The psychological and subjective experience of catatonia

doi:10.21203/rs.3.rs-1420539/v1

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Research Article

The psychological and subjective experience of catatonia

https://doi.org/10.21203/rs.3.rs-1420539/v1

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Background

Catatonia is a severe psychomotor disorder that presents as abnormality of movement which may also be excessive or severely slowed. It often inhibits communication when protracted or severe. In this study we investigated the emotive and cognitive experience of patients with catatonia during a prevalence study in an acute mental health unit from August 2020 to September 2021.

Methods

Ethical approval was received from the Nelson Mandela University Human Research Committee and convenience sampling was undertaken to recruit participants, four to eight weeks after discharge, following admission for a catatonic episode. Participants were requested to describe their thoughts, feelings and behaviours during the catatonic episode, in their own words.

Results

Forty-four (18.3%) of 241 participants had catatonia. Thirty (68.2%) of the 44 participants with catatonia provided data on their experience during the catatonic episode. The dominant themes of thoughts, feelings, and behaviors centered around yearning for or missing loved ones, heightened fear, intense anxiety, negative affect, aggression, obedience and withdrawal.

Conclusions

These findings indicate that catatonia mirrors the fight, flight, freeze and fawn reaction induced by extreme fear, anxiety or distress. Suggested psychological interventions include supportive, behavioural and cognitive behavioural strategies.

Trial registration:

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Psychology

Psychiatry

Catatonia

psychological

subjective

fear

anxiety

withdrawal

obedience

Catatonia interferes with a patient’s ability to communicate, especially when an episode is severe, protracted, or characterized by prominent mutism, excitement, or speech oddities [1]. This means patients are often unable to describe their experiences during an acute episode. In this paper, we explore the catatonic experience using self-reports collected during at follow-up from participants who screened positive for catatonia.

The psychological experience of catatonia: Patients with catatonia describe experiencing very intense emotional states. In the Northoff et al. [2] paper on the subjective experience of catatonia, 24 patients with catatonia provided self-reports at the 3-week point following an episode of catatonia. Their experience was less focused on the change in their movements and more on the change in their cognitive or affective experience. This included intense emotions that could not be controlled. There was also ambivalence, which correlates with one of the signs that may be observed in catatonia, namely ambitendency. This is the motor manifestation of being caught in two opposing actions at the same time. Northoff et al. [2] went on to categorize domains for assessment of the subjective experience of catatonia, which included the patient’s subjective description of their altered motor function, their interaction with their environment, and their emotional and cognitive experiences during the catatonic episode.

Rosebush and Mazurek [3] found that most patients felt very anxious during the catatonic episode, and 15% thought they were either already dead or were going to die. Shorter and Fink [4] and Moskowitz [6] characterized catatonia as a state of extreme fear that manifests as freezing, like that seen in some animals who respond with immobility or freezing when faced with danger. Shorter and Fink [4], address this in their book on catatonic stupor, The Madness of Fear, and ask whether catatonia is a mostly a neurological phenomenon with no psychological explanation behind it or whether it is a case of the mind remaining active during catatonia, even though one is unable to communicate.

From the 1900, catatonia was postulated to have a psychology of its own with symptoms seen as symbolic of underlying psychological drivers [4]. Around the same time, Wernicke proposed the concept of motor psychosis which was understood to view catatonia as ໿“abnormalities of motion and of speech which were independent of thought or will” [4]. Northoff postulated that it was the intensity of emotions, whether positive (as in catatonic excitement) or negative (as in catatonic stupor), that triggered catatonia [4].

Fear or a heightened state of anxiety have also been described during a catatonic episode [1–8]. This intense anxiety may be observable and accompanied by a sense of impending doom with the patient feeling that they will die. Some patients may even believe that they are already dead [8, 9].

Based on the limited studies available on patient reports about the catatonic episode, the main psychological drivers and subjective experiences of catatonia have been around intense negative emotions like fear and heightened anxiety. Novak et al. [9], postulate that one may look at catatonia from an evolutionary perspective, meaning, this is a survival mechanism, applied when there is perceived impending danger. This is similar to what Northoff [1], Shorter and Fink [4], Rosebush and Mazurek [3], and Moskowitz [5] also postulate. So, although there is still scanty literature on the psychological impact of catatonia and the subjective experience as described by patients, what is available does seem to implicate fear circuits and somehow involves the perception of immediate danger or threat that the patient perceives.

To understand this better, and also how catatonia might fit into this theory of being fear- and danger-driven, one can compare the response to fear in humans to the response seen in animals. Whether in humans or animals, it may manifest as the fight-flight-freeze response that has been described as a built-in defense mechanism triggered by fear or trauma, whether physical or psychological. Walter Cannon, a medical doctor and physiologist who studied the stress response, first described this observation back in 1915, as quoted by Quick and Spielberger [10].

Cannon’s research and pioneering work on stress and how it affects the human psyche and physical state, served to advance the study of psychosomatic medicine, highlighting how a persons’ psychological state could affect their physical health [10]. He also highlighted the response to stress and how it can drive behavior, including how danger, or conditions that generate a stress response, can evoke heightened feelings of anxiety and anger accompanied by an autonomic nervous system reaction with all its involuntary bodily changes [11]. This then drives the fight-or-flight response. Cannon’s work has been studied and expanded upon over the years and this reaction is now recognized to potentially also include the freeze-and-fawn responses, which are also linked to the same defense system against fear- or anxiety-inducing stimuli [12]. This fear reaction is explained below:

Fight – this entails facing the danger and fighting the threat aggressively.
Flight – this implies running away from the threat to try and save yourself.
Freeze – this is equivalent to playing dead through immobility until the threat passes.
Fawn – This is the submissive response which serves to avoid conflict [12, 13].

Relevance of catatonia to psychology

The medical approach to treatment emphasizes biopsychosocial interventions. Interventions for catatonia, however, are solely biological until the acute catatonic episode has settled. Psychological interventions are usually reserved for intervention until after the acute catatonic episode. Interventions like specific psychotherapies are then tailored to the underlying condition driving the catatonia.

If one accepts that the drivers of the catatonic response include fear or extreme anxiety, then the signs of catatonia may be recognized as the range of responses one gets in response to danger, as described by Cannon and expanded on by others [12, 13, 14]. Signs of catatonia, like withdrawal, immobility, and stupor, may be equivalent to the freezing aspect of the stress response; negativism and combativeness to the fight response; and automatic and passive obedience to the fawn reaction.

Having laid out the drivers of catatonia and the psychological impacts of intense emotions like fear and anxiety, one can anticipate the role that psychological interventions might play in the management of acute catatonia and in the prevention of catatonia, especially in vulnerable or at-risk individuals. By combining this knowledge with the risk profile that one could build based on the findings earlier studies conducted at the site on prevalence and risk factors of catatonia, one might be able to find applicability for psychological interventions that target the management of stress, anxiety, and fear. Catatonia responds to specific biological treatments like benzodiazepines and ECT, irrespective of the underlying cause. Similarly, one could use psychological interventions in acute catatonia to help patients manage the intense negative emotions that accompany catatonia, irrespective of the cause.

If one looks at the available evidence, one can conclude that an acute episode of catatonia is possibly the ideal time to offer psychological interventions because this is the point at which the patient may be experiencing their most intense negative emotions. This may be the ideal time to support patients with anxiety and fear management techniques to help them gain control over their reactions.

Based on the evidence by Northoff [1], Fink and Taylor [4, 15], Rosebush and Mazurek [3], and Moskowitz [5], one expects reports of fear and anxiety with different aspects that fit into the fight, flight, freeze, or fawn response to be at the forefront of participants’ self-report. The design of the enquiry undertaken in this part of the thesis was qualitative and exploratory so as not to lead participants but to rather let them set the themes for the emotive, cognitive, and behavioral experiences and responses during the catatonic episode.

Based on data from previous studies that indicate that patients are aware of their emotive and cognitive experiences during the non-communicative stage of acute catatonia, one could assume that they would be able to understand and engage with supportive interventions targeted at re-assurance and focused on helping them to manage overwhelming fear and anxiety.

This study was conducted as a complementary part of an overall study on prevalence of catatonia and aimed at researching the psychological experience of participants who had screened positive for catatonia during the prevalence study.

Aim

The aim was to explore the psychological and subjective experience of catatonia as reported by participants who were admitted during a catatonic episode to an acute mental health unit in Dora Nginza Hospital.

Objectives

The objectives were to re-assess participants who were admitted with catatonia during a 12-month prevalence study, at four to eight weeks after discharge, and to collect data on their cognitive and emotive experience during the catatonic episode.

Study design

This part of the study used a prospective qualitative exploratory method to collect descriptions of the cognitive, emotive, and behavioral changes that participants experienced during the catatonic experience four to eight weeks after discharge.

Setting

The study was in an acute mental health unit within a regional hospital in Nelson Mandela Bay in the Eastern Cape, a metro with a population of 1.2 million people [14]. Challenges like unemployment, poverty, and substance abuse, contribute to the mental health disease burden in the region [15]. Referrals to the MHU are from departments like Internal Medicine, Accident and Emergency, Obstetrics and Gynecology, Pediatrics and Child Health, and Family Medicine in the hospital. The MHU has 35 beds with a multidisciplinary team that offers assessment and interventions, including electroconvulsive therapy.

Study process

All patients diagnosed with catatonia in the mental health unit were reviewed at the psychiatry outpatient clinic four to eight weeks after discharge. Participants were assessed by the research team, using the Bush Francis Catatonia Rating Scale (BFCRS) and DSM-5 (Diagnostic and Statistical Manual-5) and the follow-up section of the data collection sheet used for the catatonia prevalence study, to screen for recurrence of catatonia. Any patient who screened positive for recurrence of catatonic symptoms was referred back to the treating team for further management.

Participants

Participants were drawn from the 44 patients who had screened positive for catatonia during the prevalence study. Thirty (68.2%) of them could be traced at follow-up for inclusion in this part of the study.

Assessment tools

The BFCRS and a pre-designed data collection sheet were used to assess participants and collect data. In the data sheet, participants were required to describe their experience during the catatonic episode through providing an account of the experience in their own words, as well as what their thoughts, feelings, and behavior were during the catatonic episode.

Sampling

Convenience sampling was conducted of patients who had consented to take part in the catatonia prevalence study.

Inclusion criteria

Patients who had been admitted with catatonia during the study period from September 2020 to end of August 2021.

Exclusion criteria

Participants who refused consent at any point of data collection were excluded as well as any participants whose catatonia had not resolved due to the limitations with communication that may often be associated with active catatonia.

Data management and analysis

The study took a qualitative narrative approach to explore the subjective experience of catatonia through interviews conducted with participants who had catatonia and field notes recorded during the outpatient assessments to gain an in-depth description of the participant’s experience of catatonia. This is an approach that collects stories about people’s experience or life events; in this instance, the focus was the lived experience of catatonia which was severe enough to require hospitalization [16, 17].

A thematic analysis of the data was conducted using the Braun and Clarke approach which has also been supported by others with themes identified through word repetition, metaphors, similarities, and keywords [18, 19, 20]. This process contributed to establishing a tentative hypothesis and theory regarding the emotive, and cognitive experience of catatonia in this cohort.

The data were analyzed in two sessions. For the first session, the researcher, assisted by two research assistants, organized the data into categories of thoughts, feelings, and behaviors of all 30 participants pooled together. Further analysis as guided by the consolidated criteria for reporting qualitative research (COREQ) was undertaken [21]. A decision tree on the processing and categorization of participant responses is reflected in Fig. 1.

In the second session we analyzed the three categories of feedback further to reach a consensus on the interpretations of keywords, similarities, repetition, and metaphors. Further, we looked for linguistic emerging themes. The process was repeated once more until data saturation was achieved on all three categories.

Thirty (68.2%) of the 44 participants who screened positive for catatonia were included in the follow-up assessment. We found that all participants used accessible, everyday language for their descriptions, which made it possible to reach consensus on the meaning of words or phrases used. Thus, we were able to compile a consensus list in each category, which highlighted keywords and themes.

Thoughts

Up to 24 (80%) of the 30 participants expressed a preoccupation with thoughts of missing close family members or loved ones and a yearning to be with them. More often than not, these would be mothers or grandmothers. Some of the missed family members or close loved ones (a best friend in one case) had passed away close to the time of admission. Table 1 shows some of the thoughts described by participants which they had during the catatonic episode.

The six (20%) participants who did not describe missing family members or yearning for them described a preoccupation with fear or anxiety (five of the six participants), death (two of the six participants), and loneliness (one participant). Five (16.7%) of the participants described that they did not know what was happening or were confused about what was happening to them. This implied a possible lack of awareness of just how sick they were and what their symptoms were.

Feelings

The most commonly recurring feeling described by participants was that of deep sadness or depression in 13 (43.3%) of the 30 cases, and a feeling of yearning for or missing family members and loved ones. The sadness or depression was described even in cases where the diagnosis of the underlying condition was not indicated as depression or appeared to be mainly psychosis or mania. Next, in seven (23.3%) of the 30 participants, feelings of fear or feeling very anxious or panicky were described. Some patients described feeling both deep sadness and fear. When compared to thoughts, only five participants described experiencing a preoccupation with fear in their thoughts, but when correlated to the feelings described, up to seven of the participants described feeling very scared during the catatonic episode.

Other recurring themes included feeling very lonely (two participants), lost (two participants), embarrassed (one participant), or feeling a sense of missing their mothers mostly and, to some extent, their grandmothers (9). One participant described a feeling of rejection and three (10%) participants described feelings of extreme anger or irritation. Three (10%) participants indicated feeling trapped, with one participant stating that he felt like he was in prison. There were also participants who described feeling lonely (three participants; 10%) or withdrawn (two participants; 6.7%). Participant descriptions of feelings during the catatonic episode are reflected in Table 2.

Behaviors

Some participants were vague about how their behavior was affected during catatonia, with some indicating they could not remember their behavior. The most frequently described behaviors were cooperative (9; 30%), followed by obeying commands of treatment team (seven participants; 23.3%), sitting still or withdrawing (six participants; 20%), and being restless and or shouting and angry (three participants, 10%). Two (6.7%) participants described that they ignored everything and everyone and another said he could not move nor express himself even though he wanted to. Table 3 describes some of the behaviors reported by participants that occurred during the catatonic episode.

Summary of findings

Thirty (68.2%) of the 44 participants with catatonia provided data on their thoughts, feelings, and behaviors during the catatonic episode. The dominant themes across thoughts, feelings, and behaviors centered around yearning for/missing loved ones with heightened fear, anxiety, and negative affect and associated behaviors being characterized by withdrawal and overly cooperative (submissive) behaviors. Other themes included feeling trapped, embarrassed, or rejected, and a preoccupation with death. Table 4 provides a summary of the emergent themes as described by participants.

The lived experience of catatonia described by participants reflects main themes of heightened fear, anxiety, and withdrawal emerging from this explorative work. This echoes descriptions by other researchers who have also explored this aspect; specifically, that of a state of heightened fear and/or anxiety [1–5]. These descriptions have equated the catatonic state to the freezing seen in some animals when overwhelmed by fear. The stillness of movement described by some participants who were conscious of experiencing this change in their behavior during the catatonic state may also be seen in this context .

When one considers the diagnostic criteria of the DSM-5 for catatonia, or the positive screening items of the BFCSI (Bush Francis Catatonia Screening Instrument), then this subjective description matches the slowed movement or stupor which are central to the diagnosis of catatonia. Up to nine (30%) of the 30 participants described some form of stillness, withdrawal, or not talking. In the catatonia prevalence study conducted at the study site, mutism was observed in (27) 61% of the 44 catatonic participants and stupor in 16 (36.4%) of them [22]. When one compares these findings on the reported subjective experience of catatonia to the objective findings of the catatonia prevalence study, nine participants, i.e., 33% of the 27 with mutism or 56.3% of the 16 with stupor, had a conscious awareness of the changes in their interactions with others or in their movements.

Another aspect worth noting is that 16 (53.3%) participants described that they were cooperating or “following commands” of the nursing staff. Firstly, this could be viewed as submission (or fawning), a defense seen in some animals in reaction to an external fearful stimulus or threat. Adams [23] described this type of animal behavior first, decades ago and more recently Dixon [24 and Reddon et al. [12] have expanded on this idea by describing it as an aggression avoidance or “saving” defense which is against the cost that aggression could bring to the animal should it be attacked after failure to submit. Dixon also highlighted the link to psychiatric disorders, linking it to signs and symptoms of depression which may in themselves be akin to the withdrawal seen in catatonia. Indeed, one of the underlying causes of catatonia is depression. Animals can thus switch from offense (fight) to submission (fawn), a reaction which is thought to be modulated via the ventromedial hypothalamus in rats and is thought to be similar in primates. This is also in line with the conceptualization by Shorter and Fink [4] of catatonia as a defense adaptation when one feels under threat, whether real or perceived.

Secondly, “automatic obedience” and “mitgehen” (extreme automatic obedience) are some of the signs contained in the BFCRS which, when present, are indicators of severity. These are not included specifically as diagnostic criteria for catatonia in the DSM-5. Again, when comparing the results of this study with the results of the assessment and prevalence of catatonia studies in the same cohort, one notes that automatic obedience and mitgehen were picked up by the assessors in two (4.5%) of the 44 participants screened for catatonia [22, 25]. The fact that there were up to 16 participants (53.3% of the 30 and 36.4% of 44) who reported some degree of obedience when describing their subjective experience of catatonia implies that even though these signs could be objectively observed in two (4.5%) of the 44 participants from the original cohort, more participants experienced some form of obedience and held an awareness of this change in their behavior.

Lastly, because sadness features prominently along with a yearning for loved ones and family members, this highlights a possible target area for intervention where the treating team could work with family and loved ones to support patients with catatonia. This could include running psycho-education sessions for patients and relatives, which may be complemented with short, well-timed family visits to maintain ongoing contact with loved ones even in the face of acute symptoms. This should be possible for patients with the retarded form of catatonia, especially if the relatives are willing to take part in some of the basic physiotherapeutic exercises that patients often must undertake to prevent the development of deep vein thrombosis or contractures. Cognitive strategies that target fear and anxiety could also be offered earlier in the treatment of catatonia.

Significance of findings and clinical applications

Understanding the subjective experience of patients with catatonia is important due to the value it brings to planning of interventions for people with catatonia. The focus is usually on medications and ECT. There may therefore be unmet needs when it comes to the psychological interventions for catatonia. Current research reflects this in that there are no suggested psychological interventions for catatonia. The findings in our study suggest the possibility of early introduction of behavioural and cognitive strategies as well as cognitive behavioural therapy (CBT) as soon as the catatonia has settled may be of some benefit in helping patients to manage the strong negative emotive experiences of catatonia. This is based on the current evidence of CBT for symptoms of anxiety, and it remains the psychologic treatment of choice for the majority of anxiety disorders [26–29]. This would also mean that instead of waiting until full remission of catatonia, which is the current practice, one would need to involve the psychology team in the multidisciplinary team management of the patient with catatonia earlier on. This could support the development of rapport earlier on and may be very useful in development of insight about the drivers of catatonic symptoms. As observed earlier, catatonia seems to be the one state where the psychological intervention is reserved until late into the condition.

Shah and Wing [30] suggested screening for precipitating stressors and targeting these through lifestyle and environmental changes coupled with stress reduction measures may help catatonic patients. These measures may be useful in the intermediate and long term but may not necessarily address catatonic symptoms in the acute stages since the nature of the presentation is such that communication is impaired. Even with the problems in communication however, some patients indicated a retained ability to follow what was going on around them.

Recommendations

The data presented in this current study imply a sense of heightened noxious emotive and cognitive experiences which implies suffering and distress. A possible approach for non-pharmacological interventions for catatonia could be to focus on broad interventions that target the immediate relief of distress due to fear and anxiety. This is postulated to be one of the many reasons why benzodiazepines are so effective for catatonia since they are anxiolytic. Other supportive measures for reducing anxiety and hyperarousal could be:

nursing in a quiet environment.
allocating core regular staff to manage the patient to allow for familiarity to develop relatively quickly.
always adopting a reassuring, approach when interacting with the patient.
providing well-timed, simplified, and regular feedback on the management plan (e.g., “Today is Tuesday. The doctor will review your treatment with you today,” “Today is Tuesday. Mary, the occupational therapist will be seeing you today,” or “Sipho, you seem to be having a better day this Tuesday” etc.).
using language without jargon when talking to the patient re-enforcing orientation whenever possible.
providing reasons for admission and a simplified plan for the day so that the patient has assurance about predictability to his immediate environment. See Table 5 for details on recommendations.
As anxiety and fear settle, use behavioural/cognitive behavioural techniques to help the patient manage overwhelming emotions and thoughts.

Strengths

This study presents data on the neglected and under-researched aspects of the psychological experiences of catatonia as described by patients.

Limitations

The qualitative method applied in this section collected subjective reports from patients one to three months after admission. Data collection therefore relied heavily on the participants’ ability to recall details of their admission, which had happened weeks prior to the interview. There is a possibility that recall may not always be accurate. What was striking, however, was the similarity in some of the experiences reported by participants, especially because the follow-up assessments were conducted on a one-on-one basis. Since many of the participants ended up describing the same cognitive, emotive, or behavioral manifestations in response to the open-ended questions and requests to share their experience, this lends a degree of reliability to the findings.

This exploratory investigation into the subjective experience of catatonia has unearthed clinically relevant data on the cognitive, emotive, and behavioral aspects of catatonia. Additionally, it has identified themes of heightened fear, anxiety, and sadness with a tendency to withdraw from interactions with others and/or to become over compliant to external stimuli, a behavior postulated to be akin to the offense versus submissive defense employed by animals against aggression or threat.

BFCSI - Bush Francis Catatonia Screening Instrument

DSM-5 - Diagnostic and Statistical Manual-5

Stats SA – Statistics South Africa

Ethics approval and consent to participate

This study received ethics approval from Nelson Mandela University, with reference H20-HEA-PSY-002

Consent for publication

Not applicable

Availability of data and materials

All data are stored at the study site and are available on request from the lead author at Nelson Mandela University, Executive Dean’s Office.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the South African Medical Research Council (grant tracking number: 2017SAMRC0SIR0000157977) and an educational grant from the Health and Welfare Sector Education and Training Authority (2018/2019HWSETA219986789).

Authors’ contributions

ZZ conceptualized the idea, collected the and analyzed the data and wrote the manuscript. SvW & MF contributed equally and supported conceptualization and editing of the manuscript. JC & LS contributed to supervision and editing of the manuscript.

Acknowledgements

The authors thank Mrs. Tyalimpi, Dr. Tshona, Dr. Beltran, Mr. Moni, Miss Mrwebi, and Miss Siphika for their support with the data collection; Miss Ncumisa Joko and Miss Hedwick Masomera for administrative study support; Miss Jolene Schaefer for supporting the editing process and Miss Carmen Stindt for the valuable comments and assistance in the data analysis.

Authors' information

ZZ is a specialist psychiatrist, was a previous chair of psychiatry and is currently Executive Dean of a faculty of health sciences with an interest in catatonia, LS and JC are Associate Professors in the Department of Psychology, SvW is Acting chair of Psychiatry with clinical and research experience in catatonia and MF is Emeritus Professor of Psychiatry with extensive research and clinical experience in catatonia.

Northoff G. Catatonia and neuroleptic malignant syndrome: psychopathology and pathophysiology. Journal of Neural Transmission. 2002; 109: 1453–1467.
Northoff G, Krill W, Wenke J, Pflug B. The subjective experience in catatonia: Systematic study of 24 catatonic patients. Psychiatr Prax. 1996;23:69–73.
Rosebush PI, Mazurek MF. Catatonia and its treatment. Schizophr Bull. 2010;36:239–42.
Shorter E, Fink M. The madness of fear. Oxford, UK: Oxford University Press; 2018.
Moskowitz AK. "Scared Stiff": catatonia as an evolutionary-based fear response. Psychol Rev. 2004;111:984–1002.
Caroff SN, Ungvari GS. Expanding horizons in catatonia research. Psychiatr Ann. 2007;37:7–9.
Daniels J. Catatonia: clinical aspects and neurobiological correlates. J Neuropsychiatry Clin Neurosci. 2009;21:371–80.
Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatry. 2016;6:391–8.
Novac AA, Bota D, Witkowski J, Lipiz J, Bota RG. Special medical conditions associated withc atatonia in the intrenal medicine setting: hyponatraemia-inducing psychosis and subsequent catatonia. The permanente Journal. 2016, 18 (3): 78–81.
Quick JC, Spielberger CD. Walter bradford cannon: pioneer of stress research. Int J Stress Manag. 1994;1:141–3.
Frothingham MB. Fight, flight, freeze, or fawn: what this response means. Simply Psychol. https://www.simplypsychology.org/fight-flight-freeze-fawn.html. 2021. Accessed 31 Jan Feb 2022
Reddon AR, Ruberto T, Reader SM. Submission signals in animal groups. Behaviour. 2021;159:1–20.
Fink M, Taylor MA. Catatonia: a clinician's guide to diagnosis and treatment. Cambridge, UK: Cambridge University Press; 2003.
Stats SA. 2021. Statistics South Africa: (2020). Nelson Mandela Bay [Internet]. Republic of South Africa. 2011 [cited25Octobet2021]. Available from: http://www.statssa.gov.za/?page_id=1021&id= nelson-mandela-bay-municipality. Accessed on 31 Jan 2022.
Thungana Y, Zingela Z, van Wyk S. First-episode psychosis and substance use in Nelson Mandela Bay: Findings from an acute mental health unit. S Afr J Psychiatry. 2019;25:1372.
Mapp T. Understanding phenomenology: the lived experience. Br J Midwifery. 2013;16. doi:10.12968/bjom.2008.16.5.29192.
Imani B, Zandi S, Khazaei S, Mirzaei M. The lived experience of HIV-infected patients in the face of a positive diagnosis of the disease: a phenomenological study. AIDS Res Ther. 2021;18:95.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
Creswell JW. Research design: qualitative and mixed methods approaches. London: Sage; 2009.
Elkatawneh HH. The five qualitative approaches: problem, purpose, and questions/the role of theory in the five qualitative approaches/comparative case study. SSRN Electron J. 2016. doi:10.2139/ssrn.2761327.
Allison Tong, Peter Sainsbury, Jonathan Craig, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, International Journal for Quality in Health Care, Volume 19, Issue 6, December 2007, Pages 349–357, https://doi.org/10.1093/intqhc/mzm042
Zingela Z, Stroud L, Cronje J, Fink M, van Wyk S. Assessment of catatonia and inter-rater reliability of three instruments: a descriptive study. Int J Ment Health Syst. 2021;15:82.
Adams DB. Brain mechanisms for offense, defense, and submission. Behav Brain Sci. 1979;2:201–13.
Dixon AK. Ethological strategies for defence in animals and humans: their role in some psychiatric disorders. Br J Med Psychol. 1998;71:417–45.
Zingela Z, Stroud L, Cronje J, Fink M, van Wyk S. A prospective descriptive study on prevalence of catatonia and correlates in an acute mental health unit in Nelson Mandela Bay, South Africa. PLoS One Psychiatry. 2020. doi:10.1136/bmjopen-2020-040176.
Loerinc, A.G., Meuret, A.E., Twohig, M.P., Rosenfield, D. Bluett, E.J., & Craske, M.G. (2015). Response rates for CBT for anxiety disorders: Need for standardized criteria. Clinical Psychology Review, Volume 42, Pages 72–82
Luong, H.K., Drummond, S.P.A., & Norton, P.J. (2020). Elements of the therapeutic relationship in CBT for anxiety disorders: A systematic review. Journal of Anxiety Disorders, (76).
Otte, C. (2012). Cognitive behavioural therapy in anxiety disorders: current state of evidence. Dialogues in Clinical Neuroscience, vol 13 (4), 413.
Springer, K. S., Levy, H. C., & Tolin, D. F. (2018). Remission in CBT for adult anxiety disorders: A meta-analysis. Clinical psychology review, 61, 1–8. https://doi.org/10.1016/j.cpr.2018.03.002
Shah A, Wing L. Psychological approaches to chronic catatonia-like deterioration in autism spectrum disorders. Int Rev Neurobiol. 2006;72:245–64.

Table 1. Thoughts experienced during a catatonic episode

Description of Thoughts

“Missing my mother”

“Missing my mother and my family”

“Missing my family”

“Missing my grandmother who passed away”

“Missing my grandmother and my kids”

“Thinking of my home, my father, my mother, and my family”

“I was wondering why I was there”

“I was wondering why I was admitted and not with my family”

“Death. Not caring about anything, even my children. Not knowing what was to come next”

“Thinking of my mother; thinking that something bad was going to happen”

“I was asking myself why I was here in hospital”

“They are coming to attack me”

“I will be killed”

“They are avoiding me” (other patients and staff)

Table 2. Feelings during an acute catatonic episode

Description of Feelings

“Not safe”

“I was scared”

“I felt sad”

“I was depressed”

“Very anxious”

“Panicky”

“Lonely”

“Embarrassed”

“Rejected”

Table 3. Behavior during catatonic episode

Description of Behavior

“I followed the staff commands”

“I cooperated with everything”

“Sitting still”

“I kept to myself”

“Kept very quiet”

“Sat still and keeping to myself”

“Not talking about anything”

“Not able to express myself”

“Cooperating and keeping to myself”

“Restless and shouting”

“Obeying. Doing what I was asked”

Table 4. Summary of emerging themes describing the subjective experience of catatonia

Summary of emerging themes from subjective descriptions of catatonia

Thoughts

Feelings

Behaviors

Fear

Yearning (Missing)

Confusion/trying to make sense of things

wondering about

death

Fear/scared/panicked/anxious

Sad and/or anxious

Confused

Trapped

Embarrassed

Rejected

Obeying commands

Cooperating with the staff (submission)

Withdrawn/keeping to self

Sitting still

Not talking

Table 5. Subjective experience of catatonia and summary recommendations for clinical practice

Experience during catatonia	Recommended Non-pharmacological interventions
Fear and Anxiety	nursing in a quiet environment with low levels of potentially stressful stimuli. allocating regular staff to nurse the patient to allow for familiarity and recognition to develop relatively quickly. taking a reassuring, non-demanding approach to interacting with the patient during the catatonic state. Emphasizing reassurance about safety of the environment and the caring aspect of the members of the multidisciplinary team involved in the patient’s management. Open, non-threatening and reassuring demeanour at all times to help in reassuring patients Open sharing of all information regarding intervention plans for care using basic, easy to follow language to ensure there is no confusion. This should be done irrespective of whether the patient is communicative or not.
Yearning for family	Psychoeducation sessions with family Short contact sessions for reassurance re ongoing family support. Increase contact with family and loved ones when aggressive outbursts decrease if patient displays any and explain this link to the patient as well i.e., it is for their safety and the safety of others. Family mediated exercise interventions and support with activities of daily living (supported by a psychotherapist and occupational therapist)
Confusion about orientation and reasons for admission	providing well-timed, simplified and regular feedback on the management plan (e.g., “Today is Tuesday. The doctor will review your treatment with you today”, or “ “Today is Tuesday. Mary, the occupational therapist will be seeing you today”, “Sipho, you seem to be having a better day this Tuesday”, etc. using simple, non-jargon language when talking to the patient and taking opportunities to re-enforce orientation and reasons for admission whenever they present themselves (as in the simple examples provided above). reasons for admission and the plan for the day should be conveyed at every patient contact to help lend a degree of predictability to the patient’s immediate environment.

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The psychological and subjective experience of catatonia

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Abstract

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