duration before ECT in the MDD group. The presence of first-line indications for using ECT from guidelines did not reduce the duration of MDEs before ECT, except where there was a previous response to ECT. The first-line indications reduced the number of lines of treatment before starting ECT. Conclusion: Even if ECT seems to be a key treatment in the elderly population due to its efficacity and safety for MDEs, the delay before this treatment is still too long. Key points: • The mean duration of depression before ECT was 8.8 months. • The duration before ECT for Bipolar Disorder (vs Major Depressive Disorder) is shorter. • The co-occurrence of chronic medical disease increased the duration before ECT in the MDD group. • Focusing on the first-line indications for using ECT, only a previous response reduces the duration of depression before ECT. [ABSTRACT FROM AUTHOR]

Research criteria for the diagnosis of prodromal dementia with Lewy bodies (DLB) include three clinical subtypes: mild cognitive impairment with Lewy bodies (MCI‐LB), delirium‐onset prodromal DLB, and psychiatric‐onset prodromal DLB. Late‐onset psychiatric manifestations are at a higher risk of developing dementia, but its relation to prodromal DLB remains unclear. In addition to the risk of severe antipsychotic hypersensitivity reactions, accurate discrimination from non‐DLB cases is important due to the potential differences in management and prognosis. This article aims to review a rapidly evolving psychiatric topic and outline clinical pictures of psychiatric‐onset prodromal DLB, including the proposed biomarker findings of MCI‐LB: polysomnography‐confirmed rapid eye movement sleep behaviour disorder, cardiac [123I]metaiodobenzylguanidine scintigraphy, and striatal dopamine transporter imaging. We first reviewed clinical pictures of patients with autopsy‐confirmed DLB. Regarding clinical reports, we focused on the patients who predominantly presented with psychiatric manifestations and subsequently developed DLB. Thereafter, we reviewed clinical studies regarding the diagnostic applications of the proposed biomarkers to patients with late‐onset psychiatric disorders. Clinical presentations were mainly late‐onset depression and psychosis; however, other clinical manifestations were also reported. Psychotropic medications before a DLB diagnosis may cause extrapyramidal signs, and potentially influences the proposed biomarker findings. These risks complicate clinical manifestation interpretation during the management of psychiatric symptoms. Longitudinal follow‐up studies with standardised evaluations until conversion to DLB are needed to investigate the temporal trajectories of core features and proposed biomarker findings. In patients with late‐onset psychiatric disorders, identification of patients with psychiatric‐onset prodromal DLB provides the opportunity to better understanding the distinct prognostic subgroup that is at great risk of incident dementia. Advances in the establishment of direct biomarkers for the detection of pathological α‐synuclein may encourage reorganising the phenotypic variability of prodromal DLB. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 24-year-old female diagnosed with familial encephalopathy with neuroserpin inclusion bodies (FENIB) who initially presented with catatonia, a rare manifestation of the condition. Topics discussed include the diagnostic challenges of distinguishing FENIB from other psychiatric disorders, the role of electroconvulsive therapy (ECT) in managing catatonic symptoms, and the impact of genetic findings on treatment and prognosis.

Objective: To ascertain the presence of catatonia in cases of pediatric postoperative cerebellar mutism syndrome (PPCMS). Method: A systematic review of PPCMS case reports of patients aged 0–17 years with sufficient clinical information to extract catatonic phenomena was undertaken following PRISMA guidelines. Standardized catatonia rating scales were applied to selected cases retrospectively to ascertain whether diagnostic criteria for catatonia were met. A case known to the authors is also presented. Results: Two hundred twenty-one suitable full-text articles were identified. Following screening and application of inclusion criteria, 51 articles were selected plus seven more from their references, reporting on 119 subjects. All cases met Bush and Francis (BF) diagnostic criteria for catatonia, 92.5% Pediatric Catatonia Rating Scale (PCRS), 52.9% ICD-11, and 44.5% DSM-5. All patients presented with mutism. The next most frequent signs were immobility/stupor (77.3%), withdrawal (35.3%), mannerisms (23.5%), and excitement/agitation (18.5%). Most cases presented with stuporous catatonia (75.6%). Catatonia most frequently occurred following resection of medulloblastoma (64.7%). Preoperative hydrocephalus occurred in 89 patients (74.8%). Conclusion: Catatonia was frequent in this PPCMS sample, with a predominant stuporous variant; it should be considered in patients with PPCMS and assessed with reliable and validated instruments for prompt diagnosis and management. [ABSTRACT FROM AUTHOR]

Background: Catatonia has been reported with withdrawal of medications. Among the various psychotropics, clozapine has been implicated to cause catatonia when abruptly withdrawn. The data regarding clozapine withdrawal catatonia are scarce and are mostly available in the form of case reports and series. Aim: In this case series, we present three cases of clozapine withdrawal catatonia and review the available literature on clozapine withdrawal clozapine. Results: All the three patients developed catatonia within 48 h to 14 days of stoppage of clozapine in the doses of 100-350 mg/day. Two of the patients experiencing clozapine withdrawal improved with reinstitution of clozapine in the previous doses along with benzodiazepines. However, one patient additionally required electroconvulsive therapy (ECT) for the management of withdrawal catatonia. A review of literature showed that clozapine withdrawal catatonia has male preponderance and has been reported with withdrawal of clozapine doses of 50-550 mg/day. The catatonia usually starts in 48 h to 2 weeks of stopping clozapine. Available literature suggests that most of the patients have been managed with restarting of clozapine, along with lorazepam and occasional patients require ECT. Conclusions: To conclude our case series and the available review of literature suggests that sudden discontinuation of clozapine can lead to withdrawal catatonia. Our cases also highlight the importance of reviewing treatment history, especially of abrupt discontinuation of clozapine when a patient on clozapine present with catatonia. This can be very helpful in deciding about further management. [ABSTRACT FROM AUTHOR]

The term “catatonia” was introduced by German psychiatrist Karl Kahlbaum in 1874. Although historically tied to schizophrenia, catatonia exhibits a diverse range of phenotypes and has been observed in various medical and neuropsychiatric conditions. Its intrinsic movement characteristics and association with hypokinetic and hyperkinetic phenomenologies place catatonia within the purview of movement disorders. Despite the presence of catatonia in psychiatry literature for over 150 years, many gaps and controversies persist regarding its etiopathogenesis, phenomenology, diagnostic criteria, and treatment. The current versions of the International Classification of Diseases (ICD‐11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) require clinicians to identify any three signs of 15 (ICD‐11) or 12 (DSM‐5) for the diagnosis of catatonia. Catalepsy and waxy flexibility are the only motor features with high specificity for the diagnosis. We highlight the gaps and controversies in catatonia as a movement disorder, emphasize the lack of a clear definition, and discuss the inconsistencies in the description of various catatonic signs. We propose the exploration of a bi‐axial classification framework similar to that used for dystonia and tremor to encourage the evaluation of underlying etiologies and to guide therapeutic decisions to improve the outcome of these patients. © 2024 International Parkinson and Movement Disorder Society. [ABSTRACT FROM AUTHOR]

Catatonia is a complex neuropsychiatric syndrome involving a constellation of psychomotor disturbances including catalepsy, waxy flexibility, stupor, mutism, negativism, agitation, posturing, stereotypes, mannerisms, grimacing, echolalia, and echopraxia. Catatonia occurs in several conditions including psychotic, affective and neurodevelopmental disorders such as autism spectrum disorder (ASD). ASD is a neurodevelopmental disorder characterized by persistent deficits in communication, social interaction, restricted interests, repetitive behaviours and sensory sensitivities. Catatonia can occur in response to life stressors such as extreme fear or threat, interpersonal conflict, tragic events or following significant loss. Those with ASD may be particularly vulnerable to the negative impact of stressors and the link between catatonia and ASD is being increasingly recognized. The overlapping features of catatonia and ASD make it difficult to differentiate often resulting in delayed or missed diagnosis. Catatonia in ASD remains a significant clinical challenge; it is difficult to diagnose and can pose debilitating difficulties for those affected. Catatonia is a treatable condition and prompt recognition is vital in securing the best possible outcome. We report a complex and unique case of a 15-year-old boy who presented with severe cognitive and functional decline with a background history of significant bullying and deterioration in his mental state. This case posed a diagnostic conundrum leading to a diagnosis of underlying ASD, anxiety and trauma. [ABSTRACT FROM AUTHOR]

Psychomotor disturbance has been identified as a key feature of psychotic disorders, with motor signs observed in upwards of 66% of unmedicated, first-episode patients. Aberrations in the cerebellum have been directly linked to sensorimotor processing deficits including processing speed, which may underly psychomotor disturbance in psychosis, though these brain-behavior-symptom relationships are unclear, in part due to within-diagnosis heterogeneity across these levels of analysis. In 339 psychosis patients (242 schizophrenia-spectrum, 97 bipolar with psychotic features) and 217 controls, we evaluated the relationship between cerebellar grey matter volume in the Yeo sensorimotor network and psychomotor disturbance (mannerisms and posturing, retardation, excitement of the Positive and Negative Syndrome Scale [PANSS]), as mediated by processing speed (assessed via the SCIP). Models included intracranial volume, age, sex, and chlorpromazine equivalents as covariates. We observed significant mediation by processing speed, with a small positive effect of the cerebellum on processing speed (ß = 0.172, p = 0.029, d = 0.24) and a medium negative effect of processing speed on psychomotor disturbance (ß = −0.254, p < 0.001, d = 0.60), with acceptable specificity and sensitivity suggesting this model is robust against unmeasured confounding. The current findings suggest a critical role of cerebellar circuitry in a well-established sensorimotor aberration in psychosis (processing speed) and the presentation of related psychomotor phenotypes within psychosis. Establishing such relationships is critical for intervention research, such as TMS. Future work will employ more dimensional measures of psychomotor disturbance and cognitive processes to capture normative and aberrant brain-behavior-symptom relationships and may also determine the magnitude of these relationships within subtypes of psychosis (e.g., disorganized behavior, catatonia). [ABSTRACT FROM AUTHOR]

Background: Attachment-based interventions have been extensively studied in neurotypical patient populations. In neurodivergent patient populations, however, emphasis on and current research into attachment-based interventions are centered on early childhood. Minimal research has been conducted in school-aged children with autism spectrum disorder (ASD), and even less research has focused on attachment-based interventions for children with significant comorbidities such as catatonia. Case Report: We present the case of a 12-year-old female that involved dyadic work in conjunction with biologic interventions for the treatment of ASD and catatonia. Psychosocial interventions were centered on an attachment-based framework and behavioral skills training that incorporated elements of parent management training. We observed and tracked the patient’s uncooperativeness, underproductive speech, emotional withdrawal, and anxiety via the Brief Psychiatric Rating Scale for Children. Attachment- and behavioral-based interventions in conjunction with psychotropic medications and electroconvulsive therapy resulted in improvements. Conclusion: This case illustrates the potential advantages that attachment- and behavioral-based psychotherapeutic interventions can confer in complex cases involving neurodivergent patients. The case also highlights the lack of current research into and understanding of attachment theory in children and adolescents with ASD. Research is needed into the role of attachment-based interventions in patients with ASD and other psychiatric comorbidities, particularly in patient populations beyond preschool age. Initiating nonbiologic interventions in conjunction with biologic interventions may also enhance outcomes and warrants further investigation. [ABSTRACT FROM AUTHOR]

Introduction: Catatonia, a psychomotor disorder characterized by diverse clinical signs, including stupor and mutism, remains elusive in its causes and a challenge to diagnose. Moreover, it is often underrecognized due to its resemblance to disorders of consciousness. However, when diagnosing catatonia, an antipsychotic medication may exacerbate the condition. The first‐line treatment typically includes benzodiazepines and/or electroconvulsive therapy (ECT). Case Report: A 60‐year‐old woman with systemic lupus erythematosus (SLE) and epilepsy presented with catatonic stupor. Despite stable treatment, she experienced an acute deterioration in consciousness, requiring hospitalization. Her condition improved markedly following a benzodiazepine challenge, as documented on EEG. This improvement was short‐lived, but a second benzodiazepine challenge restored her from E1V1M1 (stupor) to E4V5M6 within minutes, as documented by a video recording. The patient was treated with lorazepam 1.5 mg/day orally and did not experience further relapses. Discussion: The diagnosis of catatonia had been based on her scores on the Bush‐Francis Catatonia Rating Scale (BFCRS; Screening, 6/14; Severity, 19), despite meeting only two DSM‐5 criteria for catatonia (stupor and mutism). The diagnosis was supported by EEG and video documentation, excluding other potential differential diagnoses such as nonconvulsive status epilepticus and encephalopathy. Additional quantitative EEG analyses indicated that benzodiazepine administration increased brainwide alpha and beta band power significantly, suggesting that the benzodiazepine normalized attention, consciousness, and long‐range synchronization. This report additionally emphasizes the significance of video recordings in managing catatonia, and it helps in accurately tracking symptoms, documenting comprehensively, and improving patient understanding, which is crucial for treatment adherence. [ABSTRACT FROM AUTHOR]

Background: Bell's mania was first described in 1849, and other terms have been used to describe this condition, including delirious mania, mania with delirium, and excited delirium. However, no international diagnostic manual has included mania as an independent diagnostic tool. The criteria for delirious mania were proposed by Bond et al. Methods: We present a case of a man without a personal or family psychiatric history who experienced his first manic episode of delirium and psychosis at 76 years old. Conclusions: The case described in this study is compatible with mood disorders, the original description of Bell's mania, and Bond's definition of delirious mania. Although rare, extremely late‐onset primary mania can occur without personal or family psychiatric history. The initial clinical presentation of delirium requires a thorough medical investigation, including magnetic resonance imaging (MRI) and lumbar puncture with neuronal antibodies. The addition of delirious mania to the group of bipolar disorders in future editions of The International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) has therapeutic and prognostic implications. The Bond criteria can provide valuable information in this respect. Further investigations are necessary to clarify the pathophysiology and epidemiology of delirious mania. [ABSTRACT FROM AUTHOR]

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Electroconvulsive therapy (ECT) is one of the oldest known psychiatric treatments in modern times. It preceded modern pharmacotherapy for mood disorders and continues to play a major role in treatment-resistant depression (TRD). Its proven efficacy has been the inspiration behind the continued advancements in the field of neurostimulation. Electroconvulsive therapy, vagus nerve stimulation, and repetitive transcranial magnetic stimulation (rTMS), are currently approved by the US Food and Drug Administration (FDA) as neurostimulation modalities for TRD. Other modalities of neurostimulation such as transcranial direct current stimulation, deep brain stimulation, and magnetic seizure therapy have been studied and used, but are not yet FDA approved. In this article, we will focus on two modalities that are widely used and available to patients: ECT and rTMS. While both treatments are recommended for TRD, either alone or in conjunction with other treatments, they vary widely in their safety profile and treatment protocol, which impacts both patient selection and public perception. [Psychiatr Ann. 2024;54(6):e164–e169.] [ABSTRACT FROM AUTHOR]

Catatonia is characterized by psychomotor alterations and reduced contact with the environment. Initially linked to schizophrenia, it also occurs in mood disorders or organic conditions. In children, catatonia remains poorly delineated, despite dramatically increasing the risk of premature death. As data on pediatric drug-induced catatonia bears many uncertainties, we aimed to characterize its age-dependent patterns, using real-world data from the WHO safety database (VigiBase®).VigiBase® was queried for all reports of catatonia registered up to December 8th 2022. Reports involving patients <18 years were classified into 3 groups: ≤23 months, 2–11 years, and 12–17 years. Disproportionality analyses relied on the Reporting Odds Ratio (ROR), and the positivity of the lower end of the 95% confidence interval of the Information Component (IC) was required to suspect a signal. Catatonia was evoked in 421 pediatric reports. In infants, vaccines were leading. In children, the main signals involved haloperidol (ROR 104.3; 95% CI 45.6–238.5), ondansetron (ROR 40.5; 95% CI 16.5–99.5), and ciclosporin (ROR 27.4; 95% CI 13.8–54.1). In adolescents, chlorpromazine (ROR 199.1; 95% CI 134.8–294.1), benzatropine (ROR 193; 95% CI 104.1–361.6), and olanzapine (ROR 135.7; 95% CI 104.6–175.9) reached the highest RORs. In infants, catatonia was related to vaccines, it was ascribed to multiple drugs in children, and mainly to psychotropic drugs in adolescents. Less suspected drugs, such as ondansetron, were highlighted. Despite limitations inherent in spontaneous reporting systems, this study supports that a careful anamnesis is warranted to separate catatonia associated with medical conditions from drug-induced catatonia in pediatric patients. [ABSTRACT FROM AUTHOR]

This article presents a case study of a 45-year-old male with treatment-resistant depression (TRD) complicated by traumatic brain injury (TBI) and seizures. The patient underwent various treatments, including medication and electroconvulsive therapy (ECT), but his symptoms worsened. The article discusses alternative treatments for TRD, such as ketamine and psychiatric neurosurgery, highlighting their benefits, risks, and logistical considerations. It also emphasizes the need for adequate training in interventional psychiatry for psychiatrists and proposes that training requirements should be implemented to ensure knowledge of these interventions. The document also includes a list of references covering various topics related to interventional psychiatry treatments and education. [Extracted from the article]

This document is a compilation of research articles on various neuropsychiatric disorders. The articles cover topics such as the use of lithium for brain plasticity and neuroprotection, poststroke depression, biomarkers for migraine and cluster headache, atrophy in frontotemporal dementia, common neurobiological substrates for mental illness, neuroimaging in functional neurological disorder, autoimmune encephalitis, and the importance of cross-disciplinary education in neurology and psychiatry. The articles provide valuable insights into the diagnosis, treatment, and management of these disorders, as well as potential biomarkers and imaging techniques that can aid in their evaluation. [Extracted from the article]

Motor and cognitive alterations in schizophrenia-spectrum disorders (SSD) share common neural underpinnings, highlighting the necessity for a thorough exploration of the connections between these areas. This relationship is crucial, as it holds potential significance in unraveling the underlying mechanisms of SSD pathophysiology, ultimately leading to advancements in clinical staging and treatment strategies. The purpose of this review was to characterize the relationship between different hyper and hypokinetic domains of motor alterations and cognition in SSD. We systematically searched the literature (PROSPERO protocol CRD42019145964) and selected 66 original scientific contributions for review, published between 1987 and 2022. A narrative synthesis of the results was conducted. Hyper and hypokinetic motor alterations showed weak to moderate negative correlations with cognitive function across different SSD stages, including before antipsychotic treatment. The literature to date shows a diverse set of methodologies and composite cognitive scores hampering a strong conclusion about which specific cognitive domains were more linked to each group of motor alterations. However, executive functions seemed the domain more consistently associated with parkinsonism with the results regarding dyskinesia being less clear. Akathisia and catatonia were scarcely discussed in the reviewed literature. The present review reinforces the intimate relationship between specific motor alterations and cognition. Identified gaps in the literature challenge the formulation of definitive conclusions. Nevertheless, a discussion of putative underlying mechanisms is included, prompting guidance for future research endeavors. [ABSTRACT FROM AUTHOR]

Objective: To develop an individualized method for detecting cognitive adverse events (CAEs) in the context of an ongoing trial of electroconvulsive therapy for refractory agitation and aggression for advanced dementia (ECT-AD study). Methods: Literature search aimed at identifying (a) cognitive measures appropriate for patients with advanced dementia, (b) functional scales to use as a proxy for cognitive status in patients with floor effects on baseline cognitive testing, and (c) statistical approaches for defining a CAE, to develop CAEs monitoring plan specifically for the ECT-AD study. Results: Using the Severe Impairment Battery-8 (SIB-8), baseline floor effects are defined as a score of ≤5/16. For patients without floor effects, a decline of ≥6 points is considered a CAE. For patients with floor effects, a decline of ≥30 points from baseline on the Barthel Index is considered a CAE. These values were derived using the standard deviation index (SDI) approach to measuring reliable change. Conclusions: The proposed plan accounts for practical and statistical challenges in detecting CAEs in patients with advanced dementia. While this protocol was developed in the context of the ECT-AD study, the general approach can potentially be applied to other interventional neuropsychiatric studies that carry the risk of CAEs in patients with advanced dementia. [ABSTRACT FROM AUTHOR]

Major depressive disorder (MDD) is a common mood disorder. Electroconvulsive therapy (ECT) has a significant effect on treatment-resistant MDD. Esketamine may have potential advantages in improving the efficacy of ECT, and the strong affinity of this compound for NMDAR renders it a viable therapeutic option for the management of depression. This study aims to compare the effects of different doses of esketamine combined with propofol anesthesia versus propofol anesthesia alone in ECT, aiming to provide further insights for optimizing ECT and enhancing comprehensive treatment outcomes for depression. Study Design and Methods: This study was a prospective, randomized, controlled, double-blind trial involving subjects and evaluators. One hundred eleven patients scheduled for ECT were randomly assigned to three groups. In Group P, propofol at 1mg/kg was administered intravenously. In Group P+E, propofol at a dosage of 0.5mg/kg and esketamine at a dosage of 0.5mg/kg was administered intravenously. Patients in Group P+SE received propofol at a dosage of 0.75mg/kg and esketamine at a dosage of 0.25mg/kg. The same anesthesia protocol was used for the same patient until the end of the last treatment. The primary outcome measures were the Hamilton depression scale (HAMD) and the Patient Health Questionnaire-9 (PHQ-9), the Columbia-Suicide Severity Rating Scale (C-SSRS), and the Digit symbol substitution test (DSST). Secondary outcomes included length of hospital stay, readmission rate, hemodynamic status, recovery, and adverse events. Discussion: This study aimed to compare the effects of propofol combined with different doses of esketamine for ECT. The results may provide a better choice for ECT anesthesia. [ABSTRACT FROM AUTHOR]

BackgroundCatatonia is a complex syndrome with prominent psychomotor, cognitive, and affective manifestations. Among the commonly described manifestations of catatonia are mannerisms and stereotypies. Kahlbaum, who coined the term catatonia, described several presentations of mannerisms and stereotypies as complex behaviors in his monograph. However, most of the subsequent psychiatric literature has described both phenomena in the context of simple motor movements or actions.Study design or methodWe identified complex behavioral presentations of mannerisms and stereotypies described by Kahlbaum in his monograph. We summarize the development and use of mannerisms and stereotypies as psychiatric terminology since Kahlbaum, emphasizing the spectrum of behavior captured early in this usage. We list the inconsistent and interchangeable use of these terms in subsequent literature and describe recent examples of complex behavioral manifestations of mannerisms and stereotypies in the context of catatonia.Study resultsWe propose a new framework for mannerisms and stereotypies that utilizes descriptive psychopathology factors in various normative references, the context of the behavior examined, and critical pathological processes identified in mannerisms and stereotypies to identify and describe complex manifestations of these phenomena.ConclusionCatatonia continues to remain under-recognized and under-treated. Our current diagnostic tools can make mannerisms and stereotypies complex and challenging to recognize. We suggest defining stereotypies as non-contextual repetitive activities while mannerisms as non-contextual peculiarities of activities. Utilizing our proposed framework and definitions can improve the description, recognition, and treatment of catatonia.

Background Methods Results Conclusions Benzodiazepines and electroconvulsive therapy (ECT) are mainstay treatments for catatonia, a potentially life‐threatening psychomotor syndrome characterized by a range of symptoms, including immobility, mutism, stupor, posturing, and sometimes even agitation. It can be a manifestation of various underlying psychiatric or medical conditions, such as schizophrenia, mood disorders, or neurological disorders. When conventional treatments fail to alleviate symptoms, ketamine, a dissociative anesthetic, has emerged as a potential therapeutic option for catatonia. However, its precise mechanism of action in treating catatonia remains to be fully elucidated. The use of ketamine in treating treatment‐resistant catatonia in patients with schizophrenia has not been described.We describe a unique case of a 77‐year‐old female with schizophrenia for 15 years who presented with hallucinations, generalized weakness, immobility, stupor, and mutism consistent with severe catatonia. The electroencephalogram did not show seizures, and brain imaging was negative for stroke. Her catatonia was resistant to treatment with benzodiazepines and haloperidol. However, ECT was unavailable due to the COVID‐19 pandemic. She was successfully treated with a single intravenous infusion of ketamine administered at a dose of 0.5 mg/kg over 40 min with complete rapid recovery and remained stable as an outpatient.Intravenous ketamine single infusion may be a safe and feasible option in schizophrenia patients with drug‐resistant catatonia, particularly in patients for whom standard therapies are ineffective. However, its use should be approached cautiously due to the risk of exacerbation of psychosis in patients with schizophrenia.Further research is warranted to better understand the role of ketamine in the management of catatonia in this patient population. [ABSTRACT FROM AUTHOR]

Certain clinical features, like changes in presentation, the presence of neurological signs, and a poor response to treatment, mandate an organic evaluation of psychiatric illnesses. In this case series, four cases with established mental illnesses who presented with psychiatric symptoms, on evaluation by neuroimaging, were found to have neurological disorders like neurocysticercosis, sub-arachnoid hemorrhage, sub-dural hemorrhage, and lacunar infarction. They were managed with a combination of medical and surgical treatment and psychotropics, and no relapse of symptoms was noted at follow-up. The formulation of clinical practice guidelines can be a way forward in holistic management for such patients.