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Case Report of Retarded Catatonia: Always Consider Catatonia as a Differential Diagnosis of Altered Mental Status
Informe de un caso de catatonia retardada: Considerar siempre la catatonia como diagnóstico diferencial de la alteración del estado mental
Irma Munoz Verdugoa,
Corresponding author
irmamunozmd@gmail.com

Corresponding author.
, Jose Lopezb, Sandra Cordovac
a Department of Internal Medicine, Facultad de Ciencias Médicas, Universidad de Cuenca, Cuenca, Ecuador
b Department of Internal Medicine, Doctors Hospital at Renaissance DHR Hospital, McAllen, United States of America
c Department of Internal Medicine, Universidad Central del Ecuador, Quito, Ecuador
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Catatonia is a medical condition associated with mood-affective disorders&#44; schizophrenia&#44; neurological and medical conditions&#59; it is characterized by an inability to move&#44; mutism&#44; rigidity&#44; and refusal to eat&#44; among others&#46; To date&#44; there are two types&#58; retarded and excited&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;2</span></a> Some prospective studies suggest that catatonia can be observed in 10&#37; of patients at psychiatric units and in up to 30&#37; of patients admitted to medical wards&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Imbalances in the excitatory-to-inhibitory ratio &#40;EIR&#41; at the spinal and brainstem level may play a role in the etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> In addition&#44; research reported that the GABA pathway has a part in the suppression of the immune response&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> This is why some patients with catatonia respond to agonists of GABA-A receptors&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Catatonia can be diagnosed based on clinical suspicion&#44; at least four catatonic symptoms must be present for a diagnosis&#46; In addition&#44; a trial of lorazepam is required to support the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> Catatonia can be challenging when doctors are trying to obtain a medical history and physical examination because patients manifest with mutism&#44; and so this lack of information can difficult a correct diagnosis&#44; assessment&#44; and plan&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;7</span></a> Is not a rare medical condition encountered at the emergency department and in the acute care setting&#44; but due to the diverse presentation of catatonia&#44; it can be misdiagnosed&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients with catatonia and comorbid mood disorders can resolve their condition completely with benzodiazepine treatment and electroconvulsive therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> Moreover&#44; some cases will need a specialized level of care&#44; nasogastric tube placement&#44; intravenous fluids&#44; and anticoagulation to decrease morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case presentation</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient is a 59-year-old woman with a background of longstanding cirrhosis&#44; bipolar disorder&#44; and major depressive disorder with psychotic features&#44; stable on alprazolam&#44; fluoxetine&#44; and lurasidone&#46; It allowed her to live an independent life&#46; The patient was brought to the behavioral facility complaining about increased agitation&#44; auditory and visual hallucinations &#40;she was seeing bugs on her arms&#44; hair&#44; and on the wall as well as seeing a red light that was coming out from the television&#41;&#44; uncooperative&#44; no insight into her condition and judgment severely impaired&#46; In the facility&#44; the patient was started on a tapering dose of clorazepate &#40;Tranxene 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#41; detoxification schedule with thiamine and folic acid&#46; As per the mother and medical staff&#44; the patient developed an episode of tonic-clonic seizure&#44; which prompted them to transfer her to the ER&#46; Upon admission&#44; her vital signs were temperature of 101&#46;4&#44; tachycardic to 116&#44; and slightly hypertensive&#46; On examination&#44; the patient was posturing&#44; staring stuporous&#44; nonverbal&#44; nonresponsive&#44; flat affect&#44; stiff&#44; increased tone of four extremities&#44; and waxy resistance to passive movement&#46; She had&#44; another episode of seizure in the ER&#44; and an initial diagnosis of possible sepsis&#44; benzodiazepine withdrawal&#44; or hepatic encephalopathy was made&#46; She was admitted to the Internal Medicine ward&#44; and extensive neurologic&#44; infectious&#44; and toxicologic work-up &#40;amphetamine&#44; barbiturates&#44; opioids negative&#44; and benzodiazepines positive&#41; was done including lumbar and imaging such as CT head without contrast&#44; CT angiography of the neck&#44; EEG&#44; echocardiogram&#44; and chest x-ray which were normal&#46; Ammonia level was elevated just on admission&#46; The patient failed swallow evaluation and was placed on NPO&#44; metoprolol IV&#44; and lorazepam 1<span class="elsevierStyleHsp" style=""></span>mg IV BID&#44; and levetiracetam 500<span class="elsevierStyleHsp" style=""></span>mg BID&#46; Throughout hospitalization&#44; her mental status decline progressively despite the use of lactulose for metabolic encephalopathy and with only short episodes of lucidity shortly after being administered IV benzodiazepines&#44; but she remained with mutism&#44; not following commands&#44; looking in space&#44; mumbling&#46; Despite her presentation&#44; the impression was that she was suffering from acute retarded catatonic syndrome secondary to her bipolar affective disorder&#46; Psychiatry and Internal Medicine agreed to start a trial of IV benzodiazepines at a therapeutic dose for catatonia &#40;lorazepam 3<span class="elsevierStyleHsp" style=""></span>mg IV every 8 h&#41;&#46; After the administration of lorazepam patient improve substantially and progressively&#44; initially somewhat catatonic&#44; but later able to verbalize again with better eye tracking and able to ask for water and her mood was euthymic&#46; She was able to follow simple commands without difficulty&#44; the patient presented a favorable evolution without any complications A final recommendation to the patient was to be transferred to a hospital that had electroconvulsive therapy for definitive treatment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis of acute catatonia is a challenge for both hospitalists and psychiatrists because it is difficult to obtain a complete medical history from a mute patient&#46; In this context&#44; it is primordial to be sure that some medical conditions such as non-convulsive status epilepticus&#44; stroke&#44; abulia&#44; akinetic mutism&#44; delirium&#44; and dementia are not present at diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Moreover&#44; neurological emergencies &#40;neuroleptic malignant syndrome NMS&#41;&#44; need to be ruled out before considering acute catatonia as those conditions need a prompt diagnosis&#44; treatment&#44; and admission to the medical intensive care unit &#40;MICU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to Karl Kahlbaum&#44; catatonia is diagnosed when a patient has at least 4 of 11 signs and symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> The most common signs and symptoms of catatonia are immobility and mutism&#59; those are present in about 90&#37; of cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Treatment of catatonia should be started as soon as catatonia is suspected and is critical for a good patient&#39;s progress and recovery&#46; In all cases of catatonia&#44; the underlying disorder &#40;e&#46;g&#46; undiagnosed bipolar disorder&#41; has to be addressed&#46; It is a priority to discontinue any potential hazardous drugs that cause catatonia such as dopamine antagonists&#44; anticonvulsants&#44; and antipsychotics&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Current recommendations are based on the general condition of the patient&#46; For instance&#44; non-life-threatening catatonia is treated by the administration of benzodiazepines&#46; If the patient responds within one week&#44; there is no need to continue the benzodiazepine medication at discharge&#46; However&#44; if the patient has a slow response &#40;clinical response after the first week&#41; there is a need to initiate electroconvulsive therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the most common benzodiazepines &#40;GABA agonist drugs&#41; used in catatonia are lorazepam and clonazepam&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">11&#44;13</span></a> Initially&#44; it is recommended to start with a dose of 2<span class="elsevierStyleHsp" style=""></span>mg of lorazepam intravenously&#46; If there is a good response&#44; it is advised to schedule the drug up to three times a day&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Benzodiazepines&#8217; response has been demonstrated in many studies&#44; a clinical response is achieved within 3<span class="elsevierStyleHsp" style=""></span>hours after the administration of lorazepam&#46; The oral route is preferred&#44; however&#44; when that is not feasible an intramuscular or intravenous route should be used&#46; Most patients recovered their baseline clinical state with a lorazepam dose between 1 to 3<span class="elsevierStyleHsp" style=""></span>mg&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14&#44;15</span></a> As the patient&#39;s mental state improves focus should be placed on the underlying medical condition&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> In our case&#44; no organic cause was identified and we focused on treating the acute catatonic state&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Duration of therapy varies according to clinical response&#59; some patients might need a single dose and other patients might require multiple doses or even a continuous infusion&#46; Response to therapy can be evaluated by the Bush-Francis catatonia scale&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> After a therapeutic dose of lorazepam is achieved&#44; tapering of the drug should be done slowly to prevent a new episode of catatonia&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Research about other therapeutic options than lorazepam is controversial and non-conclusive&#46; Current treatments studied for catatonia are clonazepam&#44; antipsychotics &#40;olanzapine&#41;&#44; dantrolene&#44; amantadine&#44; and zolpidem which have been reported good results&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16&#8211;18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Antipsychotics have been evaluated in patients with catatonia and an underlying psychotic condition&#46; Among the antipsychotics studied&#44; there is clozapine&#44; which is a low-affinity dopamine receptor agonist&#46; Clozapine showed a beneficial effect in psychotic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> The use of second-generation &#40;atypical&#41; antipsychotics was preferred over traditional first-generation because of the lower risk of developing neuroleptic malignant syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> Even though antipsychotics were used in some cases&#44; the current recommendation is against the use of all dopamine blocking drugs &#40;antiemetic agents&#44; first and second-generation antipsychotics&#41; because all antipsychotics might worsen catatonia&#46; If the underlying disorder is a psychotic condition that needs antipsychotic medication&#44; the antipsychotic drug could be resumed with extreme caution only once the patient is stable&#44; eating and drinking adequately&#44; and without any signs of catatonia&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Clonazepam was used in some studies only after achieving an initial response with lorazepam&#46; Clonazepam was preferred over lorazepam in patients who needed longer hospitalization&#46; The pharmacologic properties of clonazepam&#44; a longer half-life&#44; were well suited for patients suffering from catatonia and COVID-19 pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Olanzapine and lorazepam&#44; as a combination therapy&#44; showed a good response in patients with catatonia secondary to anti-NMDA receptor encephalitis&#46; Olanzapine alone was not as effective as in combination with lorazepam to improve agitation&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Zolpidem has been studied in cases of resistant catatonia in adolescents&#46; The drug has a similar mechanism of action to lorazepam&#44; a positive allosteric effect on GABA-A receptors&#46; However&#44; zolpidem binds to a specific subunit &#40;alpha1&#41; rather than a non-specific site on the receptor&#46; Zolpidem might be a non-benzodiazepine alternative in cases of resistant catatonia&#44; although more research is needed&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">According to Freitas de Lucena et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a>&#44; 500<span class="elsevierStyleHsp" style=""></span>mg of amantadine intravenously can be beneficial in the treatment of catatonia as many motor scores showed a complete improvement after a couple of hours&#46; However&#44; amantadine is not routinely used because has dopamine agonist properties and can exacerbate psychotic symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Electroconvulsive therapy &#40;ECT&#41; is a well-studied treatment for catatonia&#46; ECT in combination with benzodiazepines is recommended as initial treatment in patients with life-threatening &#40;malignant&#41; catatonia&#46; In addition&#44; ECT is recommended in patients who did not respond within the first week of lorazepam administration&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In some studies&#44; the frequency of bilateral ECT was three-time per week&#46; In addition&#44; unilateral ECT was preferred over bilateral to prevent cognitive impairments such as headaches and memory loss&#46; These adverse effects might be related to the frequency of electroconvulsive therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> In our patient&#44; lorazepam was the initial treatment and ECT was considered as a definitive treatment&#46; Multiple studies showed a recovery rate of up to 80&#37; with lorazepam alone&#44; ECT alone&#44; and ECT after lorazepam&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">There are common complications in catatonia such as refusing to eat&#44; dehydration&#44; pneumonia&#44; pressure ulcers&#44; deep venous thrombosis&#44; and pulmonary embolus&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">2&#44;6</span></a> In the last decade&#44; catatonia has had an excellent response &#40;80&#37;&#41; and prognosis to benzodiazepines &#40;lorazepam&#41;&#46; The patients who do not respond to lorazepam usually have a bad prognosis later&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">6&#44;15</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Catatonia is underdiagnosed due to the lack of awareness of the condition among both medical doctors and psychiatrists&#46; We always have to consider acute catatonia syndrome among our differential diagnoses for altered mental status&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">As catatonia is a highly treatable condition&#44; there must be a high suspicion to diagnose and treat this disease&#46; Failure to do so increases the morbidity and mortality outcome among patients&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">More research is required to do a catatonia protocol&#44; thereby it is important to have further data on patients with catatonia&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">ECT has proved to be efficacy in refractory catatonia&#44; as well as in the incomplete response to benzodiazepines&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicto de intereses</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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    "fechaAceptado" => "2022-02-02"
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            1 => "Benzodiacepinas"
            2 => "Terapia electroconvulsiva"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Catatonia is a rare neuropsychiatric condition&#59; it is estimated that around 10&#37; of patients with mood disorders present signs and symptoms of catatonia&#46; A catatonic syndrome is characterised by mutism&#44; negativism&#44; rigidity&#44; and stupor&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 59-year-old patient with a medical history of bipolar disorder who was admitted to the internal medicine service due to a seizure episode&#46; During hospitalisation&#44; the patient presented significant worsening of her clinical condition&#44; showing marked symptoms of stupor and catatonia&#46; Once the neurological and metabolic etiologies of altered mental status had been ruled out&#44; pharmacological treatment with high doses of lorazepam was started&#46; The patient had a complete clinical remission&#44; and her evolution was favourable without any complications&#46; Electroconvulsive therapy was recommended as a definitive treatment&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The diagnosis of catatonia is a challenge for both hospitalists and psychiatrists due to the clinical presentation of catatonia&#46; In reporting this clinical case&#44; we want to emphasise the importance of taking into account the catatonic syndrome in our differential diagnoses in patients with altered mental status&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La cataton&#237;a es una condici&#243;n neuropsiqui&#225;trica poco frecuente&#44; se estima que cerca del 10&#37; de los pacientes con trastornos afectivos presentan signos y s&#237;ntomas de cataton&#237;a&#46; El s&#237;ndrome se caracteriza cl&#237;nicamente por mutismo&#44; negativismo&#44; rigidez y estupor&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso cl&#237;nico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se describe el caso cl&#237;nico de una paciente de 59 a&#241;os con antecedentes de trastorno bipolar&#44; ingresada por el servicio de medicina interna por un episodio de crisis convulsiva&#46; Durante la hospitalizaci&#243;n&#44; la paciente present&#243; un importante deterioro cl&#237;nico&#44; marcado estupor y s&#237;ntomas de cataton&#237;a&#46; Una vez descartadas etiolog&#237;as neurol&#243;gicas y metab&#243;licas de la alteraci&#243;n del estado de conciencia&#44; se inici&#243; el tratamiento farmacol&#243;gico con altas dosis de lorazepam&#46; El cuadro cl&#237;nico de la paciente evolucion&#243; favorablemente con una remisi&#243;n cl&#237;nica completa&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El diagn&#243;stico de cataton&#237;a constituye un reto tanto para m&#233;dicos internistas como psiquiatras por su presentaci&#243;n cl&#237;nica&#46; Con el reporte de este caso cl&#237;nico se desea enfatizar la importancia de considerar al s&#237;ndrome catat&#243;nico en nuestros diagn&#243;sticos diferenciales en pacientes con alteraci&#243;n del estado de conciencia&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sign&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37; Of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immobility&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mutism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Withdrawal and refusal to eat&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Staring&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Negativism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Posturing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Rigidity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Waxy flexibility&#47;catalepsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Stereotypy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Echolalia or echopraxia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Verbigeration&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 00347450
Original language: English
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