Perinatal Catatonia: A Case Report and Literature Review

Author's Accepted Manuscript

Perinatal Catatonia: A Case Report and Literature Review Nina Gonzales M.D., Davin Kenneth Quinn M.D. , William Rayburn M.D.

PII: DOI: Reference:

S0033-3182(14)00014-0 http://dx.doi.org/10.1016/j.psym.2014.01.009 PSYM435

To appear in:

Psychosomatics

Cite this article as: Nina Gonzales M.D., Davin Kenneth Quinn M.D., William Rayburn M.D., Perinatal Catatonia: A Case Report and Literature Review, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2014.01.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

AttachedismanuscriptIDPsycho13110373.R1.  ManuscriptID:Psycho13110373.R1  ManuscriptType:ReviewArticle  ManuscriptTitle:PerinatalCatatonia:ACaseReportandLiteratureReview  CorrespondingAuthor:Dr.NinaGonzales  SubmittingAuthorContactInformation:Dr.Gonzales,NinaMSC095030 1UniversityofNewMexico Albuquerque NewMexico UnitedStates 87131 Tel:5052722223  OriginalSubmittedDate:27Nov2013  SubmittedDate:20Jan2014  RevisedDate(ifapplicable):20Jan2014  AcceptedDate:20Jan2014  AllAuthor(s):Gonzales,Nina;Quinn,Davin;Rayburn,William  AllAuthor(s)Email:[email protected],[email protected], [email protected] 

 

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ˆ‘”˜ƒ‰‹ƒŽ„Ž‡‡†‹‰Ǥ ‘ŽŽ‘™‹‰ƒ–‘–ƒŽ‘ˆ–‡–”‡ƒ–‡–•ǡ•ǤŠƒ†‘–ƒ„Ž‡ ‹’”‘˜‡‡–‘ˆƒˆˆ‡…–ǡƒ’’‡–‹–‡ƒ†’‡”•‘ƒŽŠ›‰‹‡‡Ǥ’‡‡…Š‹’”‘˜‡†ˆ”‘‡ƒ”Ž›—–‡ –‘Žƒ–‡–ƒ†‹’‘˜‡”‹•Š‡†ǡƒ†Š‡”‡‰ƒ–‹˜‹•”‡•‘Ž˜‡†ǤŠ‡™ƒ•†‹•…Šƒ”‰‡†–‘Š‘‡™‹–Š Š‡”Š—•„ƒ†‘•‡”–”ƒŽ‹‡ƒ†ŠƒŽ‘’‡”‹†‘ŽǤ  ™‘‘–Š•ˆ‘ŽŽ‘™‹‰†‹•…Šƒ”‰‡•Ǥ’”‡•‡–‡†ƒ‰ƒ‹–‘ƒ‡‡”‰‡…›†‡’ƒ”–‡–™‹–Š ”‡–—”‘ˆ†‡’”‡••‹˜‡ƒ†…ƒ–ƒ–‘‹…•›’–‘•ƒ–͵ͻ™‡‡•‰‡•–ƒ–‹‘Ǥ—”‹‰‡˜ƒŽ—ƒ–‹‘•Ǥ …‘’Žƒ‹‡†‘ˆ…‘–”ƒ…–‹‘•ƒ†™ƒ••—„•‡“—‡–Ž›–”ƒ•ˆ‡””‡†–‘ƒƒ…ƒ†‡‹…–‡”–‹ƒ”›…ƒ”‡ Š‘•’‹–ƒŽƒ†ƒ†‹––‡†–‘–Š‡ƒ–‡”ƒŽǦˆ‡–ƒŽ‡†‹…‹‡•‡”˜‹…‡ˆ‘”’‘••‹„Ž‡’”‡–‡”Žƒ„‘”Ǥ •›…Š‹ƒ–”‹……‘•—Ž–ƒ–‹‘™ƒ•‘„–ƒ‹‡†ˆ‘”ƒ••‹•–ƒ…‡™‹–Šƒƒ‰‡‡–ƒ•™‡ŽŽƒ• †‡–‡”‹ƒ–‹‘‘ˆ†‡…‹•‹‘ƒŽ…ƒ’ƒ…‹–›ǡƒ••Ǥ™ƒ•”‡“—‡•–‹‰–‘‰‘Š‘‡ƒ‰ƒ‹•–‡†‹…ƒŽ ƒ†˜‹…‡ǤŠ‡™ƒ•†‡‡‡†–‘‘–Šƒ˜‡†‡…‹•‹‘ƒŽ…ƒ’ƒ…‹–›ƒ••Š‡™ƒ•—ƒ„Ž‡–‘ƒ’’”‡…‹ƒ–‡–Š‡ ”‹••‘ˆ”‡ˆ—•‹‰–”‡ƒ–‡–Ǥ•Ǥǯ•‘–Š‡”™ƒ•ƒ’’‘‹–‡†•—””‘‰ƒ–‡†‡…‹•‹‘ƒ‡”ˆ‘”Š‡” ‡†‹…ƒŽ†‡…‹•‹‘•—†‡”•–ƒ–‡Žƒ™ǡƒ•Š‡”Š—•„ƒ†™ƒ•—ƒ„Ž‡–‘„‡”‡ƒ…Š‡†Ǥ•›…Š‹ƒ–”›ƒ† ƒ–‡”ƒŽǦˆ‡–ƒŽ‡†‹…‹‡†‹•…—••‡†–Š‡”‹••ƒ†„‡‡ˆ‹–•‘ˆ‹‡†‹ƒ–‡ƒ‰‰”‡••‹˜‡ ’•›…Š‹ƒ–”‹……ƒ”‡ƒ•™‡ŽŽƒ•–Š‡”‹••ƒ†„‡‡ˆ‹–•‘ˆ‹†—…–‹‘‘ˆŽƒ„‘”˜‡”•—•™ƒ‹–‹‰ˆ‘” •’‘–ƒ‡‘—•Žƒ„‘”Ǥ –™ƒ•ƒ‰”‡‡†‘„›„‘–Š–‡ƒ•–Šƒ–†‡Ž‹˜‡”›‘ˆ•Ǥǯ•ˆ‡–—•ˆ‘ŽŽ‘™‡†„› †‡ˆ‹‹–‹˜‡’•›…Š‹ƒ–”‹…–”‡ƒ–‡–‘ˆŠ‡”…‘†‹–‹‘”‡ˆŽ‡…–‡†–Š‡„‡•–„ƒŽƒ…‡‘ˆ‘„•–‡–”‹…ƒŽ ƒ†’•›…Š‹ƒ–”‹…”‹•ǡƒ••–ƒ†ƒ”†–”‡ƒ–‡–•‘ˆ…ƒ–ƒ–‘‹ƒ•—…Šƒ•„‡œ‘†‹ƒœ‡’‹‡•ƒ† …ƒ””‹‡†”‹••ˆ‘”–Š‡ˆ‡–—•Ǥ‡…ƒ—•‡•Ǥ™ƒ•‘‹ƒŽŽ›…‘‘’‡”ƒ–‹˜‡™‹–Šˆ‡–ƒŽ‘‹–‘”‹‰ ƒ†‡šƒ‹ƒ–‹‘ǡƒ–”‹ƒŽ‘ˆ•’‘–ƒ‡‘—•Žƒ„‘”™ƒ•—†‡”–ƒ‡Ǥ †—…‡†Žƒ„‘”ƒ†…‡•ƒ”‡ƒ •‡…–‹‘™‡”‡•–‹ŽŽ…‘•‹†‡”‡†‘’–‹‘•‹ˆ•Ǥ„‡…ƒ‡—ƒ„Ž‡–‘ˆ‘ŽŽ‘™…‘ƒ†•–‘’—•Š †—”‹‰•’‘–ƒ‡‘—•Žƒ„‘”ƒ†’—––Š‡ˆ‡–—•ƒ†Š‡”•‡Žˆƒ–”‹•‘ˆ…‘’Ž‹…ƒ–‹‘•‘ˆ†‡Ž‹˜‡”›Ǥ  ›ͶͲ™‡‡•ƒ†ͳ†ƒ›•ǤŠƒ†‘–•’‘–ƒ‡‘—•Ž›†‡Ž‹˜‡”‡†ǡ–Š‡”‡ˆ‘”‡Š‡”Žƒ„‘”™ƒ• ‹†—…‡†ǤŠ‡˜ƒ‰‹ƒŽŽ›†‡Ž‹˜‡”‡†ƒƒŽ‡‹ˆƒ–ǡ„‹”–Š™‡‹‰Š–™ƒ•͵ǡ͵ͻͷ‰”ƒ•ǡ’‰ƒ”•™‡”‡ ͺƒ†ͻǡƒ†‘…‘‰‡‹–ƒŽ†‡ˆ‡…–•™‡”‡‘–‡†Ǥ•Ǥ†‹†™‡ŽŽ‹–Š‡’‘•–’ƒ”–—’‡”‹‘†ƒ† ™ƒ•†‹•…Šƒ”‰‡†–‘–Š‡‹’ƒ–‹‡–’•›…Š‹ƒ–”‹…ˆƒ…‹Ž‹–›‘–Š‡ˆ‹”•–’‘•–’ƒ”–—†ƒ›ǤŠ‡…Š‘•‡ –‘‘–„”‡ƒ•–ˆ‡‡†–Š‡‹ˆƒ–ǤŠ‡„ƒ„›™ƒ•†‹•…Šƒ”‰‡†‹•ƒ–‹•ˆƒ…–‘”›…‘†‹–‹‘ǡ–‘„‡…ƒ”‡† ˆ‘”„›ƒƒ–‡”ƒŽƒ—–Ǥ  –Š‡‹’ƒ–‹‡–’•›…Š‹ƒ–”‹…—‹–ǡ•Ǥ™ƒ•ƒ‰ƒ‹‘–‡†–‘„‡‹•‘Žƒ–‹˜‡ǡ”ƒ”‡Ž›‰‡––‹‰‘—–‘ˆ „‡†ǡ™‹–Š‡‰ƒ–‹˜‹•ǡ—–‹•ǡƒ†˜‡”›’‘‘”Š›‰‹‡‡ƒ†ƒ’’‡–‹–‡Ǥ‡”–”ƒŽ‹‡™ƒ•–‹–”ƒ–‡† –‘ʹͲͲ‰†ƒ‹Ž›–‘–ƒ”‰‡–†‡’”‡••‹‘ƒ†ŠƒŽ‘’‡”‹†‘Ž–‘ʹǤͷ‰–™‹…‡†ƒ‹Ž›–‘–ƒ”‰‡– ’•›…Š‘•‹•Ǥ‘”ƒœ‡’ƒͳ‰„›‘—–Š–™‹…‡†ƒ‹Ž›™ƒ•‹–”‘†—…‡†ˆ‘”…ƒ–ƒ–‘‹…•›’–‘• ™‹–Š‹Ž†‹’”‘˜‡‡–‘ˆ„‘–Š‡‰ƒ–‹˜‹•ƒ†—–‹•Ǥ™ƒ•”‡‹‹–‹ƒ–‡†ˆ‘”ƒ–‘–ƒŽ‘ˆ ͳʹ–”‡ƒ–‡–•Ǥ ‘ŽŽ‘™‹‰—„‡”ͳͲǡ‹–™ƒ•ˆ‡Ž––Šƒ––”‡ƒ–‡–Šƒ†”‡ƒ…Š‡†ƒ’Žƒ–‡ƒ— ƒ†•Ǥǯ•‡†‹…ƒ–‹‘”‡‰‹‡™ƒ•ƒ—‰‡–‡†™‹–Š‹”–ƒœƒ’‹‡–‹–”ƒ–‡†–‘ͳͷ‰ƒ– „‡†–‹‡Ǥ‹–Š–Š‡ƒ„‘˜‡–”‡ƒ–‡–”‡‰‹‡•Š‡‹…”‡ƒ•‹‰Ž›ƒ’’‡ƒ”‡†„”‹‰Š–‡”ǡ™ƒ•Ž‡•• ‹•‘Žƒ–‹˜‡–‘Š‡””‘‘ǡŠ‡”Š›‰‹‡‡ƒ†ƒ’’‡–‹–‡‹’”‘˜‡†ǡƒ†‡‰ƒ–‹˜‹•”‡•‘Ž˜‡†Ǥ‡” •’‡‡…ŠǡŠ‘™‡˜‡”ǡ”‡ƒ‹‡†‹’‘˜‡”‹•Š‡†™‹–Š‘†‡”ƒ–‡Žƒ–‡…›ƒ†•Š‡–ƒŽ‡†‹‹ƒŽŽ› ƒ„‘—––Š‡„ƒ„›ǤŠ‡†‡‹‡††‡’”‡••‡†‘‘†ǡƒŠ‡†‘‹ƒǡ•—‹…‹†ƒŽ‹†‡ƒ–‹‘ǡƒ—†‹–‘”›Ȁ˜‹•—ƒŽ ŠƒŽŽ—…‹ƒ–‹‘•ǡ‘”’ƒ”ƒ‘‹ƒ–Š”‘—‰Š‘—–ƒ†‹••‹‘ǤŠ‡™ƒ•…‘—•‡Ž‡†ƒ„‘—–„‹”–Š…‘–”‘Ž ‘’–‹‘•„—–†‡…Ž‹‡†ƒŽŽ‡–Š‘†•ǤŠ‡™ƒ•†‡‡‡†„ƒ…–‘’”‡˜‹‘—•„ƒ•‡Ž‹‡ƒ† †‹•…Šƒ”‰‡†Š‘‡‹–‘–Š‡…ƒ”‡‘ˆŠ‡”‘–Š‡”ǤŠ‡ˆƒ–Š‡”‘ˆ–Š‡„ƒ„›™ƒ•‘Ž‘‰‡”‹˜‘Ž˜‡† ƒ––Š‹•–‹‡†—‡–‘—‘™”‡ƒ•‘•ǤŠ‡‹ˆƒ–…‘–‹—‡†–‘„‡–ƒ‡…ƒ”‡‘ˆ„›ƒƒ–‡”ƒŽ ƒ—–Ǥ––‡’–•™‡”‡ƒ†‡–‘…‘–ƒ…––Š‡’ƒ–‹‡––‘ˆ‘ŽŽ‘™—’‘Š‡”…‘†‹–‹‘ǡŠ‘™‡˜‡”ƒ– –Š‡–‹‡‘ˆ–Š‹•™”‹–‹‰–Š‡›Šƒ˜‡„‡‡—•—……‡••ˆ—ŽǤ 

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Discussionǣ ƒ–ƒ–‘‹ƒ‹•ƒ’•›…Š‘‘–‘”•›†”‘‡–›’‹…ƒŽŽ›…Šƒ”ƒ…–‡”‹œ‡†„›—–‹•ǡ•–—’‘”ǡ…ƒ–ƒŽ‡’•›ǡ ‡…Š‘’Š‡‘‡ƒǡ•–‡”‡‘–›’‹‡•ǡƒ†ƒ‡”‹••ʹǤ –…ƒ‘……—”‹–Š‡…‘–‡š–‘ˆ‡†‹…ƒŽǡ ‡—”‘Ž‘‰‹…ƒŽǡ‘”’•›…Š‹ƒ–”‹…†‹•‡ƒ•‡͵Ǥƒ–ƒ–‘‹ƒ‹•”ƒ”‡Ž›†‡•…”‹„‡†‹–Š‡…‘–‡š–‘ˆ ’”‡‰ƒ…›‘”–Š‡’‘•–’ƒ”–—’‡”‹‘†ǤŠ”‡‡…ƒ•‡•‡”‹‡•‘ˆ’‡”‹ƒ–ƒŽ…ƒ–ƒ–‘‹ƒ™‡”‡ ‹†‡–‹ˆ‹‡†‹–Š‡‡†‹…ƒŽŽ‹–‡”ƒ–—”‡ǣ‘„‡Ž‹ͳͻ͸Ͳ†‡•…”‹„‡†͵͵’”‡‰ƒ–’ƒ–‹‡–•™‹–Š Dz’•›…Š‘–‹…ƒ‰‹–ƒ–‹‘‘”…ƒ–ƒ–‘‹ƒdz–”‡ƒ–‡†™‹–ŠͶǤ•ƒŽŽʹͲͲͶ•–—†›‹ƒ‹™ƒ‘ˆͳͷ ’‘•–’ƒ”–—‡–ƒŽŽ›‹ŽŽ’ƒ–‹‡–•ˆ‘—†ƒ’”‡˜ƒŽ‡…‡‘ˆ…ƒ–ƒ–‘‹…ˆ‡ƒ–—”‡•‹–Šƒ–‰”‘—’‘ˆ ʹ͸Ǥ͸Ψȋˆ‘—”’ƒ–‹‡–•ȌͷǤ ‹ƒŽŽ›ǡƒʹͲͳ͵ †‹ƒ…ƒ•‡•‡”‹‡•†‡•…”‹„‡†ͳ͵’ƒ–‹‡–•™Š‘ ”‡…‡‹˜‡†ˆ‘”…ƒ–ƒ–‘‹…ƒ‰‹–ƒ–‹‘‹ƒ…‘Š‘”–‘ˆ͹ͺ’ƒ–‹‡–•’•›…Š‹ƒ–”‹…ƒŽŽ›Š‘•’‹–ƒŽ‹œ‡† ˆ‘”’‘•–’ƒ”–—’•›…Š‘•‹•ǡ›‹‡Ž†‹‰ƒ’”‡˜ƒŽ‡…‡‘ˆͳ͸Ǥ͹Ψ‹–Šƒ–’‘’—Žƒ–‹‘͸Ǥ•‡ƒ”…Š‘ˆ –Š‡‰Ž‹•ŠǦŽƒ‰—ƒ‰‡‡†‹…ƒŽŽ‹–‡”ƒ–—”‡‹–Š‡ƒ–‹‘ƒŽ‹„”ƒ”›‘ˆ‡†‹…‹‡†ƒ–ƒ„ƒ•‡ ȋ—„‡†Ȍˆ‘”–Š‡–‡”•̶…ƒ–ƒ–‘‹ƒ̶ƒ†̶’‡”‹ƒ–ƒŽǡ̶̶’‡”‹’ƒ”–—ǡ̶̶’”‡‰ƒ–ǡ̶̶’”‡’ƒ”–—ǡ̶ ̶ƒ–‡’ƒ”–—ǡ̶̶’‘•–’ƒ”–—ǡ̶ƒ†̶’—‡”’‡”ƒŽǡ̶ƒ†ƒƒŽ›•‹•‘ˆ”‡ˆ‡”‡…‡Ž‹•–•—…‘˜‡”‡† ͳͷƒ††‹–‹‘ƒŽ…ƒ•‡•‘ˆ…ƒ–ƒ–‘‹ƒ‘……—””‹‰†—”‹‰‘”ƒˆ–‡”’”‡‰ƒ…›ȋƒ„Ž‡ͳȌǤ‘†‹–‹‘• ƒ••‘…‹ƒ–‡†™‹–Š–Š‡…ƒ–ƒ–‘‹…•›†”‘‡‹–Š‡•‡…ƒ•‡•‹…Ž—†‡†‡—”‘Ž‡’–‹…ƒŽ‹‰ƒ– •›†”‘‡ǡ’ƒ”ƒ‡‘’Žƒ•–‹…Ž‹„‹…‡…‡’ŠƒŽ‹–‹•ǡƒ–›’‹…ƒŽ’‘•–‡”‹‘””‡˜‡”•‹„Ž‡‡…‡’ŠƒŽ‘’ƒ–Š›ǡ ‡…Žƒ’•‹ƒǡƒ†…‡”‡„”‘˜ƒ•…—Žƒ”†‹•‡ƒ•‡ǤŠ‡—‡š’‡…–‡†Ž›Š‹‰Š”ƒ–‡‘ˆ‘”‰ƒ‹…‡–‹‘Ž‘‰‹‡• ‹–Š‡‹†‹˜‹†—ƒŽ…ƒ•‡•ƒ›‹†‹…ƒ–‡ƒ‡‡†ˆ‘”Š‡‹‰Š–‡‡†…‘…‡”ˆ‘”—†‡”Ž›‹‰‡†‹…ƒŽ ƒ†‡—”‘Ž‘‰‹…ƒŽ…‘†‹–‹‘•™Š‡…Ž‹‹…‹ƒ•ƒ”‡ˆƒ…‡†™‹–Šƒ’‡”‹ƒ–ƒŽ…ƒ–ƒ–‘‹… ’ƒ–‹‡–Ǥ…Žƒ’•‹ƒǡ™‹–Š‹–•ƒ••‘…‹ƒ–‡†ƒ—–‘‘‹…‹•–ƒ„‹Ž‹–›ƒ†‡—”‘–‘š‹……‘’Ž‹…ƒ–‹‘•ǡ •Š‘—Ž†„‡•’‡…‹ˆ‹…ƒŽŽ›”—Ž‡†‘—–Ǥ‘–Š•‡‹œ—”‡•ƒ†’‘•–‡”‹‘””‡˜‡”•‹„Ž‡‡…‡’ŠƒŽ‘’ƒ–Š›ƒ”‡ ‘™•‡“—‡Žƒ‡ˆ”‘‡…Žƒ’•‹ƒƒ†ƒ›„‡ƒ••‘…‹ƒ–‡†™‹–Šƒ†‡˜‡…ƒ—•ƒ–‹˜‡‘ˆ …ƒ–ƒ–‘‹ƒ͹ǡͺǤ††‹–‹‘ƒŽŽ›ǡ–Š‡–”‡ƒ–‡–‘ˆ‡…Žƒ’•‹ƒ‹•‡‡”‰‡–†‡Ž‹˜‡”›‘ˆ–Š‡ ˆ‡–—•ͻǤ”‡…‡’–‘”‡…‡’ŠƒŽ‹–‹•™ƒ••’‡…‹ˆ‹…ƒŽŽ›†‹ƒ‰‘•‡†‹–Š”‡‡’”‡‰ƒ–’ƒ–‹‡–• ™‹–Š…ƒ–ƒ–‘‹…•›’–‘•ͳͲǢ•‡”‘Ž‘‰‹…ƒŽ•–—†‹‡•ǡƒ‰‡–‹…”‡•‘ƒ…‡‹ƒ‰‹‰‘ˆ–Š‡„”ƒ‹ǡ ‡Ž‡…–”‘‡…‡’ŠƒŽ‘‰”ƒ’Š›ǡƒ†…‡”‡„”‘•’‹ƒŽˆŽ—‹†ƒƒŽ›•‹••Š‘—Ž†„‡‘„–ƒ‹‡†‹•‹‹Žƒ” …ƒ•‡•Ǥ 



ComplicationsofCatatoniainPregnancy ƒ–ƒ–‘‹ƒ†—”‹‰’”‡‰ƒ…›’”‡•‡–•—‹“—‡…ŠƒŽŽ‡‰‡•ˆ‘”–Š‡–”‡ƒ–‹‰…Ž‹‹…‹ƒǡ ’ƒ”–‹…—Žƒ”Ž›‹ƒ–‡’ƒ”–—’ƒ–‹‡–•Ǥƒ–ƒ–‘‹ƒ…ƒ…ƒ””›•‹‰‹ˆ‹…ƒ–”‹••‘ˆ‡†‹…ƒŽ …‘’Ž‹…ƒ–‹‘•ˆ‘”–Š‡ˆ‡–—•ƒ•™‡ŽŽƒ•–Š‡‘–Š‡”ǡ‡•’‡…‹ƒŽŽ›‹ˆ•›’–‘•ƒ”‡’”‘Ž‘‰‡†Ǥ—” Ž‹–‡”ƒ–—”‡•‡ƒ”…Š”‡˜‡ƒŽ‡†…ƒ–ƒ–‘‹ƒ‹’”‡‰ƒ…›…ƒ’”‡•‡–™‹–Šƒ”ƒ‰‡‘ˆ’‘–‡–‹ƒŽŽ› Šƒ”ˆ—Ž•›’–‘•‹…Ž—†‹‰ƒ‰‹–ƒ–‹‘ǡ‹‘„‹Ž‹–›ǡ‡‰ƒ–‹˜‹•ǡ—–‹•ƒ†•–—’‘”Ǥ ‰‹–ƒ–‹‘…ƒŽ‡ƒ†–‘„‘–Š’ƒ–‹‡–ƒ†•–ƒˆˆ‹Œ—”‹‡•ƒ•™‡ŽŽƒ•…‘’Ž‹…ƒ–‹‘•†—”‹‰˜ƒ‰‹ƒŽ †‡Ž‹˜‡”›‹ˆ–Š‡’ƒ–‹‡–‹•‘–ƒ„Ž‡–‘…‘‘’‡”ƒ–‡ƒ–ƒ’’”‘’”‹ƒ–‡–‹‡•ǤŠ‡‹‘„‹Ž‹–›ƒ† ™‹–Š†”ƒ™ƒŽ‘ˆ…ƒ–ƒ–‘‹ƒƒ›Ž‡ƒ†–‘ƒ–‡”ƒŽ†‡Š›†”ƒ–‹‘ǡƒŽ—–”‹–‹‘ǡ—•…—Žƒ”ƒ–”‘’Š› ƒ†•’ƒ•–‹……‘–”ƒ…–—”‡•ǡ†‡‡’˜‡‘—•–Š”‘„‘•‹•ǡ•‹—Ž…‡”ƒ–‹‘ǡƒ†ƒ•’‹”ƒ–‹‘ ’‡—‘‹ƒͳͳǤ—–‹•ƒ†•–—’‘”…ƒŽ‡ƒ†–‘’‘‘”…‘—‹…ƒ–‹‘„‡–™‡‡’ƒ–‹‡–ƒ† •–ƒˆˆƒ„‘—–•‹‰•ƒ†•›’–‘•‘ˆˆ‡–ƒŽ†‹•–”‡••‘”Žƒ„‘”ǡƒ•™‡ŽŽƒ•–‘‹’ƒ‹”‡†ƒ„‹Ž‹–›–‘ „‘†™‹–Šƒ†…ƒ”‡ˆ‘”ƒ‹ˆƒ–ƒˆ–‡”†‡Ž‹˜‡”›ǤŠ‡‘”‡–‹…ƒŽ”‹••–‘–Š‡ˆ‡–—•™‹–Šƒ‘–Š‡” •—ˆˆ‡”‹‰ˆ”‘†‡’”‡••‹‘‹…Ž—†‡‹–”ƒ—–‡”‹‡‰”‘™–Š”‡•–”‹…–‹‘ǡ’”‡–‡” …‘–”ƒ…–‹‘•Ȁ†‡Ž‹˜‡”›ǡˆ‡–ƒŽƒ„‘”ƒŽ‹–‹‡•ǡƒ†•–‹ŽŽ„‹”–Šͳʹǡͳ͵Ǥ‡˜‡”‡…‘’Ž‹…ƒ–‹‘•‘ˆ ƒŽ‹‰ƒ–…ƒ–ƒ–‘‹ƒ‹…Ž—†‡”Šƒ„†‘›‘Ž›•‹•ǡ”‡ƒŽˆƒ‹Ž—”‡ǡ›‘…ƒ”†‹ƒŽ‹ˆƒ”…–‹‘ǡ‡–ƒ„‘Ž‹… ƒ…‹†‘•‹•ǡ†‹••‡‹ƒ–‡†‹–”ƒ˜ƒ•…—Žƒ”…‘ƒ‰—Žƒ–‹‘ǡƒ††‡ƒ–ŠͳͳǤ ‹˜‡–Š‡•‡‰”ƒ˜‡ …‘’Ž‹…ƒ–‹‘•ǡ–Š‡˜‹ƒ„‹Ž‹–›ƒ†™‡Žˆƒ”‡‘ˆ–Š‡ˆ‡–—•—•–„‡™‡‹‰Š‡†‹–Š‡„ƒŽƒ…‡™‹–Š–Š‡ ™‡Žˆƒ”‡‘ˆ–Š‡…ƒ–ƒ–‘‹…‘–Š‡”ǡƒ†ƒ˜‘‹†ƒ…‡‘ˆ–Š‡•‡…‘’Ž‹…ƒ–‹‘••Š‘—Ž†„‡ˆƒ…–‘”‡†

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‹–‘”‹•Ǧ„‡‡ˆ‹–ƒƒŽ›•‡•‘ˆƒ‰‰”‡••‹˜‡—•‡‘ˆ’Šƒ”ƒ…‘Ž‘‰‹…ƒ†•‘ƒ–‹…–”‡ƒ–‡–•–Šƒ– ƒ›‡š’‘•‡–Š‡ˆ‡–—•–‘ƒ†˜‡”•‡‡ˆˆ‡…–•Ǥ  ‹”•–ǦŽ‹‡–”‡ƒ–‡–‘ˆ…ƒ–ƒ–‘‹ƒ‹•Š‹‰ŠǦ†‘•‡„‡œ‘†‹ƒœ‡’‹‡•ǡ—’–‘ʹͲ‹ŽŽ‹‰”ƒ•‘ˆ Ž‘”ƒœ‡’ƒ’‡”†ƒ›ͳͶǢƒ•ƒ›ƒ•ͺͲΨ‘ˆ…ƒ•‡•‘ˆ…ƒ–ƒ–‘‹ƒ™‹ŽŽ”‡•’‘†˜‹‰‘”‘—•Ž›–‘ „‡œ‘†‹ƒœ‡’‹‡–Š‡”ƒ’›ƒŽ‘‡ͳͷǤ‡…‘†ǦŽ‹‡–”‡ƒ–‡–‹•‡Ž‡…–”‘…‘˜—Ž•‹˜‡–Š‡”ƒ’›ȋȌǡ ™‹–Š—’–‘ͺͷΨ‘ˆ…ƒ–ƒ–‘‹…•›†”‘‡•‹’”‘˜‹‰‘ͳǤ††”‡••‹‰—†‡”Ž›‹‰ ‡–‹‘Ž‘‰‹‡•‘ˆ…ƒ–ƒ–‘‹ƒ•—…Šƒ•‡–ƒ„‘Ž‹…†‹•ƒ””ƒ›ǡ‹ˆŽƒƒ–‘”›…‘†‹–‹‘•ǡ•‡‹œ—”‡•ǡ ƒ…“—‹”‡†„”ƒ‹‹Œ—”›ǡ‡†‹…ƒ–‹‘•ǡ‹ˆ‡…–‹‘•ǡƒ†’•›…Š‹ƒ–”‹……‘†‹–‹‘•ƒ”‡‹’‡”ƒ–‹˜‡–‘ ’”‡˜‡–‹–•”‡…—””‡…‡͵ǤŽ‰‘”‹–Š•ˆ‘”–”‡ƒ–‡–‘ˆ…ƒ–ƒ–‘‹ƒƒ†˜‹•‡‡ƒ”Ž›ǡ”ƒ’‹†ǡƒ† ƒ‰‰”‡••‹˜‡—•‡‘ˆ„‡œ‘†‹ƒœ‡’‹‡•ƒ†–‘ƒ˜‘‹†’”‘‰”‡••‹‘–‘ƒŽ‹‰ƒ–…ƒ–ƒ–‘‹ƒ ͳ͸Ǥ‘™‡˜‡”ǡ„‡œ‘†‹ƒœ‡’‹‡•ƒ”‡”ƒ–‡†ƒ•–‡”ƒ–‘‰‡‹…‹–›…Žƒ••ƒ††”—‰•„›–Š‡ ‘‘† ƒ†”—‰†‹‹•–”ƒ–‹‘ǡ‡ƒ‹‰–Š‡›ƒ”‡Ž‹‡Ž›–‘…ƒ—•‡„‹”–Š†‡ˆ‡…–•‘”’‡”‹ƒ–ƒŽ …‘’Ž‹…ƒ–‹‘•ǤʹͲͳͳ‡–ƒǦƒƒŽ›•‹•”‡˜‹‡™‹‰„‡œ‘†‹ƒœ‡’‹‡•ƒˆ‡–›‹’”‡‰ƒ…›—•‹‰ͻ •–—†‹‡•™‹–Š‘˜‡”‘‡‹ŽŽ‹‘’”‡‰ƒ…‹‡•ˆ‘—†–Šƒ–™Š‹Ž‡„‡œ‘†‹ƒœ‡’‹‡•†‹†‘–ƒ’’‡ƒ” –‘‹…”‡ƒ•‡–‡”ƒ–‘‰‡‹…”‹•‹‰‡‡”ƒŽǡ…ƒ•‡Ȃ…‘–”‘Ž••—‰‰‡•–‡†ƒ–™‘ˆ‘Ž†‹…”‡ƒ•‡†”‹•‘ˆ ‘”ƒŽ…Ž‡ˆ–ͳ͹Ǥ –Š‡–Š‹”†–”‹‡•–‡”ǡ„‡œ‘†‹ƒœ‡’‹‡•…ƒ…‘–”‹„—–‡–‘ƒ‡‘ƒ–ƒŽƒ„•–‹‡…‡ •›†”‘‡ǡ‡‘ƒ–ƒŽŠ›’‘–‘‹ƒƒ†ƒ’‡ƒǡ–‡’‡”ƒ–—”‡†›•”‡‰—Žƒ–‹‘ƒ†’‘‘” •—…Ž‹‰ͳͺǤ‹•–Š‡–”‡ƒ–‡–‘ˆ…Š‘‹…‡ˆ‘”’”‡‰ƒ–’ƒ–‹‡–•™‹–Š•‡˜‡”‡’•›…Š‹ƒ–”‹… •›’–‘•ǡƒ•‹–Šƒ•‡‰Ž‹‰‹„Ž‡”‹••‘ˆ–‡”ƒ–‘‰‡‹…‹–›ˆ”‘–Š‡Ž‹‹–‡†—•‡‘ˆƒ‡•–Š‡•‹ƒ ‹†—…–‹‘ƒ‰‡–•ǣ‡–Š‘Š‡š‹–ƒŽŠƒ•‘‘™ƒ†˜‡”•‡•‹†‡‡ˆˆ‡…–•‹’”‡‰ƒ…›Ǣ ƒ–‹…Š‘Ž‹‡”‰‹…••—…Šƒ•‰Ž›…‘’›””‘Žƒ–‡Šƒ˜‡‘–„‡‡•Š‘™–‘…ƒ—•‡ˆ‡–ƒŽƒ†˜‡”•‡‡ˆˆ‡…–• ‹‡‹–Š‡”ƒ‹ƒŽ•–—†‹‡•‘”…Ž‹‹…ƒŽ‹˜‡•–‹‰ƒ–‹‘•Ǣƒ†•—……‹›Ž…Š‘Ž‹‡†‘‡•‘–…”‘••–Š‡ ’Žƒ…‡–ƒ‹ƒ’’”‡…‹ƒ„Ž‡ƒ‘—–•ͳͻǡʹͲǤŠ‹Ž‡…‘•‹†‡”‡†‡š–”‡‡Ž›•ƒˆ‡‹’”‡‰ƒ…›ǡ ‹–•‡ŽˆŠƒ•„‡‡ƒ••‘…‹ƒ–‡†™‹–Š”ƒ”‡…ƒ•‡•‘ˆ’Žƒ…‡–ƒŽƒ„”—’–‹‘ǡŠ‡ƒ–—”‹ƒǡ˜ƒ‰‹ƒŽ „Ž‡‡†‹‰ǡ’”‡–‡”Žƒ„‘”ǡˆ‡–ƒŽŠ‡ƒ”–”ƒ–‡†‡…‡Ž‡”ƒ–‹‘•ǡƒ†‡˜‡‹•…ƒ””‹ƒ‰‡ʹͲǡʹͳǤŠ‡”‹•• ‘ˆƒ‰‰”‡••‹˜‡—•‡‘ˆ„‡œ‘†‹ƒœ‡’‹‡•ƒ†•Š‘—Ž†„‡ˆƒ…–‘”‡†‹–‘–Š‡…Ž‹‹…ƒŽ†‡…‹•‹‘Ǧ ƒ‹‰”‡‰ƒ”†‹‰ƒ…ƒ–ƒ–‘‹…’”‡‰ƒ–’ƒ–‹‡–ȋ•‡‡ƒ„Ž‡ʹȌǤ‹–Š”‡‰ƒ”†–‘‡Ž‡…–”‘†‡ ’Žƒ…‡‡–‹ˆ‘”…ƒ–ƒ–‘‹ƒǡ™Š‹Ž‡„‹–‡’‘”ƒŽŠƒ•„‡‡–”ƒ†‹–‹‘ƒŽŽ›ˆƒ˜‘”‡†ǡ‘”‡ ‡˜‹†‡…‡‹•ƒ……——Žƒ–‹‰–Šƒ–”‹‰Š–—‹Žƒ–‡”ƒŽ’Žƒ…‡‡–…ƒ„‡‡ˆˆ‡…–‹˜‡ˆ‘”…ƒ–ƒ–‘‹ƒǡ™‹–Š ƒ‹’”‘˜‡†…‘‰‹–‹˜‡•‹†‡‡ˆˆ‡…–’”‘ˆ‹Ž‡ʹʹǤ‹ˆ”‘–ƒŽ’Žƒ…‡‡–™ƒ•‘–—–‹Ž‹œ‡†‹–Š‹•…ƒ•‡ †—‡–‘‹•–‹–—–‹‘ƒŽ’”ƒ…–‹…‡ǡ„—–ƒ›ƒŽ•‘‘ˆˆ‡”…‘‰‹–‹˜‡ƒ†˜ƒ–ƒ‰‡•ƒ†•’‡‡†‹‡””‡…‘˜‡”› ˆ”‘…ƒ–ƒ–‘‹ƒ‘˜‡”„‹–‡’‘”ƒŽ’Žƒ…‡‡–‹•‡Ž‡…–’‘’—Žƒ–‹‘•ʹ͵Ǥ



–Š‡”…Žƒ••‡•‘ˆ’•›…Š‘–”‘’‹…‡†‹…ƒ–‹‘•ƒ›„‡‡‡†‡†–‘ƒ††”‡••—†‡”Ž›‹‰‡–‹‘Ž‘‰‹‡• ‘ˆ’‡”‹ƒ–ƒŽ…ƒ–ƒ–‘‹ƒǤ •ƒ”‡ˆ‹”•–Ž‹‡–”‡ƒ–‡–ˆ‘”†‡’”‡••‹‘ǤŠ‡”‡‹•Ž‹‹–‡† ‡˜‹†‡…‡‘ˆ–‡”ƒ–‘‰‡‹…‡ˆˆ‡…–•ˆ”‘–Š‡—•‡‘ˆƒ–‹†‡’”‡••ƒ–•‹’”‡‰ƒ…›ǡ™‹–Š–Š‡ ‡š…‡’–‹‘‘ˆ’ƒš‹Ž™Š‹…Š‹•ƒ••‘…‹ƒ–‡†™‹–ŠŠ‡ƒ”–†‡ˆ‡…–•ʹ͵Ǥš’‘•—”‡–‘•‡Ž‡…–‹˜‡•‡”‘–‘‹ ”‡—’–ƒ‡‹Š‹„‹–‘”•Žƒ–‡‹’”‡‰ƒ…›Šƒ•„‡‡ƒ••‘…‹ƒ–‡†™‹–Š–”ƒ•‹‡–‡‘ƒ–ƒŽ …‘’Ž‹…ƒ–‹‘••—…Šƒ•‹””‹–ƒ„‹Ž‹–›ƒ†‡—”‘„‡Šƒ˜‹‘”ƒŽ…Šƒ‰‡•ʹ͵Ǥ‡‰ƒ”†‹‰ƒ–‹’•›…Š‘–‹… —•‡‹’”‡‰ƒ…›ǡ‘•‹‰‹ˆ‹…ƒ––‡”ƒ–‘‰‡‹…‡ˆˆ‡…–Šƒ•„‡‡†‘…—‡–‡†™‹–Š …ŠŽ‘”’”‘ƒœ‹‡ǡŠƒŽ‘’‡”‹†‘Žǡ‘”’‡”’Š‡ƒœ‹‡ʹͶǤ‡…‘†‰‡‡”ƒ–‹‘ƒ–‹’•›…Š‘–‹…•ƒ”‡ ƒ••‘…‹ƒ–‡†™‹–Š‹…”‡ƒ•‡†”ƒ–‡•‘ˆ‰‡•–ƒ–‹‘ƒŽ‡–ƒ„‘Ž‹……‘’Ž‹…ƒ–‹‘•ǡ„‘–Š†‡…”‡ƒ•‡†ƒ† ‹…”‡ƒ•‡†„‹”–Š™‡‹‰Š–ǡƒ†–Š‡”ƒ’‡—–‹…ƒ„‘”–‹‘ʹ͵ǦʹͷǤ



 ˆƒ–‡”ƒŽ…ƒ–ƒ–‘‹ƒ‘……—”•‹…Ž‘•‡’”‘š‹‹–›–‘–‡”ǡ–Š‡–”‡ƒ–‹‰’•›…Š‹ƒ–”‹…ƒ† ‘„•–‡–”‹…ƒŽ–‡ƒ•—•–™‡‹‰Š–Š‡”‹••ƒ†„‡‡ˆ‹–•‘ˆ•‡˜‡”ƒŽ…Ž‹‹…ƒŽ†‡…‹•‹‘•ǣ ͳȌŠ‘—Ž†–”‡ƒ–‡–ˆ‘”…ƒ–ƒ–‘‹ƒ…‘‡…‡„‡ˆ‘”‡‘”ƒˆ–‡”†‡Ž‹˜‡”›ǫŠ‹•™‹ŽŽ†‡’‡†‘ –Š‡‰‡•–ƒ–‹‘ƒŽƒ‰‡‘ˆ–Š‡ˆ‡–—•ǡ˜‹ƒ„‹Ž‹–›‘ˆ–Š‡ˆ‡–—•‹ˆ†‡Ž‹˜‡”‡†‡ƒ”Ž›ǡƒ†–Š‡”‹••–‘–Š‡

ͷ

ˆ‡–—•ƒ†‘–Š‡”ˆ”‘–”‡ƒ–‡–‘ˆ…ƒ–ƒ–‘‹ƒ™‹–Š„‡œ‘†‹ƒœ‡’‹‡•‘”Ǥ ʹȌŠ‘—Ž††‡Ž‹˜‡”›‹ƒ…ƒ–ƒ–‘‹…‘–Š‡”’”‘…‡‡†˜‹ƒ˜ƒ‰‹ƒŽ†‡Ž‹˜‡”›‘”…‡•ƒ”‡ƒ •‡…–‹‘ǫŠ‹•™‹ŽŽ†‡’‡†‘–Š‡‘–Š‡”̵•ƒ„‹Ž‹–›–‘…‘‘’‡”ƒ–‡™‹–Š‹•–”—…–‹‘•†—”‹‰ƒ ˜ƒ‰‹ƒŽ†‡Ž‹˜‡”›ǡ”‹•‘ˆ…ƒ–ƒ–‘‹…ƒ‰‹–ƒ–‹‘†—”‹‰†‡Ž‹˜‡”›ǡƒ†•–ƒ„‹Ž‹–›‘ˆ–Š‡ˆ‡–—•–‘ —†‡”‰‘Žƒ„‘”Ǥ  —”’ƒ–‹‡–ǯ•’”‡•‡–ƒ–‹‘’‘•‡†•‡˜‡”ƒŽ†‹Ž‡ƒ•ˆ‘”–Š‡–”‡ƒ–‡––‡ƒǤŠ‡’ƒ–‹‡–†‹† ‘–Šƒ˜‡ƒ’•›…Š‹ƒ–”‹…‘”‡†‹…ƒŽŠ‹•–‘”›ǡ™ƒ•‘ˆ…‘‘ƒ‰‡ˆ‘”ˆ‹”•–‡’‹•‘†‡‘ˆ‡–ƒŽ ‹ŽŽ‡••ǡƒ†Šƒ†‘”ƒŽ•…”‡‡‹‰Žƒ„‘”ƒ–‘”›•–—†‹‡•ƒ†–Š‡”‡ˆ‘”‡ƒ††‹–‹‘ƒŽ–‡•–‹‰™ƒ• ‘–†‡‡‡†‡…‡••ƒ”›Ǥ‘™‡˜‡”ǡ‰‹˜‡–Š‡ˆ”‡“—‡…›‘ˆ‘”‰ƒ‹…‡–‹‘Ž‘‰‹‡•‹’—„Ž‹•Š‡† …ƒ•‡”‡’‘”–•‘ˆƒ–‡’ƒ”–—…ƒ–ƒ–‘‹ƒǡˆ—”–Š‡”™‘”—’•—…Šƒ•™‹–Š„”ƒ‹‹ƒ‰‹‰ǡ ǡƒ† Ž—„ƒ”’—…–—”‡ƒ›Šƒ˜‡„‡‡Œ—•–‹ˆ‹‡†–‘”—Ž‡‘—–‡†‹…ƒŽƒ†‡—”‘Ž‘‰‹…ƒŽ‡–‹‘Ž‘‰‹‡•Ǥ• Š‡”ˆ‹”•–’”‡•‡–ƒ–‹‘™ƒ•ƒ––Š‡ʹͶ–Š™‡‡‘ˆ’”‡‰ƒ…›ǡ•‡”–”ƒŽ‹‡™ƒ••‡Ž‡…–‡†ƒ•‹‹–‹ƒŽ –”‡ƒ–‡–ˆ‘”’”‡•—‡†’•›…Š‘–‹…ƒ†…ƒ–ƒ–‘‹…†‡’”‡••‹‘ǡ‰‹˜‡‹–•”‡Žƒ–‹˜‡•ƒˆ‡–›‹ ’”‡‰ƒ…›…‘’ƒ”‡†–‘‘–Š‡” •Ǥ‘”ƒœ‡’ƒ™ƒ••’‡…‹ˆ‹…ƒŽŽ›‘–…Š‘•‡–‘–”‡ƒ–Š‡” …ƒ–ƒ–‘‹…•›’–‘•†—‡–‘–Š‡”‹••–‘–Š‡ˆ‡–—•‡š’‘•‡†–‘„‡œ‘†‹ƒœ‡’‹‡•‹–Š‡–Š‹”† –”‹‡•–‡”ƒ•†‹•…—••‡†ƒ„‘˜‡Ǥ‘™‡˜‡”ǡƒ‘‡Ǧ–‹‡–‡•–†‘•‡‘ˆŽ‘”ƒœ‡’ƒʹ‰…‘—Ž†Ž‹‡Ž› Šƒ˜‡„‡‡ƒ––‡’–‡†•ƒˆ‡Ž›ǡ–‘•‡‡‹ˆ”ƒ’‹†‹’”‘˜‡‡–‹…ƒ–ƒ–‘‹…•›’–‘•…‘—Ž†„‡ ‘„–ƒ‹‡†Ǥƒ‹–‡ƒ…‡–”‡ƒ–‡–•™‡”‡…‘•‹†‡”‡†ǡŠ‘™‡˜‡”–Š‡›™‡”‡‘–ˆ‡ƒ•‹„Ž‡ †—‡–‘–Š‡’ƒ–‹‡–Ž‹˜‹‰•‡˜‡”ƒŽŠ‘—”•ˆ”‘–Š‡…Ž‘•‡•–ˆƒ…‹Ž‹–›Ǥ ƒ††‹–‹‘ǡ–Š‡”‡‹• ‡˜‹†‡…‡–Šƒ–…‘‰‹–‹˜‡„‡Šƒ˜‹‘”ƒŽ–Š‡”ƒ’›ǡ‹–‡”’‡”•‘ƒŽ–Š‡”ƒ’›ǡ‘”Ž‹‰Š––Š‡”ƒ’›…ƒ „‡Š‡Ž’ˆ—Žˆ‘”†‡’”‡••‹‘‹–Š‡’‡”‹ƒ–ƒŽ’‡”‹‘†ƒ†…‘—Ž†Šƒ˜‡„‡‡…‘•‹†‡”‡†‹‘—” ’ƒ–‹‡–ʹ͸Ǥ



Conclusion ‡”‹ƒ–ƒŽ…ƒ–ƒ–‘‹ƒ‹•ƒ”ƒ”‡’Š‡‘‡‘ǡƒ†ƒ›„‡ƒ••‘…‹ƒ–‡†™‹–Š…‘’Ž‹…ƒ–‹‘•ˆ‘” „‘–Š‘–Š‡”ƒ†ˆ‡–—•‹ˆ—†‡”–”‡ƒ–‡†‘”–”‡ƒ–‡†–‘‘ƒ‰‰”‡••‹˜‡Ž›ǤŽ‹‹…‹ƒ••Š‘—Ž†•–”‘‰Ž› …‘•‹†‡””—Ž‹‰‘—–‘”‰ƒ‹…‡–‹‘Ž‘‰‹‡•‘ˆ…ƒ–ƒ–‘‹ƒǡƒ†™‘”…Ž‘•‡Ž›™‹–Š‘„•–‡–”‹…ƒŽ •‡”˜‹…‡•–‘’‡”ˆ‘”…ƒ”‡ˆ—Ž”‹•Ǧ„‡‡ˆ‹–ƒƒŽ›•‹•ƒ•’ƒ”–‘ˆ†‡–‡”‹‹‰–”‡ƒ–‡–’Žƒ•Ǥ  References ͳǤ‘ŠŽƒ†ǡƒ””‘ŽŽǡ ƒ…‘„› ǣ‹–Š‡–”‡ƒ–‡–‘ˆ–Š‡…ƒ–ƒ–‘‹…•›†”‘‡Ǥ  ˆˆ‡…–‹•ͳͻͻ͵ǢʹͻǣʹͷͷǦʹ͸ͳǤ ʹǤ ”‹……Š‹‘‡ ǡ—•Š ǡ ‘œ†ƒ”ǡ ”ƒ…‹•ǡ ‹ǣ‡…‘‰‹–‹‘ƒ†–”‡ƒ–‡–‘ˆ–Š‡ …ƒ–ƒ–‘‹…•›†”‘‡Ǥ  –‡•‹˜‡ƒ”‡‡†ͳͻͻ͹Ǣͳʹǣͳ͵ͷǦͳͶ͹Ǥ ͵Ǥƒ””‘ŽŽǡˆ‹•‘ ǡ‡‡†› ǡ‡†”‡ǡ‘—–”‘•ǡ‹Ž‘ǣƒ–ƒ–‘‹…†‹•‘”†‡” †—‡–‘‰‡‡”ƒŽ‡†‹…ƒŽ…‘†‹–‹‘Ǥ ‡—”‘’•›…Š‹ƒ–”›Ž‹‡—”‘•…‹ͳͻͻͶǢ͸ǣͳʹʹǦͳ͵͵Ǥ ͶǤ‘„‡Žǣ ‡–ƒŽ†ƒƒ‰‡†—‡–‘ǡ‹•—Ž‹…‘ƒǡ…ŠŽ‘”’”‘ƒœ‹‡ǡ‘””‡•‡”’‹‡ǤǤǤ ”…Š‹˜‡•‘ˆ ‡‡”ƒŽ•›…Š‹ƒ–”›ͳͻ͸ͲǢʹǣ͸Ͳ͸Ǧ͸ͳͳ ͷǤƒ‹ ǡ—ƒ‰ǣƒ–ƒ–‘‹…ˆ‡ƒ–—”‡•‘–‡†‹’ƒ–‹‡–•™‹–Š’‘•–’ƒ”–—‡–ƒŽ‹ŽŽ‡••Ǥ •›…Š‹ƒ–”›ƒ†Ž‹‹…ƒŽ‡—”‘•…‹‡…‡•ʹͲͲͶǢͷͺǣͳͷ͹Ǧͳ͸ʹǤ ͸Ǥƒ„— ǡŠ‹’’‡•™ƒ›ǡŠƒ†”ƒǣ•‡‘ˆ‡Ž‡…–”‘…‘˜—Ž•‹˜‡–Š‡”ƒ’›ȋȌ‹ ’‘•–’ƒ”–—’•›…Š‘•‹•ǣƒƒ–—”ƒŽ‹•–‹…’”‘•’‡…–‹˜‡•–—†›Ǥ”…Š‘‡•‡–‡ƒŽ–ŠǤ ʹͲͳ͵Ǣͳ͸ǣʹͶ͹ǦʹͷͳǤ ͹Ǥ’‹‡‰‡Žǡƒ”‡ŽŽǣ…ƒ•‡‘ˆ…ƒ–ƒ–‘‹ƒ†—‡–‘’‘•–‡”‹‘””‡˜‡”•‹„Ž‡‡…‡’ŠƒŽ‘’ƒ–Š› •›†”‘‡–”‡ƒ–‡†•—……‡••ˆ—ŽŽ›™‹–Šƒ–‹Š›’‡”–‡•‹˜‡•ƒ†ƒ†Œ—…–‹˜‡‘Žƒœƒ’‹‡Ǥ ‡‘•’ •›…Š‹ƒ–”›ʹͲͳͳǢ͵͵ȋ͵Ȍǣ͵ͲʹǤ‡͵ǦͷǤ ͺǤ‹ ǡƒ‰‹ǡ…Š”ƒ‡†‡”ǡŠ‡‡Ž‡”ǣ …–ƒŽ…ƒ–ƒ–‘‹ƒƒ•ƒƒ‹ˆ‡•–ƒ–‹‘‘ˆ ‘…‘˜—Ž•‹˜‡•–ƒ–—•‡’‹Ž‡’–‹…—•Ǥ ‡—”‘Ž‡—”‘•—”‰•›…Š‹ƒ–”›ͳͻͺ͸ǢͶͻȋ͹Ȍǣͺ͵͵Ǧͺ͵͸Ǥ

͸

ͻǤ‹„ƒ‹ǣ‹ƒ‰‘•‹•ǡ’”‡˜‡–‹‘ǡƒ†ƒƒ‰‡‡–‘ˆ‡…Žƒ’•‹ƒǤ„•–‡– ›‡…‘ŽʹͲͲͷǢ ͳͲͷȋʹȌǣͶͲʹǦͳͲǤ ͳͲǤ—ƒ”ǡ ƒ‹ǡ‡…Šƒ–ǡ•—ƒ•ƒǡƒˆƒ‡Žǡ‹œƒ™ƒǡ‡–ƒŽǣ–‹ǦǦ‡–Š›ŽǦǦ ƒ•’ƒ”–ƒ–‡”‡…‡’–‘”‡…‡’ŠƒŽ‹–‹•†—”‹‰’”‡‰ƒ…›Ǥ”…Š‡—”‘ŽʹͲͳͲǢ͸͹ȋ͹ȌǣͺͺͶǦͺͺ͹Ǥ ͳͳǤŠ‹Ž„”‹…ǡ—ƒ•ǤƒŽ‹‰ƒ–…ƒ–ƒ–‘‹ƒǤ ‡—”‘’•›…Š‹ƒ–”›ͳͻͻͶǢ͸ǣͳǦͳ͵Ǥ ͳʹǤ‡‡†•‡ǡ‘”–‡•‡ǡŽ‡•‡ǡ‡”‹•‡ǣ”‡–‡”„‹”–Šƒ†‹–”ƒǦ —–‡”‹‡‰”‘™–Š”‡–ƒ”†ƒ–‹‘ƒ‘‰…Š‹Ž†”‡‘ˆ™‘‡™‹–Š•…Š‹œ‘’Š”‡‹ƒǤ” •›…Š‹ƒ–”› ͳͻͻͻǢͳ͹ͷǣʹ͵ͻǦʹͶͷǤ ͳ͵Ǥƒ•‹Žǡ—Ž‹ƒǡ‡‹Ž‡ ǡ‘•‡” ǡ‘—”–‹•ǡŽŽ‹‰–‘ǡ ƒ‹‡•‘ ǣ ƒ–‡”ƒŽƒ†ˆ‡–ƒŽ‘—–…‘‡•ƒ‘‰™‘‡™‹–Š†‡’”‡••‹‘Ǥ ‘‡•‡ƒŽ–Šȋƒ”…Š–Ȍ ʹͲͳͲǢͳͻȋʹȌǣ͵ʹͻǦ͵͵ͶǤ ͳͶǤ ‹ǡƒ›Ž‘”Ǥƒ–ƒ–‘‹ƒǣƒ…Ž‹‹…‹ƒǯ•‰—‹†‡–‘†‹ƒ‰‘•‹•ƒ†–”‡ƒ–‡–Ǥƒ„”‹†‰‡ ‹˜‡”•‹–›”‡••ǡƒ„”‹†‰‡ǡʹͲͲ͵Ǥ ͳͷǤ‘•‡„—•Š ǡ‹Ž†‡„”ƒ†ǡ —”Ž‘‰ ǡƒœ—”‡ ǣƒ–ƒ–‘‹…•›†”‘‡‹ƒ‰‡‡”ƒŽ ’•›…Š‹ƒ–”‹…‹’ƒ–‹‡–’‘’—Žƒ–‹‘ǣˆ”‡“—‡…›ǡ…Ž‹‹…ƒŽ’”‡•‡–ƒ–‹‘ǡƒ†”‡•’‘•‡–‘ Ž‘”ƒœ‡’ƒǤ Ž‹•›…Š‹ƒ–”›ͳͻͻͲǢͷͳǣ͵ͷ͹Ǧ͵͸ʹǤ ͳ͸Ǥƒǡƒ”‘ˆˆǡŽ‡‹‡”ǡ‡ŽœǡŽ‹‰ǡƒ›ƒ•Š‹†ƒǣ‡–ŠƒŽ…ƒ–ƒ–‘‹ƒǤ

•›…Š‹ƒ–”›ͳͻͺ͸ǢͳͶ͵ȋͳͳȌǣͳ͵͹ͶǦͳ͵ͺͳǤ ͳ͹Ǥƒ–‘ǡ‘”‡––‹ǡ‘”‡ ǣŠ‡ ‡–ƒŽƒˆ‡–›‘ˆ‡œ‘†‹ƒœ‡’‹‡•ǣ’†ƒ–‡†‡–ƒǦ ƒƒŽ›•‹•Ǥ „•–‡– ›ƒ‡…‘ŽƒʹͲͳͳǢ͵͵ȋͳȌǣͶ͸ȂͶͺ ††‹•ǡ‡–ƒŽǣƒ™‡—•‡ƒš‹‘Ž›–‹…•†—”‹‰’”‡‰ƒ…›™‹–Š‘—–ƒš‹‡–›ǫƒ ƒŠ›•‹…‹ƒ ʹͲͲͲǢͶ͸ǣͷͶͻȂͷͷͳ ͳͺǤ‡˜›ǡ’‹‘ǣ‡‘ƒ–ƒŽ™‹–Š†”ƒ™ƒŽ•›†”‘‡ǣƒ••‘…‹ƒ–‡††”—‰•ƒ†’Šƒ”ƒ…‘Ž‘‰‹… ƒƒ‰‡‡–ǤŠƒ”ƒ…‘–Š‡”ƒ’›ͳͻͻ͵Ǣͳ͵ȋ͵ȌǣʹͲʹǦʹͳͳǤ ͳͻǤ‡’”‘–‘šǤ‘”‰Ǥƒ•–ƒ……‡••‡†‘˜‡„‡”͹ǡʹͲͳ͵Ǥ ʹͲǤƒƒ–…‹‘‰Ž—ǡ—”—ǣŠ‡—•‡‘ˆ‡Ž‡…–”‘…‘˜—Ž•‹˜‡–Š‡”ƒ’›‹’”‡‰ƒ…›ǣƒ”‡˜‹‡™Ǥ •” •›…Š‹ƒ–”›‡Žƒ–…‹ʹͲͳͳǢͶͺȋͳȌǣ͸ǦͳͲǤ ʹͳǤ†‡”•‘ǡ‡–‹ Ǥǣ‹’”‡‰ƒ…›ǣƒ”‡˜‹‡™‘ˆ–Š‡Ž‹–‡”ƒ–—”‡ˆ”‘ͳͻͶͳ–‘ʹͲͲ͹Ǥ •›…Š‘•‘‡†ǤʹͲͲͻ ‡„Ǣ͹ͳȋʹȌǣʹ͵ͷǦͶʹǤ ʹʹǤ”‹•–ƒ…Š‘ǡ ‡™‡•ǡ‘ǡ‘™ƒ›Ǥ—……‡••ˆ—Ž—•‡‘ˆ”‹‰Š–—‹Žƒ–‡”ƒŽˆ‘” …ƒ–ƒ–‘‹ƒǣƒ…ƒ•‡•‡”‹‡•Ǥ ʹͲͳ͵Ǣȏ’—„ƒŠ‡ƒ†‘ˆ’”‹–Ȑ ʹ͵ǤŠ—–ƒ‡ǡŠ‹”–ŠƒŽ‹ ǡ—”ƒŽ‹†Šƒ”ƒǡ—ƒ”ǡ—ƒ” ǡ ƒ‰ƒ†Šƒ”Ǥ‘—„Ž‡Ǧ „Ž‹†”ƒ†‘‹œ‡†…‘–”‘ŽŽ‡†•–—†›•Š‘™‹‰•›’–‘ƒ–‹…ƒ†…‘‰‹–‹˜‡•—’‡”‹‘”‹–›‘ˆ „‹ˆ”‘–ƒŽ‘˜‡”„‹–‡’‘”ƒŽ‡Ž‡…–”‘†‡’Žƒ…‡‡–†—”‹‰‡Ž‡…–”‘…‘˜—Ž•‹˜‡–Š‡”ƒ’›ˆ‘” •…Š‹œ‘’Š”‡‹ƒǤ”ƒ‹–‹—Žƒ–‹‘ʹͲͳ͵Ǣ͸ǣʹͳͲǦʹͳ͹Ǥ ʹ͵Ǥ‘‡”•ǡ‹•‡”ǡ–‡™ƒ”–ǡ„‡”Žƒ†‡” ǡ‡ŽŽǡ–‘–Žƒ†ǡƒ‹ǡ Šƒ—†”‘ǡ‘…™‘‘†ǣŠ‡ƒƒ‰‡‡–‘ˆ†‡’”‡••‹‘†—”‹‰’”‡‰ƒ…›ǣƒ”‡’‘”–ˆ”‘ –Š‡‡”‹…ƒ•›…Š‹ƒ–”‹…••‘…‹ƒ–‹‘ƒ†–Š‡‡”‹…ƒ‘ŽŽ‡‰‡‘ˆ„•–‡–”‹…‹ƒ•ƒ†

›‡…‘Ž‘‰‹•–•Ǥ ‡‘•’•›…Š‹ƒ–”›ǤʹͲͲͻ‡’Ǧ…–Ǣ͵ͳȋͷȌǣͶͲ͵Ǧͳ͵Ǥ†‘‹ǣ ͳͲǤͳͲͳ͸ȀŒǤ‰‡Š‘•’’•›…ŠǤʹͲͲͻǤͲͶǤͲͲ͵ ʹͶǤ ‡–‹Ž‡ǣ–‹’•›…Š‘–‹…–Š‡”ƒ’›†—”‹‰‡ƒ”Ž›ƒ†Žƒ–‡’”‡‰ƒ…›Ǥ•›•–‡ƒ–‹…”‡˜‹‡™Ǥ …Š‹œ‘’Š”—ŽŽǤʹͲͳͲƒ›Ǣ͵͸ȋ͵ȌǣͷͳͺǦͶͶǤ†‘‹ǣͳͲǤͳͲͻ͵Ȁ•…Š„—ŽȀ•„ͳͲ͹Ǥ’—„ʹͲͲͺ‡’ͳͳǤ ʹͷǤ”•–”‘‰ǣ  —‹†‡Ž‹‡•‘•›…Š‹ƒ–”‹…‡†‹…ƒ–‹‘•‡—”‹‰”‡‰ƒ…›ƒ† ƒ…–ƒ–‹‘Ǥ ƒŠ›•‹…‹ƒǤʹͲͲͺ‡’ͳͷǢ͹ͺȋ͸Ȍǣ͹͹ʹǦ͹͹ͺǤ ʹ͸ǤŒ‘ƒǡƒ”‡ǡ‹ǣ‹’‘Žƒ”†‡’”‡••‹‘†—”‹‰’”‡‰ƒ…›ǣ‘’Šƒ”ƒ…‘Ž‘‰‹… –”‡ƒ–‡–‘’–‹‘•Ǥ‘‡•‡ƒŽ–Šȋ‘†‰ŽȌǤʹͲͳͲ —ŽǢ͸ȋͶȌǣͷ͸ͷǦ͹͸Ǥ†‘‹ǣ ͳͲǤʹʹͳ͹Ȁ™Š‡ǤͳͲǤʹ͹Ǥ ʹ͹Ǥ ‡”˜ƒ•‘‹ǡ—„”› ǤǦǤǣ…ƒ–ƒ–‘‹…•›†”‘‡‹ƒ’‘•–’ƒ”–—ƒŒ‘”†‡’”‡••‹˜‡ ‡’‹•‘†‡™‹–Š’•›…Š‘–‹…ˆ‡ƒ–—”‡•Ǥ…Š™‡‹œ”…Š‡—”‘Ž•›…Š‹ƒ–”ʹͲͲͺǢͳͷͻǣ͵ͻͶǦ͵ͻ͸Ǥ ʹͺǤ”ƒ‡’‡Ž‹ǡ‡…–—”‡•‘…Ž‹‹…ƒŽ•›…Š‹ƒ–”›ǡʹ†‡†Ǥ‹ŽŽ‹ƒ‘‘†ǡ‡™‘”ǡͳͻͲͷǣ

͹

ͳʹͻǦͳ͵͵Ǥ ʹͻǤŽ‡…™‡ Ǥ”‘†—…–‹‘‘ˆ•Ž‡‡’ƒ†”‡•–‹’•›…Š‘–‹……ƒ•‡•Ǥ”…Š‡—”‘Ž

•›…Š‹ƒ–”›ͳͻ͵ͲǢʹͶǣ͵͸ͷǦ͵͹ʹǤ

͵ͲǤ”‘™ ǡƒ•‘ ǣƒš›ˆŽ‡š‹„‹Ž‹–›‹ƒ’‘•–’ƒ”–—™‘ƒǦǦƒ…ƒ•‡”‡’‘”–ƒ† ”‡˜‹‡™‘ˆ–Š‡…ƒ–ƒ–‘‹…•›†”‘‡Ǥ•›…Š‹ƒ–”ͳͻ͹͵ǢͶ͹ȋͳȌǣͻͷǦͳͲ͵Ǥ ͵ͳǤ‘””ƒ– ǤǤǣƒ–ƒ–‘‹…›†”‘‡‡•—Ž–‹‰‹‡ƒ–ŠǤƒ Ǥ•›…Š‹ƒ–”›ͳͻͺͶǢ ʹͻȋʹȌǣͳͶ͹ǦͳͷͲǤ ͵ʹǤ”‘…‹‰–‘ ǡƒ–‡•ǡ ‹ŽŽ‹ƒǣ”‡’ƒ”–—•›…Š‘•‹•Ǥ ‘—”ƒŽ‘ˆˆˆ‡…–‹˜‡‹•‘”†‡”• ͳͻͻͲǢͳͻǣ͵ͳǦ͵ͷǤ ͵͵Ǥƒ…ŠǦǦ‹–ƒ ǡ‡ƒ‹‡”‹ǣ‡†‹…‘Ž‡‰ƒŽ‘’Ž‹…ƒ–‹‘•‘ˆ‘•–’ƒ”–—ƒ–ƒ–‘‹ƒǤ‡•–  ‡†ͳͻͻʹǢͳͷ͸ǣͶͳ͹ǦͶͳͻ ͵ͶǤƒœ‹‹ǡ‹‡ƒ”ǡ‘—Ž‹‰ƒǡ…—ŽŽ› ǡŠ‘ǡ‹–œ‹Ž‡‘•ǣ—‡”’‡”ƒŽ•›…Š‘•‹• ‹‹…‹‰…Žƒ’•‹ƒǤŠ‡ ‘—”ƒŽ‘ˆƒ–‡”ƒŽǦ ‡–ƒŽ‡†‹…‹‡ͳͻͻ͸Ǣͷǣ͵͸Ǧ͵ͺ ͵ͷǤ‹–ƒ„ƒ›ƒ•Š‹ǡƒƒ‘–‘ǡ ”‘•ƒ™ƒǡƒ”—‘–‘ ǡ ——‹Ǥ‘•–’ƒ”–—…ƒ–ƒ–‘‹ƒ ƒ••‘…‹ƒ–‡†™‹–Šƒ–›’‹…ƒŽ’‘•–‡”‹‘””‡˜‡”•‹„Ž‡‡…‡’ŠƒŽ‘’ƒ–Š›•›†”‘‡Ǥ ‡—”‘’•›…Š‹ƒ–”› Ž‹‡—”‘•…‹ʹͲͲ͹ǢͳͻȋͳȌǣͻͳǦʹǤ ͵͸Ǥ•’‹‘ŽƒǦƒ†—”‹ŽŽ‡ǡƒ‹”‡œǦ‡”—†‡œ ǡ ”‹……Š‹‘‡ ǣ”‡‰ƒ…›ƒ†ƒŽ‹‰ƒ– …ƒ–ƒ–‘‹ƒǤ ‡‡”ƒŽ‘•’‹–ƒŽ•›…Š‹ƒ–”›ʹͲͲ͹Ǣʹͻǣ͸ͻǦ͹ͳ ͵͹Ǥ‹–‡”ǣ‘•–’ƒ”–—…ƒ–ƒ–‘‹ƒƒ••‘…‹ƒ–‡†™‹–Šƒ–›’‹…ƒŽ’‘•–‡”‹‘””‡˜‡”•‹„Ž‡ ‡…‡’ŠƒŽ‘’ƒ–Š›•›†”‘‡Ǥ ‘—”ƒŽ‘ˆ‡—”‘’•›…Š‹ƒ–”›Ž‹‹…ƒŽ‡—”‘•…‹‡…‡ʹͲͲ͹ǢͳͻǣͳǤ ͵ͺǤ—ǡ‘‘”‡ ǣƒ”ƒ‡‘’Žƒ•–‹……‡’ŠƒŽ‹–‹•”‡•‡–‹‰ƒ•‘•–’ƒ”–—•›…Š‘•‹•Ǥ •›…Š‘•‘ƒ–‹…•ʹͲͳͳǢͷʹǣ͸ ͵ͻǤ…ƒ”–Š›ǡ‹‡‡ ǡ…‡ƒǡ‡‘‰ƒǡŠ‡‡Šƒ ǡ›…Šǡ‡–ƒŽǣ–‹Ǧ ”‡…‡’–‘”‡…‡’ŠƒŽ‹–‹•™‹–Šƒ••‘…‹ƒ–‡†…ƒ–ƒ–‘‹ƒ†—”‹‰’”‡‰ƒ…›Ǥ ‘—”ƒŽ‘ˆ‡—”‘Ž‘‰› ʹͲͳʹǢʹͷͻǣʹ͸͵ʹǦʹ͸͵ͷǤ ͶͲǤ–”ƒ‹ǡ‡Ž–œ‡”Ǧ”‘†›ǡ—ŽŽƒ”†ǡ ƒ›‡•ǣ‘•–’ƒ”–—…ƒ–ƒ–‘‹ƒ–”‡ƒ–‡†™‹–Š ‡Ž‡…–”‘…‘˜—Ž•‹˜‡–Š‡”ƒ’›ǣƒ…ƒ•‡”‡’‘”–Ǥ ‡‡”ƒŽ‘•’‹–ƒŽ•›…Š‹ƒ–”›ʹͲͳʹǢ͵ͶǣͶ͵͸Ǥ‡͵Ǧ Ͷ͵͸Ǥ‡ͶǤ ͶͳǤƒ”ǡƒš‡ƒǡ”‹˜‡†‹ ǣŽ‡…–”‘…‘˜—Ž•‹˜‡”‡ƒ–‡–‹ƒ–ƒ–‘‹ƒ‘ˆ ‡”‡„”‘˜ƒ•…—Ž‘Ǧ‘ƒ‰—Ž‘’ƒ–Š›Ǥ ‘—”ƒŽ‘ˆʹͲͳ͵ǢʹͻȋͳȌǣ‡ͺǦ‡ͻǤ ͶʹǤ—”ƒ†ǡ”—†‡–ǡ—›ƒǡ‘–‡Ž‘ ǣ”‡‰ƒ–ƒ†…ƒ–ƒ–‘‹ƒǤ—””‡–•›…Š‹ƒ–”› ʹͲͳ͵ǢͳʹȋͺȌǣͶͶǦͶͻǤ

ͺ

Table 1: Published cases of peripartum catatonia in the medical literature.4-6,28-42 N = number; Gest. Age = gestational age; NR = not reported; PP = postpartum; ECT = electroconvulsive therapy; wks = weeks; MDD = major depressive disorder; IV = intravenous; GMC = general medical condition; PMR = psychomotor retardation; PRES = posterior reversible encephalopathy syndrome; NMDA = N-methyl-D-aspartate.

Study

N

Mother’s Age

Gest. Age

Diagnosis

Treatment

Catatonic Symptoms

Kraepelin, 1905

1

29

NR

“katatonia”

Supportive care

Mutism, stupor, echolalia, catalepsy, stereotypy, negativism

Bleckwenn, 1930

1

30

NR

“Catatonic dementia praecox”

Sodium amobarbital

Mutism, stupor, negativism, withdrawal

Sobel et al, 1960

33 NR

Prepartum

“agitation or catatonia”

ECT

NR

Brown et al, 1973

1

27

36 hours PP

subarachnoid hemorrhage

supportive care

waxy flexibility, mutism

Morrant et al, 1984

1

29

9 wks PP

Schizophrenia vs. Chlorpromazine, haloperidol, encephalitis vs. NMS vs. other antibiotics infection

Brockington et al, 1990

1

NR

8 wks PP

postpartum psychosis

chlorpromazine negativism amitriptyline, ECT mutism

Bach Y Rita et al,1992

1

22

1.5 wks PP

postpartum psychosis

ECT

waxy flexibility, posturing, negativism

Ranzini et al, 1996

1

28

21 wks

puerperal psychosis

delivery

akinetic stupor, mutism

Polster et al,1999

1

29

23 wks

schizophrenia

lorazepam, loxapine,

PMR, poverty of speech

Posturing, excitement, stupor

nortriptyline, ECT Lai et al, 2004

4

25-38

0.5-2 wks PP

MDD, schizophrenia, psychosis due to GMC

IV lorazepam

stupor, mutism, immobility, negativism

EspinolaNadurille et al, 2007

1

22

21 wks

puerperal psychosis vs. NMS

ECT, IV lorazepam, clozapine

muscular rigidity, mutism

Kitabayashi et al, 2007

1

19

2 wks PP

atypical PRES

Midazolam, etizolam, ethyl loflazepate

catatonic stupor

Yu et al, 2011

1

29

11 wks PP

paraneoplastic encephalitis

ECT, steroids, plasmapheresis rituximab

stereotypies

McCarthy et al, 2012

1

32

8 wks

NMDA receptor encephalitis

plasma exchange stereotypies, waxy flexibility

Strain et al, 2012

1

18

22 wks PP

postpartum psychosis

lorazepam, olanzapine, ECT

mutism, negativism

Kar et al, 2013

1

27

2 wks PP

cerebrovasculo-c oagulopathy

IV lorazepam, risperdal, ECT

mutism, apathy, disorganized behavior

Durand et al, 1 2013

42

31 wks

schizophrenia with catatonia

haloperidol, lorazepam

mutism, psychomotor retardation

PP

NR

ECT

“catatonic agitation”

Babu et al, 2013

13 NR

Table 2: Risk Analysis of Catatonia Treatment in Pregnancy Risks of Aggressive Treatment Benzodiazepines Neonatal abstinence syndrome Neonatal hypotonia (in 3rd trimester) Cleft palate (in 1st trimester) ECT Miscarriage Placental abruption Vaginal bleeding Pre-term labor Fetal heart decelerations Risks of Conservative Treatment Prolonged Catatonia Deep venous thrombosis/Pulmonary embolus Dehydration Spastic contractures Muscular atrophy Skin ulceration Aspiration pneumonia Maternal Psychiatric Illness Intrauterine growth restriction Preterm contractions Preterm delivery Fetal abnormalities Stillbirth