Catatonia and refractory agitation in an updated flow chart for the evaluation of emotional-behavioral disturbances in severely ill children

Abstract

Dear Editor, A flow chart regarding the evaluation and management of emotional– behavioral disturbances in severely ill children admitted to a pediatric intensive care unit (PICU) was presented to the scientific community of intensive care medicine in 2009 [1]. At that time we concluded that future refinements were expected to be unveiled. Despite the overall satisfactory experiences with the initial flow chart we increasingly experienced that it needs to be expanded with at least two additional items, i.e., (1) ‘‘Catatonic features’’ and (2) ‘‘Refractory agitation’’ (Fig. 1). Regarding catatonia: adding this item is a necessary adaptation due to the fact that there is an increasing amount of scientific literature, coming from both neurology and psychiatry, regarding a re-appraisal of catatonic features in general and of catatonia in pediatric neuro-psychiatry in particular [2]. These new developments have resulted in a proposed whole new chapter exclusively devoted to catatonia in the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [3]. Catatonia (meaning pervasive (motor) tension) is defined as a severe psychomotor disturbance with a primary presentation due to a mood disorder or schizophrenia. Besides, and in our context much more importantly, it has a secondary presentation attributable to any of the ‘acronymic’ I WATCH DEATH causes of delirium. The most characteristic features of catatonia are: catalepsy (bizarre postural fixity, especially of the limbs and head), opisthotonus (severe backwards hyperextension and rigidity of the whole body) and/or (a)typical motor agitation. Other symptoms are negativism (apparently motiveless resistance), stupor (extreme hypoactivity, minimally responsive to stimuli), and stereotypy (repetitive, non-goal directed motor activity such as finger-play, repeatedly touching, patting or rubbing self). According to a growing consensus, two or more symptoms suffice to diagnose catatonia. The above mentioned features deserve in their own right—especially in critical illness—a thorough evaluation and so we have added them to our updated flow chart. Treatment consists of treating the I WATCH DEATH causes and/or administering benzodiazepines in high dosages and/ or giving electroconvulsive therapy. Refractory agitation is a common and important issue in everyday critical care medicine. It can be defined as: lasting agitation after repeatedly checking the aforementioned flow chart items and its treatment results. If agitation still persists, this leads to the new and last box: ‘‘Refractory agitation’’. This extra item is of clinical importance: for it can be a sign of (1) ongoing agitation in the course of delirium—which is also a very known and common problem in acute adult psychosis [4]; (2) paradoxal agitation due to the administration of possibly any drug, but especially