Katatonia

Abstract

Modern psychiatric nosologies separate catatonia along the lines of presumed etiology: bipolar, major depression, schizophrenia, and/or due to a general medical condition. Catatonic signs have always possessed significant diagnostic, therapeutic, and prognostic value. Kahlbaum’s description of this syndrome in his monograph “Katatonia” included careful documentation of phenomenology. Kahlbaum selected the term katatonia to describe “tension insanity.” He felt that the neuromotor signs were more important than the content of delusions (e.g. megalomania). While he felt that he was describing a unitary illness, he did identify mood disturbance, psychosis, and medical factors in this new illness.¹ In modern times, the term catatonia has become limited to describe a specifier of neuropsychiatric illnesses.

The authors of this article feel that the term katatonia should be used to describe a group of neuropsychiatric illnesses presenting with catatonic signs. This may prevent the misconception that “catatonia is schizophrenia” and improve the detection of katatonia in patients. Specifically, katatonia is also observed in mood disorders, general medical conditions, and pervasive developmental disorders. The literature also supports the view of Dr. Leo Kanner and his description for neuromotor and neuropsychiatric signs in autistic disorder. This scale is named in honor of Dr. Kanner. It was developed by the authors and includes some of Dr. Kanner’s core concepts. This paper will identify the clinical features of katatonia and introduce the KANNER scale (see Appendix 1) to improve conceptualization, detection, and measurement of this important clinical syndrome.

Introduction

Karl Ludwig Kahlbaum is best known for his description of catatonia. He presented his first description of catatonia in Innsbruck in 1869 and later wrote his monograph entitled Katatonia in 1873.¹ Since then, the presence of catatonic signs has always held diagnostic, therapeutic, and prognostic value.²

Kahlbaum’s description of this syndrome in his monograph included careful documentation of phenomenology. He selected the term katatonia to describe “tension insanity” and held that the neuromotor signs (e.g., waxy flexibility) were more important than the content of delusions (e.g., megalomania). While he was convinced that he was describing a unitary illness, he did identify mood disturbances, psychosis, and medical factors in this new illness.²

Kahlbaum described katatonia as a syndrome of motor abnormalities including mutism, negativism, stereotypies, catalepsy (waxy flexibility), and verbigeration.¹ Kraepelin included catatonia as belonging to the group of dementia praecox, but acknowledged that “catatonic morbid phenomena” occurred in different psychiatric disorders.³

In modern times the terms catatonic and catatonia have unfortunately become limited to describe specifiers for neuropsychiatric illnesses. The clinical term catatonia therefore holds minimal conceptual importance in clinical practice. For instance, Larner defines catatonia as a state of unresponsiveness with maintained immobility, posturing, mutism, and refusal to eat or drink. He lists several signs that may or may not be present (including incontinence).⁴ Meanwhile Rogers has argued that catatonia is an extrapyramidal disorder.⁵ Fink and Taylor point out that in the two centuries since catatonia was first described, psychiatric terminology has changed many times.⁶

The authors propose that the term katatonia (with a “k”) be used to describe this cross-sectional clinical syndrome to avoid continuation of the more recent nosological confusion. In the published literature, katatonia has staged a remarkable comeback over the past 15 to 20 years, with several rating scales, brain imaging and genetic studies, and neurochemical theories that underscore the importance of this clinical entity.^6–7 However, research on katatonia has been limited by the lack of a psychopathological definition and clear conceptual understanding of the subject. This may explain why the existing catatonia rating instruments differ from each other in terms of the definition and number of individual symptoms.^7–11

There is some variability of katatonia across various psychiatric disorders.¹¹ Thus, reexamination of the reliability and validity of catatonia rating scales across the various neuropsychiatric illnesses is recommended. Furthermore, the need for a new conceptual understanding of katatonia has been suggested because of the fluidity of the boundaries of the concept.¹² This review addresses the clinical concepts and attempts to describe katatonia over the past few decades. A new rating scale and a conceptual outline for this important clinical entity will be presented.

Research Criteria Defining Katatonia

Kanner’s autism. Kanner identified autism in 11 children between 2 and 8 years of age.^13–15 He described stereotypy, echolalia, and other neuromotor and neurodevelopmental signs. His classification was quickly adopted into the psychiatric nomenclature. Currently, autism (autistic disorder) has been placed as a subcategory of pervasive developmental disorders. Consequently, more emphasis has been placed on the social and emotional domains than the motor signs. There are several observations suggesting that catatonia and autism may have common underlying pathophysiology and treatment response.¹⁶ The Autism Behavioral Checklist (ABC) does not define catatonic signs to the extent of detecting catatonic symptomatology in patients with autism. The autism rating scales fail to quantify items to show treatment response to the catatonic features. Consequently, we feel that there is a need for a new rating scale to assess katatonia in autism and pervasive developmental disorders. To date, there have been no studies of systematic ratings of catatonia in autism.

Lohr and Wisniewski (1987). Lohr and Wisniewski¹⁷ proposed criteria for the catatonic syndrome, requiring one cardinal feature and two secondary features.¹ Northoff found that all patients who met this criteria scored at least 8 (>7) on the Northoff Catatonia Scale (NCS).⁹ Catalepsy, positivism, or negativism (1 of these 3) must be present to meet Lohr and Wisniewski’s criteria.¹⁷ Their criteria may not take into account immobility, excitement, and withdrawal (refusal to eat and drink) and may exclude a number of patients with catatonic symptomatology.

These criteria advanced the study of catatonia and highlighted important concepts that underlie catatonia. The clinician, however, may be challenged with some patients with katatonia who fail to meet this set of criteria but not others. Unfortunately, no rating scale was developed from these criteria.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (1994). The development of DSM-IV brought about a new set of criteria for catatonia as a subtype of schizophrenia as well as a specifier for bipolar disorder and major depression. DSM-IV also included catatonia due to a general medical condition. DSM-IV catatonia criteria required 2 out of 5 signs, except for catatonia due to a general medical condition, where only 1 out of 5 was needed. We have previously pointed out the deficiencies of the DSM-IV and DSM-IV-TR (Text Revision) criteria.¹⁸ There is currently no rating scale for DSM-IV or DSM-IV-TR catatonia criteria. Stompe et al¹⁹ found that the sensitivity was greater for diagnoses with a higher number of items in katatonia criteria.

Rosebush et al (1990). Rosebush et al²⁰ described the Kahlbaum criteria with more than two cardinal features with more than one secondary feature. They used this criteria to identify catatonic features and measure treatment response. The Rosebush rating scale was proposed but it has never been published. Northoff examined this proposed rating scale and found it to have high correlation with other catatonia rating scales.⁹ The Rosebush criteria do not take into account catatonic excitement and positivism (e.g., automatic obedience, mitgehen, ambitendency). This set of criteria is helpful but may exclude a number of patients with catatonic signs.

Rogers Scale (1991). The Modified Rogers Scale rates both extrapyramidal signs (EPS) and catatonic signs.⁵ It contains several conceptual approaches to catatonia and catatonic signs. It is founded upon the concept that catatonic features are a form of EPS. Consequently the phenomenology is rated independent of presumed etiology and medications (e.g., antipsychotics). Rogers lists 36 motor signs and describes a neuropsychiatric motor examination. Each item is rated on a scale of 0 to 2 with scores ranging from 0 to 72. The Rogers scale has not been widely used in treatment. The Modified Rogers Scale provides definitions for gegenhalten, mitgehen, stereotypy, mannerism, echopraxia, bizarre gait, aprosodic speech, excitement, and negativism. It also describes overcompliance, iteration (the repetition of movements), and hypermetamorphosis. This scale has been used in institutional populations, including patients with mental retardation. It was also used by Starkstein et al²¹ in a treatment study of catatonic features in patients with Parkinson’s disease and depression.

The Bush-Francis Catatonia Rating Scale (1996). The Bush-Francis Catatonia Rating Scale (BFCRS) was the first instrument constructed for the systematic, standardized, and quantifiable examination of catatonia using operationally defined signs and symptoms.²² The BFCRS consists of 23 items accompanied by specific instructions to standardize the examination. Seventeen items are scored on a 0 to 3 scale while the remaining six are rated as either absent (“0”) or present (“3”). Selection of the items was based on a review of the classical and contemporary literature. The inter-rater reliability of BFCRS was established on 28 acutely ill patients presenting with catatonic syndrome that arose in the context of various psychiatric disorders. Catatonia ratings with the BFCRS predicted a high probability of treatment responsiveness to lorazepam.²³ Since its development, the BFCRS has been the most commonly used scale in research in catatonia. It is readily available for clinical use and has been translated into several languages. Our research team has used the BFCRS and considers it the gold standard compared to other scales.

The Northoff Catatonia Scale (1999). The Northoff Catatonia Scale (NCS) was based upon Kahlbaum’s descriptions of catatonia including 1) hypokinesias, 2) hyperkinesias, 3) affective symptoms, and 4) behavioral alterations. The NCS contains 40 items, rated from 0 to 2, with the scores ranging from 0 to 80. Northoff et al⁹ performed extensive evaluation of the NCS and compared it to several rating scales. They found the NCS to be valid and reliable for rating catatonia. Also, hypokinesias and hyperkinesias were independent of antipsychotic medication. There was no significant difference between the NCS and the modified Rogers scale in the detection of catatonic patients. A score of >7 on the NCS separated catatonic from noncatatonic psychiatric patients. A factor analysis yielded four components that were characterized as 1) affective, 2) hypoactive, 3) hyperactive, and 4) behavioral.

In their editorial, Rosebush and Mazurek⁷ pointed out that catatonia seemed to disappear from the landscape over the last century because psychiatry sought out verbal, introspective, and ‘interviewable’ patients. They expressed concerns regarding the affective and behavioral sections of the NCS because catatonic patients may be difficult to interview. These two sections may reduce the accuracy of the NCS in patients who are mute and exhibit negativism.⁷

The Braunig Catatonia Rating Scale (2000). Braunig, Kruger, and Shugar developed Catatonia Rating Scale (CRS)¹⁰ for catatonia that has 21 items with possible scores of 0 to 4 (absent, minimal, moderate, marked, severe). These are defined by time intervals of observation during a 45-minute examination (<2 minutes, 2–10 minutes, 10–20 minutes, >20 minutes). The scores range from 21 to 84.

The scale is based on the work of several German language authors (Wernicke, Kraepelin, Kleist, Kahlbaum, Blueler, Meyer-Gross, and Leonhard). They group mitgehen and echophenomena under “abnormal suggestibility of will” (i.e., gegengriefen). This scale has been studied under factor analysis, but has not been used to measure treatment response.^10,11

Fink and Taylor Criteria (2003). Fink and Taylor made a strong argument for a separate classification for catatonia (katatonia) in DSM-V.⁶ They proposed a set of criteria for the detection and diagnosis of catatonia that is based on the earlier work of Taylor.²⁴ They did recommend the use of the BFCRS for research and clinical use. Consequently, the Fink and Taylor criteria (and the earlier version) have been used in screening for catatonia in at least two case series studies.^25,26

Concerns Over Catatonia Rating Scales

In spite of the classical history of catatonic signs, there is much confusion over the reference definitions for the terms used in these rating scales. Definitions tend to vary from one scale to the other.²⁷ These include mannerisms versus stereotypy, catalepsy versus waxy flexibility, and mitgehen versus mitmachen. Most North American psychiatry textbooks fail to adequately define these terms. Each rating scale has the support of its own research group leading to lack of uniformity in catatonia rating scales. In research and clinical institutions, there may be differing views regarding the weight of scale items. Consequently, most of these scales are not routinely used to measure treatment response. The BFCRS is most commonly cited for treatment studies in the North American publications. These scales may also not be sensitive enough to measure treatment response.²⁷

In view of the variety of neuropsychiatric and general medical conditions that can manifest with catatonic features, a generic catatonia rating instrument would be insufficient to capture catatonia in specific patient populations and consequently would need modification.⁶ Wong et al²⁸ tested the BFCRS in a sample of patients with chronic schizophrenia where catatonic features are frequently encountered. Using Rasch analysis, the authors constructed a 20-item scale from the BFCRS that was useful in their population of chronic catatonics. They suggested that rigidity, grasp reflex, and autonomic abnormality (and perhaps impulsivity) do not measure the same construct as other BFCRS signs in chronically ill patients with schizophrenia.²⁸ The BFCRS Revised version was shorter and simpler that the original BFCRS and better suited to identifying catatonic signs in patients with chronic schizophrenia.²⁸

Treatment Response in Katatonia

Peralta et al²⁹ and Barnes et al³⁰ remind us that catatonia is found across a wide range of psychiatric, neurological, and medical disorders, and this generally supports Kahlbaum’s idea of a unitary phenomenology and pathology. The response to lorazepam or electroconvulsive therapy (ECT) does not follow the primary psychiatric diagnosis. In fact, it is katatonia that responds to these treatments. While some authors have noted a trend toward less favorable improvement for catatonic symptoms in schizophrenia as compared to mood disorders, this has not been consistently or conclusively demonstrated. Nonetheless, the presence of katatonia predicts a favorable response of these signs to interventions like intravenous amobarbital, lorazepam (and other benzodiazepines), and ECT. Katatonia seems to be associated with a favorable prognosis, when diagnosed and treated promptly. There is clinical evidence to suggest that failure to diagnose katatonia or provide effective psychiatric treatment may result in a poor outcome.³⁰

Directions for Future Research

The KANNER scale should be compared against a gold standard. We propose testing the KANNER rating scale against the BFCRS. While other scales have merit, there is limited experience with these scales in North America. The KANNER scale has three components; each should be tested separately (Appendices 2–4). It may be useful to call together a consensus panel to propose criteria, evaluate rating scales, and identify treatment standards. This has been done for other neuropsychiatric illnesses, such as Lewy body dementia. Furthermore, since the KANNER is a neuromotor examination, a training video or DVD with patients or simulation actors might be helpful to achieve improved understanding of katatonia and create a core standardization in the rating of katatonia (Table 1).

TABLE 1.

Comparison of BFCRS versus KANNER

Dimension	BFCRS	KANNER
Screening	Items 1–17	“Wired’N Mired” mnemonic in part I
Rating	Items 1–23	Items 1–18 in part II
Multiple signs (2 or more signs per item)	Items 2,5,7	None
Items for test of catatonia	None	Items 1–12 in Part III
Range of scores	0–3 (Items 1–17 are 1, 2, or 3; Items 18–23 are 0 or 3)	0–8 (Items 1–18 )
Total scores	0–69	0–144
Motor exam	Less precise	More precise
Terminology	Classical	Standard
Use in chronic catatonia	May need some revision28	Unknown
Standardized	Yes	No
Conceptual underpinning	Kahlbaum’s description	Kahlbaum, Northoff, and use of termination of movement as a test

Proposal

We propose the KANNER scale as a unifying instrument for quantifying katatonic core features (a) across the broad range of neuropsychiatric illnesses and (b) in the specific contexts of autism and pervasive developmental disorders. The KANNER scale is named after Leo Kanner (1894–1981), who described the neuromotor and neurodevelopmental features of autism, which are also features of katatonia.^13–15 We feel it is necessary to identify katatonia in patients with other neuropsychiatric illnesses, including schizophrenia and mood disorders, and due to general medical conditions (Table 1).

Based on our review and analysis from a large body of literature, the clinical signs for a possible and a probable diagnosis of catatonia are contained within the KANNER scale. Since there is no true gold standard for diagnosis, the sensitivity and specificity of this scale cannot be easily ascertained. Because the KANNER scale is based on an exhaustive and comprehensive review, we propose that it be adopted and tested prospectively for its clinical utility, sensitivity, and specificity.

Appendix 1. KANNER scale acronym

KANNER scale

Katatonia

Autism

Neuropsychiatric and

Neuromovement

Examination

Rating

Appendix 2. PART 1. KANNER scale screening

WIRED `N MIRED: mnemonic for screening for katatonia^22,31

Waxy flexibility/catalepsy	Yes/ No
Immobility	Yes/ No
Refusal to eat or drink	Yes/ No
Excitement	Yes/ No
Deadpan staring	Yes/ No
Negativism	Yes/ No
Mutism	Yes/ No
Impulsivity	Yes/ No
Rigidity	Yes/ No
Echolalia/echopraxia	Yes/ No
Direct observation of catatonic features in nursing notes in the past day to past week	Yes/ No

These catatonic signs cannot be discounted nor removed unless recorded in error. These are observations only. Medical and psychiatric etiologies cannot be used to exclude any signs.

If there are two or more signs detected, then perform Part 2 of the KANNER scale

Appendix 2. PART 2. KANNER scale

1. 1. Excitement: Extreme nongoal-directed hyperactivity, constant motor activity. This may include aggressive movements and walking for prolonged periods.

   • 0 = Absent

   • 2 = Excessive motion, intermittent

   • 4 = Constant motion, hyperkinesis without rest periods

   • 6 = Extreme motoric excitement, frenzied motor activity

   • 8 = Extreme motoric excitement with potential or actual harm

2. 2. Immobility: Extreme hypoactivity, immobile.

   • 0 = Absent

   • 2 = Mild hypoactivity or bradykinesia

   • 4 = Bradykinesia, but is able to move on request

   • 6 = Akinesia with few spontaneous movements but may be able to move on command

   • 8 = Akinesia with few spontaneous movements, lasting greater than one day

3. 3. Stupor: Minimally responsive to stimuli.

   • 0 = Absent

   • 2 = Inert, but may interact briefly

   • 4 = No reaction to any external stimuli

   • 6 = No reaction to noxious stimuli

   • 8 = No reaction to deep, painful stimuli

4. 4. Mutism: Verbally unresponsive or minimally responsive.

   • 0 = Absent

   • 2 = Verbal response to questions only (speech-prompt) or occasional spontaneous utterances

   • 4 = Verbally unresponsive to majority of questions

   • 6 = No speech; does not speak when spoken to

   • 8 = No speech for greater than one day

5. 5. Staring: Fixed gaze, avoidant gaze, decreased blinking.

   • 0 = Absent

   • 2 = Poor eye contact, decreased blinking but will look at examiner

   • 4 = Gaze held, occasionally shifts attention to examiner

   • 6 = Fixed gaze; does not look at examiner; may look when requested

   • 8 = Fixed gaze/staring for greater than one day

6. 6. Posturing: Spontaneous maintenance of posture(s).

   • 0 = Absent

   • 2 = Brief episodes of “freezing” in a position for usually less than one minute

   • 4 = Longer episodes of more than one minute for less than one day

   • 6 = Bizarre posture, twisted or contorted body position less than one day

   • 8 = Any posture maintained for more than one day

7. 7. Grimacing: Facial spasms, facial tics, or odd facial expressions.

   • 0 = Absent

   • 2 = Present, with major provocation

   • 4 = Present, with minor provocation

   • 6 = Present, without any provocation, spontaneously

   • 8 = Present, with prolonged grimace or “facial cramp”

8. 8. Stereotypy: Repetitive, nongoal-directed movements.

   • 0 = Absent

   • 2 = Present, without injury

   • 4 = Present, with minor self injury (e.g., removes scab with frequent movements)

   • 6 = Present, with significant self injury (e.g., puts finger into eye and scratches cornea)

   • 8 = Present, with severe self injury (loss of function such as loss of one eye, one hand)

9. 9. Mannerisms: Repetitive, goal-directed but noncontextual movements (e.g., saluting a door or brushing hair without comb or brush in hand).

   • 0 = Absent

   • 2 = Present, without injury

   • 4 = Present with minor self injury (e.g., removes patch of hair from frequent combing movements)

   • 6 = Present with significant self injury (e.g., abrades scalps with frequent combing)

   • 8 = Present with severe self-injury (loss of function, loss of skin integrity from extensive excoriation)

10. 10. Rigidity: Maintenance of a rigid position despite efforts to be moved; may be transient.

    • 0 = Absent

    • 2 = Mild cog-wheeling

    • 4 = Moderate, increased muscle tone; may wax and wane

    • 6 = Severe, lead-pipe rigidity

    • 8 = Extreme, resists all movement; limb cannot be repositioned

11. 11. Flaccidity: Maintenance of a slack muscle tone; may be transient.

    • 0 = Absent

    • 2 = Mild, reduced muscle tone

    • 4 = Moderate, reduced muscle tone; may wax and wane

    • 6 = Severe, reduced muscle tone and movement; for less than one day

    • 8 = Extreme, reduced muscle tone and movement; for greater than one day

12. 12. Negativism: Resistance to instructions or attempts to move or examine the patient.

    • 0 = Absent

    • 2 = Mild resistance (e.g., will not follow some commands)

    • 4 = Moderate resistance (e.g., will not follow any commands, refuses to open mouth on examiner’s request or for nursing staff to administer oral medication)

    • 6 = Severe resistance (e.g., will not open eyelids for examiner or nursing staff)

    • 8 = Opposition (e.g., holds eyelids or mouth shut even after efforts to gently open them)

    • 8 = Active negativism; does the opposite of examiner’s request (e.g,. opens mouth when told to close mouth)

13. 13. Refusal to eat.

    • 0 = Absent

    • 2 = Minimal food intake for less than one day

    • 4 = Reduced food intake or odd food rituals for more than one day

    • 6 = Reduced food intake or odd food rituals for more than one day; eats only when fed by another person, or with frequent prompts

    • 8 = Requires nasogastric tube or supplemental feeding

14. 14. Refusal to drink.

    • 0 = Absent

    • 2 = Minimal fluid intake for less than one day

    • 4 = Reduced fluid intake or odd drinking rituals for more than one day

    • 6 = Reduced fluid intake or odd drinking rituals for more than one day; drinks only with assistance of another person or frequent prompts

    • 8 = Requires IV hydration or supplemental fluids

15. 15. Impulsivity: Sudden changes in behavior without provocation.

    • 0 = Absent

    • 2 = Occasionally acts up or runs away without prior warning

    • 4 = Frequently acts up and runs away at least once per week

    • 6 = Constant impulsive behavior; requires constant supervision

    • 8 = Extreme impulsive behavior, with great potential for harm (e.g. swallows spoons, coins or runs into walls)

16. 16. Nudism: Removes clothes or presents nude in public without provocation.

    • 0 = Absent

    • 2 = Present; missing some articles of clothing

    • 4 = Present; missing most articles of clothing (e.g., appears in underwear)

    • 6 = Present; is undressed or nude in semiprivate area

    • 8 = Present; is nude in public areas without provocation

17. 17. Incontinence (psychogenic): Incontinent even after taken to bathroom, without significant bowel or bladder disease.

    • 0 = Absent

    • 2 = Present; occasional diurnal urinary incontinence

    • 4 = Present; frequent diurnal urinary incontinence

    • 6 = Present, diurnal fecal incontinence

    • 8 = Both fecal and urinary incontinence

18. 18. Combativeness: Hostility and/or striking out at others suddenly in a nongoal-directed manner.

    • 0 = Absent

    • 2 = Occasionally hostile toward others; low potential for injury (e.g., irrational, angry verbal outbursts)

    • 4 = Frequently hostile toward others; occasionally strikes out; moderate potential for injury

    • 6 = Constantly hostile toward others; frequently strikes out; serious danger to others

    • 8 = Combative and/or has struck out at others or objects in past week (e.g., has broken down a door)

Record Total Score = ________ Range (0 to 144)

Appendix 2. PART 3. KANNER scale examination for catatonic signs

Patients with catatonia exhibit some unique responses to interaction with the examiner and the environment. These responses tend not to be associated with clinical severity in chronic populations. Consequently, the presence of these signs from the examination tends to confirm the presence of catatonia, but should not be used for initial assessment or treatment response. These signs may wax and wane over time.

1. A. Confirmatory tests for catatonic signs—speech

1. 1. Parroting (Echolalia): Patient repeats spoken word, in parrot-like fashion.

   • 0 = Absent

   • 1 = Repeats entire phrase, complete echolalia

   • 1 = Repeats end of phrase, terminal echolalia or logoclonia

   • 1 = Repeats beginning of phrase, initial echolalia

2. 2. Gibberish (verbigeration): Patient produces nonsense words or sounds.

   • 0 = Absent

   • 1 = Word salad, sensible words, nonsensical sequence, rapid cadence

   • 1 = Babbling, nonsense words in sensible cadence

   • 1 = Yelling words or phrases at loud volume, but out of context

3. 3. Perseveration: Repeatedly returns to same topic or persists with same movement.

   • 0 = Absent

   • 1 = Repeats same answer to previous question

   • 1 = Repeats same action for a previous request

   • 1 = Returns to same topic or phrase in conversation

4. B. Confirmatory tests for catatonic signs—motor

5. 4. Waxy flexibility: Patient maintains examiner’s imposed postures for greater than one minute.

   • 0 = Absent

   • 1 = Present

6. 5. Catalepsy: Patient maintains examiner imposed postures briefly but gradually returns limb to a position of rest within one minute.

   • 0 = Absent

   • 1 = Present

7. 6. Echopraxia: Mimicking of examiner’s movements.

   • 0 = Absent

   • 1 = Present

8. 7. Command-verbal (automatic obedience and ambitendency): Exaggerated cooperation with examiner’s request or spontaneous continuation of movement requested or patient becomes “motorically stuck” in indecisive, hesitant movement.

   • 0 = Absent

   • 1 = Present—follows even senseless and illogical commands (automatic obedience)

   • 1 = Present—follows the motoric command instead of the verbal command (automatic obedience)

   • 1 = Present—follows the motoric command partway, then stops (ambitendency)

9. 8. Command-motor (mitgehen): Arm raising in response to light pressure of finger, despite instructions to the contrary (e.g., patient walks hand-in-hand with examiner after being told not to).

   • 0 = Absent

   • 1 = Present—goes with examiner after light touch of hand-in-hand

   • 1 = Present—light touch overcomes the position of the limb

10. 9. Paratonia (gegenhalten): Equal and opposite motoric resistance to passive movement of a limb.

    • 0 = Absent

    • 1 = Present—continuous oppositional force

    • 1 = Present—intermittent oppositional force

11. 10. Grasp reflex: Closes hand on examiner’s digit upon contact with patient’s palm.

    • 0 = Absent

    • 1 = Present—fingers flex slightly with initial pressure

    • 1 = Present—finger and thumbs fold over examiner’s finger

    • 1 = Patient grasps examiner’s finger, loosely or tightly

    • 1 = Patient hooks examiner’s fingers with flexion of fingers

12. 11. Metronome test: Patient persists with movement of limb initiated by examiner.

    • 0 = Absent

    • 1 = Present—arm continues to swing back and forth multiple (4 or more) times before coming to rest at the patient’s side

    • 1 = Present—arm continues to swing back like a metronome

13. 12. Magnetism: Patient moves his limb toward outstretched hand of the examiner.

    • 0 = Absent

    • 1 = Present—patient’s wrist moves toward examiner’s open hand (0.5–2 inches)

    • 1 = Present—patient’s wrist moves to the palm of examiner’s open hand

    • 1 = Present—patient is excessively compliant in examination (e.g., told to sit on examination table but lays back on table)

Record total # of confirmatory signs = ________ Range (0–12)

Appendix 3.

KANNER scale examination—confirmatory tests

#	PROCEDURE	SYMPTOMS
1	Examiner observes patient while behind nurses station on unit or in clinic.	Activity level, abnormal movements
2	Examiner observes patient while trying to engage in a, conversation “My name is Dr. Carroll. Can you say Dr.Carroll?” “Can you name five towns in our state (province)?” “Which towns would you like to visit someday?”	Parroting (echolalia) gibberish (verbigeration), perseveration
3	Examiner places patient’s arm in the air at a 90-degree angle. If it remains stationary, this is waxy flexibility. If it falls slowly to side, this is catalepsy.	Waxy flexibility
4	Examiner scratches head in exaggerated manner, then puts one open hand on left temple and watches patient, then puts the other open hand on right temple and watches patient.	Echopraxia
5	Examiner extends hand stating “Do NOT shake my hand.” Patient may become motorically stuck. Examiner states, “Place your left wrist on your right wrist.” “Good, now place your left wrist on your left wrist.”	Command-verbal (automatic obedience and ambitendency)
6	Examiner asks patient to extend arm. Examiner places one finger beneath patient’s hand and tries to raise it slowly after stating, “Do NOT let me raise your arm.”	Command-motor (mitgehen)
7	Examiner passively flexes patient’s arm at the elbow. Examiner uses greater and lesser force to determine if the degree of motor resistance changes according to the force applied.	Paratonia (gegenhalten)
8	Examiner places index finger flat on palm of patient’s hand. Patient’s fingers and thumb are observed for flexion.	Grasp reflex
9	Patient’s arm is at rest at his side. Examiner says, “I will swing your arm back and forth. When I let go you let it come to rest as it will.”	Metronome test
10	Patient’s arm is at rest. Examiner reaches slowly with extended hand open as if to grasp patient’s wrist at about three inches from wrist of patient’s resting arm.	Magnetism

Appendix 4.

KANNER scale—test examples

SYMPTOMS	EXAMPLES
Parroting (echolalia)	Patient says “My name, My name, My name…” = initial echolalia; Says “Dr. Carroll, Dr. Carroll…” = terminal echolalia; Says “My name is Dr. Carroll” = complete echolalia
Gibberish (verbigeration)	Patient says “Cleveland, land of cleve, cleve of land” = gibberish
Perseveration	Patient says “I would like to go to Cleveland.” Any other town? Says “I would like to go to Cleveland.” Can you name a town in Indiana? Says “Cleveland” = perseveration
Waxy flexibility	Examiner folds patient’s fingers to makes a fist and then the patient’s fingers hold shape of fist for over one minute = waxy flexibility
Catalepsy	Examiner folds patient’s fingers to makes a fist but the patient’s fingers only slowly return to position of rest = catalepsy
Echopraxia	Examiner holds open hands on his head as if he has horns like a moose. Patient imitates examiner and holds “moose position” even if briefly = echopraxia
Command-verbal	Patient is given a series of unusual commands and follows them.
Automatic obedience and ambitendency	Patient tries to touch left wrist to itself = automatic obedience. Patient observed to freeze during a contrary request. Bends slightly when told “Don’t tie your shoe” = ambitendency
Command-motor (mitgehen)	Patient is told to remain in place while examiner grasps patient’s hand lightly. Examiner pulls slightly and patient follows despite instruction = mitgehen; Examiner says “Do NOT let me raise your arm.” Yet with light pressure of examiner’s finger the patient’s arm rises = mitmachen
Paratonia	Patient is told to relax arm, yet flexion of elbow joint brings resistance that is proportionate to examiner’s force = paratonia
Grasp reflex	Examiner’s finger is placed on patient’s palm and the patient’s fingers flex slightly or form a fist over the finger = grasp reflex
Metronome test	Patient’s arm swings back and forth like a pendulum before coming to rest = positive metronome test (an iteration of an imposed movement)
Magnetism	Patient’s arm raises slightly toward examiner’s hand, or moves to examiner’s hand as if by a magnetic force = magnetism