Joshua R. Wortzel, MD, MPhil

 is a psychomotor syndrome that features too little (hypokinetic), too much (hyperkinetic), or abnormal (parakinetic) movement and presents in association with primary mental illness or other medical conditions.

 An individual with catatonia may develop life-threatening autonomic abnormalities—a condition called malignant catatonia. Persistent or severe catatonia can also lead to a wide variety of medical complications (

 Prompt identification and management are imperative.

 Potential Medical Complications of Persistent or Severe Catatonia

An estimated 5% to 10% of acute psychiatric inpatients have catatonia, with a growing body of literature describing catatonia in acute medical settings as well.

 Despite the prevalence of catatonia and its clinical impact, catatonia remains widely underdiagnosed. In fact, 2 separate studies found that roughly only 1 in 10 cases of catatonia was recognized by psychiatric inpatient treatment teams.

 Although several factors likely play a role, we believe that a widespread lack of understanding catatonia’s clinical diversity may be a large reason catatonia so often goes undiagnosed.

To explore this possibility, we collaborated with Andrew Francis, MD, PhD, senior author of the Bush-Francis Catatonia Rating Scale (BFCRS). Published in 1996, the BFCRS is the most widely used scale to assess catatonia in clinical and research settings.

 We began by creating a detailed BFCRS Training Manual and Coding Guide to describe each item on the scale and to provide a semistructured interview to guide scoring.

Next, we created an online module to assess how well clinicians and trainees in psychiatry could identify the features of catatonia. The module consisted of standardized patient videos that participants were asked to score using the 23-item BFCRS and multiple-choice questions on individual BFCRS items. A total of 482 medical students, psychiatry trainees, and psychiatrists from more than 150 medical institutions around the world participated in our study.

Overall, participants answered correctly 69% of the BFCRS items when scoring standardized patient videos and 55% of multiple-choice items. After adjusting for demographics using multivariable regression, we found that, compared with medical students, psychiatrists correctly identified only 2 more items on the BFCRS when scoring standardized videos.

We also were curious to know whether a video-based online educational module could improve the accuracy of catatonia recognition. After taking the assessments above, participants were invited to take a 1-hour educational course on catatonia that reviewed each item on the BFCRS as illustrated through a series of narrated standardized patient exams and onscreen explanations. Participants’ knowledge was reassessed directly after completing the module and 3 months later. We found substantial improvements in catatonia recognition on follow-up assessments across all stages of training.

Across the sample, postmodule scoring of standardized patient videos improved from 69% to 87% correct responses, with limited attrition in performance to 81% correct responses at 3 months. After completing this module, medical students outperformed psychiatrists who had not yet taken the educational module, and, at 3 months, psychiatry resident participants also outperformed psychiatrists at study baseline.

Based on favorable responses to this project and participant feedback, we subsequently created a set of 23 point-of-care videos on how to score each BFCRS item. With these videos, we illustrate some of the diversity of how each BFCRS item can present. For example, grimacing can involve a variety of facial movements; mannerism pertains to patterns of speech or body movements; and negativism can manifest as physical resistance to examination or as relational opposition. These videos also offer guidance on scoring item severity. Finally, to enhance clinical utility, we have created a hyperlinked version of the BFCRS that links users to these point-of-care videos and to the corresponding pages on the BFCRS Training Manual and Coding Guide.

Now that this project is complete, we have made this suite of catatonia educational materials freely available online at 

 Our goal in creating these resources is to equip clinicians to identify catatonia both accurately and reliably. Catatonia involves a variety of motoric and behavioral findings, so education to improve its identification should prioritize audiovisual depictions of its features. We hope that these video-based resources will serve this role.

These videos also reinforce comments in the ICD-11, clarifying that several of catatonia’s diagnostic features require physical examination (ie, catalepsy, waxy flexibility, and rigidity).

 We invite psychiatric clerkships and residency programs to incorporate these materials into their curricula, investigators to use these resources to ensure standardized definitions across studies, and practicing psychiatrists to learn more about this compelling clinical condition.

 is an assistant professor of psychiatry at the University of Rochester Medical Center, New York. 

 is chief resident in psychiatry at the University of Rochester Medical Center, New York. The authors are indebted to Andrew Francis, MD, PhD, for his collaboration on this project and to Hochang B. Lee, MD, for supporting this work.

The project described in this article was supported by the Department of Psychiatry at the University of Rochester Medical Center, including internal funds and statistical analysis by the Quantitative Methods Core. The authors declare no relevant conflicts of interest. Dr Oldham is supported by a K23 award through the National Institute on Aging (AG072383).

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)

. American Psychiatric Association Publishing; 2022.

2. Walther S, Stegmayer K, Wilson JE, Heckers S. 

Structure and neural mechanisms of catatonia

Prevalence of catatonia and its moderators in clinical samples: results from a meta-analysis and meta-regression analysis

4. van der Heijden FMM, Tuinier S, Arts NJM, Hoogendoorn MLC, Kahn RS, Verhoeven WMA. 

Catatonia: disappeared or under-diagnosed?

5. Ghaziuddin N, Dhossche D, Marcotte K. 

Retrospective chart review of catatonia in child and adolescent psychiatric patients

Catatonia. I. rating scale and standardized examination

7. Wortzel JR, Maeng DD, Francis A, Oldham MA. 

Prevalent gaps in understanding the features of catatonia among psychiatrists, psychiatry trainees, and medical students

8. Wortzel JR, Maeng DD, Francis A, Oldham MA. 

Evaluating the effectiveness of an educational module for the Bush-Francis Catatonia Rating Scale

9. Bush-Francis Catatonia Rating Scale assessment resources. University of Rochester Medical Center. Accessed May 17, 2022. 

https://www.urmc.rochester.edu/psychiatry/divisions/collaborative-care-and-wellness/bush-francis-catatonia-rating-scale.aspx

10. ICD-11 for mortality and morbidity statistics: catatonia. World Health Organization. February 2022. Accessed May 31, 2022. 

https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/486722075

Articles

An estimated 5% to 10% of acute psychiatric inpatients have catatonia—yet catatonia remains widely underdiagnosed.

What Are Clinicians Missing About Catatonia?

Image from the Bush-Francis Catatonia Rating Scale assessment resources (Mark Oldham, MD; Joshua Wortzel, MD)

Catatonia is a psychomotor syndrome that features too little (hypokinetic), too much (hyperkinetic), or abnormal (parakinetic) movements. It presents in association with either primary mental illness or other medical conditions.

 An individual with catatonia can develop life-threatening autonomic abnormalities, a condition called malignant catatonia. Severe or persistent catatonia can also lead to a variety of medical complications including thromboembolic disease, pressure ulcers, contractures, aspiration pneumonia, malnutrition, and dehydration.

 We began by creating a detailed BFCRS Training Manual and Coding Guide to describe each item on the scale and to provide a semi-structured interview to guide scoring.

Next, we created an online module to assess how well clinicians and trainees in psychiatry could identify the features of catatonia. The module consisted of standardized patient videos that participants were asked to score using the 23-item BFCRS and multiple-choice questions on individual BFCRS items. A total of 482 medical students, psychiatry trainees, and psychiatrists from more than 150 medical institutions globally participated in our study.

 Overall, participants answered correctly 69% of the BFCRS items when scoring standardized patient videos and 55% of multiple-choice items. After adjusting for demographics using multivariable regression, we found that, compared to medical students, psychiatrists correctly identified only 2 more items on the BFCRS when scoring standardized videos.

We were also curious whether a video-based online educational module could improve the accuracy of catatonia recognition. After taking the assessments above, participants were invited to take a 1-hour educational course on catatonia that reviewed each of the items on the BFCRS as illustrated through a series of narrated standardized patient exams and onscreen explanations. Participants’ knowledge was reassessed directly after completing the module and 3 months later. We found substantial improvements in catatonia recognition on follow-up assessments across all stages of training.

 Across the sample, post-module scoring of standardized patient videos improved from 69% to 87% correct, with limited attrition in performance to 81% correct at 3 months. After completing this module, medical students outperformed psychiatrists who had not yet taken the educational module, and, at 3 months, psychiatry resident participants still outperformed psychiatrists at study baseline.

 We invite psychiatric clerkships and residency programs to incorporate these materials into their curricula, researchers to use these resources to ensure standardized definitions across studies, and practicing psychiatrists to learn more about this compelling clinical condition.

 is an assistant professor of psychiatry at the University of Rochester Medical Center. 

 is chief resident in psychiatry at the University of Rochester Medical Center. The authors are indebted to Andrew Francis, MD, PhD, for his collaboration on this project and to Hochang B. Lee, MD, for supporting this work.

The project described in this piece was supported by the Department of Psychiatry at the University of Rochester Medical Center, including internal funds and statistical analysis by the Quantitative Methods Core.The authors declare no relevant conflicts of interest. Dr Oldham is supported by a K23 award through the National Institute on Aging (AG072383).

Diagnostic and Statistical Manual of Mental Disorders (DSM5-TR)

4. van der Heijden FM, Tuinier S, Arts NJ, et al. 

Catatonia: disappeared or under-diagnosed? 

9. Wortzel JR, Oldham MA. Bush-Francis Catania Rating Scale assessment resources. University of Rochester Medical Center. 2022. Accessed May 17, 2022. 

10. ICD-11 for mortality and morbidity statistics. World Health Organization. 2022. Accessed May 31, 2022. 

Despite its prevalence and clinical impact, catatonia remains widely underdiagnosed. What are clinicians missing?

So That’s What Catatonia Looks Like?

COMMENTARY: FROM THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY CLIMATE COMMITTEE

As we prepare for the second online annual meeting of the 

, it is a safe bet that few of us are thinking how wonderful it is to stay at home. While online conferences have much to offer, many of us miss the collegial interactions and invigorating break from office routine.

At the same time, we have become accustomed to the efficiency of online meetings—the decreased time and cost of travel, the comforts of controlling what others see and do not see, and the chance to spend more time with family. The environmental benefits of online meetings are also enormous. Large conferences can 

 the carbon dioxide equivalent (CO2e) emissions of an entire city in a single week.

 on the carbon footprint of APA meetings, we found that by holding its 2020 Philadelphia meeting online, the APA saved roughly 20,000 metric tons CO2e emissions—the equivalent of burning 22 million pounds of coal or 500 acres of dense forest.

Psychiatrists increasingly appreciate the costs of this carbon. Climate change affects mental health in a myriad of ways, through temperature changes that 

 pharmaceutical safety and neurophysiology,

 existential stressors and eco-anxiety in a whole generation of young individuals, and climate-related traumas from forest fires to coastal flooding.

 Some of us are also aware of the degree to which we, the health care system, are the problem. American health care generates more greenhouse gases than many countries, and it 

 more than 400,000 disability-adjusted life-years annually.

 The APA has wisely recognized climate change as a top priority,

 and our response must be to reduce our carbon emissions—as well as respond to the damage they cause—bringing our practice in line with international goals for sustainability.

But sustainability is more than just cutting carbon emissions. Sustainability means creating a system where all of us can thrive—plants, animals, humans, and planet. This requires adequate financial resources, social justice, and social connectivity, while also decreasing the destruction of our planetary home. As we prepare for this second online meeting, it is an opportunity to reflect: Where can psychiatry become more sustainable? What can online meetings accomplish? What parts of in-person contact are important to retain, and how?

During our panel discussion, “The Carbon Footprint of Cancelling the APA, a Virtual Match, and More: Impacts of Psychiatric Activity on Global Warming and How to Respond,” we will explore these issues, presenting research on the carbon footprint of residency interview travel by Daniel Brooks Bernstein and our research on the APA’s carbon footprint. We found that the carbon footprint of APA meetings may vary 3-fold by location in the United States, with northeastern locations optimally minimizing the aggregate 

. We also analyzed how the APA’s carbon footprint would change with different kinds of meetings—regional, online, and so on. For example, we have found that regional meetings could cut carbon emissions by 24% to 53%, and as much as 85% to 86% if nonregional attendees participated online.

Bernstein, a Stanford medical student, found that each of his classmates generated an average of 12,331 pounds of CO2 to complete their residency interviews, with 1 candidate generating as much as 44,000 pounds of CO2. Surely some of these flights are unnecessary to the development of these gifted doctors, especially given the climate and health costs of their travel.

Professional meetings are crucial for socialization, networking, mentoring, and learning. The casual conversations and meals that surround the program are important for the development of a professional identity and lead to creative advancement in clinical practice, research, and policy. Psychiatry especially prizes sustaining connections. But, in truth, many of our assumptions about what binds us to each other have been challenged by the ways we interact now through social media, telecommunications, and our recent rapid adjustment to telepsychiatry. The APA could achieve emissions reductions well within the target of the 

or residency interview procedure, which would help our profession fulfill the Hippocratic Oath to “do no harm.” Using our experiences from the past 2 years, we can find ways to make changes that not only maintain sustainable connections to one another and our patients, but also contribute to the sustainability of our planet.

The panel will also include an overview of the carbon footprint of US health care and a discussion of its sustainable solutions by Todd Sack, MD, FACP, and panel chair Elizabeth Haase, MD. We look forward to sharing ideas and discussing what psychiatry should relinquish and what must be retained as we innovate for new climate-changed realities.

 is a medical student at the University of Pennsylvania School of Medicine. 

is a resident at the University of Rochester School of Medicine. 

 is associate professor of psychiatry at the University of Nevada School of Medicine at Reno and acts as medical director at Carson Tahoe Health, Outpatient Behavioral Health Services.

1. Klöwer M, Hopkins D, Allen M, Higham J. An analysis of ways to decarbonize conference travel . . . 

2. Wortzel JR, Stashevsky A, Wortzel JD, et al. 

Estimation of the carbon footprint associated with attendees of the American Psychiatric Association annual meeting

3. Wortzel J, Haase E. The effects of rising global temperatures on mental health. 

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.4b24

4. Hayes K, Blashki G, Wiseman J, et al. Climate change and mental health: risks, impacts and priority actions. 

Environmental impacts of the U.S. health care system and effects on public health

6. Ursano RJ, Morganstein JC, Cooper R. APA official actions: Position statement on mental health and climate change. APA Official Actions. 2017:1.❒

Sustainability is more than just cutting carbon emissions. It means creating a system where all of us can thrive—not just survive.

Joshua R. Wortzel, MD, MPhil

Articles

What Are Clinicians Missing About Catatonia?

So That’s What Catatonia Looks Like?

Can Psychiatry Sustain Connections While Hosting Sustainable Conferences?