Author's Accepted Manuscript

Perinatal Catatonia: A Case Report and Litera-

ture Review
Nina Gonzales M.D., Davin Kenneth Quinn M.D.
, William Rayburn M.D.

PII: S0033-3182(14)00014-0
DOI: http://dx.doi.org/10.1016/j.psym.2014.01.009
Reference: 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
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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:negonzales28@gmail.com,davinquinn@yahoo.com,
WRayburn@salud.unm.edu








‡”‹ƒ–ƒŽƒ–ƒ–‘‹ƒ
‹ƒ ‘œƒŽ‡•ǡǤǤ
ƒ˜‹‡‡–Š—‹ǡǤǤ
‹ŽŽ‹ƒƒ›„—”ǡǤǤ

Introduction
ƒ–ƒ–‘‹ƒ‹•ƒ’‘–‡–‹ƒŽŽ›†‡˜ƒ•–ƒ–‹‰’•› Š‘‘–‘”†‹•‘”†‡” Šƒ”ƒ –‡”‹œ‡†„›‡‹–Š‡”
‹‘„‹Ž‹–›ƒ†•–—’‘”‘”ƒ‰‹–ƒ–‡†‡š ‹–‡‡–ǡƒ†‹• ƒ—•‡†„›’•› Š‹ƒ–”‹ ǡ‡†‹ ƒŽǡƒ†
‡—”‘Ž‘‰‹ ƒŽ ‘†‹–‹‘•Ǥ–ƒ†ƒ”†–”‡ƒ–‡–ˆ‘”–Š‹•†‹•‘”†‡”‹•Š‹‰ŠǦ†‘•‡„‡œ‘†‹ƒœ‡’‹‡•
‘”‡Ž‡ –”‘ ‘˜—Ž•‹˜‡–Š‡”ƒ’›ǡ™‹–Š‡ˆˆ‹ ƒ ›”ƒ–‡•‘ˆ—’–‘ͺͷΨͳǤ‡”›Ž‹––Ž‡”‡•‡ƒ” ŠŠƒ•
‡š’Ž‘”‡†–Š‡’”‡˜ƒŽ‡ ‡‘”–”‡ƒ–‡–‘ˆ ƒ–ƒ–‘‹ƒ‹’”‡‰ƒ–™‘‡ǡƒ’‘’—Žƒ–‹‘‹
™Š‘„‡œ‘†‹ƒœ‡’‹‡•ƒ”‡‰‡‡”ƒŽŽ› ‘–”ƒ‹†‹ ƒ–‡††—‡–‘’‘••‹„Ž‡–‡”ƒ–‘‰‡‡•‹•ƒ†
‘–Š‡”’‘–‡–‹ƒŽ ‘’Ž‹ ƒ–‹‘•–‘–Š‡ˆ‡–—•Ǥ‡†‡• ”‹„‡Š‡”‡ƒ ƒ•‡‘ˆ’‡”‹ƒ–ƒŽ ƒ–ƒ–‘‹ƒ

ͳ
†—‡–‘ƒŒ‘”†‡’”‡••‹˜‡†‹•‘”†‡”–”‡ƒ–‡†™‹–Š‡Ž‡ –”‘ ‘˜—Ž•‹˜‡–Š‡”ƒ’›ȋȌǡƒ†”‡˜‹‡™
–Š‡Ž‹–‡”ƒ–—”‡‘ ƒ–ƒ–‘‹ƒ‹’”‡‰ƒ ›ƒ†–Š‡’‘•–’ƒ”–—’‡”‹‘†Ǥ

CaseReport
•Ǥǡƒʹ͵›‡ƒ”Ǧ‘Ž† ͳͲˆ‡ƒŽ‡ƒ–ʹͶ™‡‡•‰‡•–ƒ–‹‘ǡ™ƒ•„”‘—‰Š––‘ƒ’•› Š‹ƒ–”‹ 
‡‡”‰‡ ›”‘‘†—‡–‘‘‡‘–Š‘ˆ——•—ƒŽ„‡Šƒ˜‹‘”•ǤŠ‡Šƒ†„‡ ‘‡™‹–Š†”ƒ™ǡ
†‡’”‡••‡†ǡƒ†Šƒ†–ƒ‡–‘ ”ƒ™Ž‹‰‘–Š‡ˆŽ‘‘”ǡ Ž‹‰‹‰–‘Š‡”ˆƒ‹Ž›‡„‡”•̵ Ž‘–Š‡•
ƒ† ‡ƒ•‡Ž‡••Ž› ”›‹‰ǤŠ‡™‘—Ž†„‡‰–Š‡–‘Š‡Ž’Š‡”†‡•’‹–‡Šƒ˜‹‰Š‡”‘™Š‘‡ǡ
‡’Ž‘›‡–ǡƒ†•’‘—•‡ǤŠ‡™ƒ•—ƒ„Ž‡–‘ ‘˜‡”•‡‹ƒ‡ƒ‹‰ˆ—Ž™ƒ›ǡƒ†™ƒ•‘–
‘•‘Žƒ„Ž‡†—”‹‰–Š‡•‡‡’‹•‘†‡•ǤŠ‡•‡„‡Šƒ˜‹‘”•™‘—Ž†‘ —”ƒŽŽ†ƒ›Ž‘‰—–‹Ž–Š‡‡ƒ”Ž›
‘”‹‰™Š‡•Š‡™‘—Ž†ˆƒŽŽƒ•Ž‡‡’ǤŠ‡†‹†‘–‡ƒ–™‡ŽŽǡ•Ž‡‡’”‡‰—Žƒ”Ž›ǡ‘”–‡†–‘
’‡”•‘ƒŽŠ›‰‹‡‡Ǥ’”‡•‡–ƒ–‹‘Š‡”˜‹–ƒŽ•ǡ’Š›•‹ ƒŽ‡šƒǡ‘„•–‡–”‹ ƒŽ‡šƒƒ†Žƒ„•
‹ Ž—†‹‰ ‘’Ž‡–‡„Ž‘‘† ‘—–ǡ ‘’”‡Š‡•‹˜‡‡–ƒ„‘Ž‹ ’ƒ‡Žǡ˜‹–ƒ‹ͳʹƒ†ͳŽ‡˜‡Ž•ǡ
Ž‹˜‡”ˆ— –‹‘–‡•–•ǡ’”‡ƒŽ„—‹ǡ—”‹ƒŽ›•‹•ǡ–Š›”‘‹†•–‹—Žƒ–‹‰Š‘”‘‡ǡ—”‹‡–‘š‹ ‘Ž‘‰‹ 
• ”‡‡ǡƒ†–”‡’‘‡ƒ’ƒŽŽ‹†—ƒ–‹„‘†›™‡”‡ƒŽŽ™‹–Š‹‘”ƒŽŽ‹‹–•Ǥ•Ǥ™ƒ•ƒ†‹––‡†
–‘ƒ‹’ƒ–‹‡–’•› Š‹ƒ–”‹ ™ƒ”†™‹–Šƒ’”‡•—’–‹˜‡†‹ƒ‰‘•‹•‘ˆ’•› Š‘•‹•‘–‘–Š‡”™‹•‡
•’‡ ‹ˆ‹‡†ȋȌǤ‹ˆˆ‡”‡–‹ƒŽ†‹ƒ‰‘•‹•‹ Ž—†‡†• Š‹œ‘’Š”‡‹ˆ‘”†‹•‘”†‡”ǡ†‡’”‡••‹‘
™‹–Š’•› Š‘–‹ ˆ‡ƒ–—”‡•ǡ„‹’‘Žƒ”†‹•‘”†‡”™‹–Š’•› Š‘–‹ ˆ‡ƒ–—”‡•ǡƒ†’•› Š‘•‹•†—‡–‘
‰‡‡”ƒŽ‡†‹ ƒŽ‹ŽŽ‡••Ǥ

•ǤŠƒ†‘’”‡˜‹‘—•”‡’‘”–‡†’•› Š‹ƒ–”‹ Š‹•–‘”›‘”•‹‹Žƒ”‡’‹•‘†‡•Ǥ ‡”ˆƒ‹Ž›
’•› Š‹ƒ–”‹ Š‹•–‘”›™ƒ••‹‰‹ˆ‹ ƒ–ˆ‘”ƒ— Ž‡™Š‘™ƒ•’•› Š‹ƒ–”‹ ƒŽŽ›Š‘•’‹–ƒŽ‹œ‡†ˆ‘”
Dz‘††„‡Šƒ˜‹‘”•Ǥdz‡†‹ ƒ–‹‘•‹ Ž—†‡†‘Ž›’”‡ƒ–ƒŽ˜‹–ƒ‹•ƒ†•Š‡Šƒ†‘‘™
ƒŽŽ‡”‰‹‡•ǤŠ‡”‡™ƒ•‘”‡’‘”–‡†•‹‰‹ˆ‹ ƒ–’ƒ•–‡†‹ ƒŽŠ‹•–‘”›‘”•—„•–ƒ ‡ƒ„—•‡ǤŠ‡
™ƒ•ƒ””‹‡†–‘–Š‡ˆƒ–Š‡”‘ˆ–Š‡„ƒ„›„—–Ž‹˜‡†™‹–ŠŠ‡”‘–Š‡”†—‡–‘ƒ”‹–ƒŽ’”‘„Ž‡•ǡ
ƒ†™‘”‡†ƒ”‡–ƒ‹ŽŒ‘„ƒ–ƒŽƒ”‰‡†‡’ƒ”–‡–•–‘”‡Ǥ ‘”†‹‰–‘ˆƒ‹Ž›ǡŠ‡”„ƒ•‡Ž‹‡
–‡’‡”ƒ‡–™ƒ•‰‡‡”ƒŽŽ›“—‹‡–™‹–Šˆ‡™ˆ”‹‡†•Ǥ

–Š‡’•› Š‹ƒ–”‹ —‹–ǡ–Š‡’ƒ–‹‡– ‘–‹—‡†–‘‡šŠ‹„‹–‘††„‡Šƒ˜‹‘”••— Šƒ• ”ƒ™Ž‹‰
ƒ”‘—†‘Š‡”‡‡•ƒ†’Žƒ›‹‰™‹–ŠŠ‡”ˆ‘‘†‘–Š‡ˆŽ‘‘”ǤŠ‡Šƒ†‹‹ƒŽ•’‡‡ ŠǡˆŽƒ–
ƒˆˆ‡ –ǡ’‘‘”‡‡”‰›ǡ’‘‘” ‘ ‡–”ƒ–‹‘ǡŠ›’‡”•‘‹ƒǡ’‘‘”’‡”•‘ƒŽŠ›‰‹‡‡ǡƒ††ƒ‹Ž›
ˆŽ— –—ƒ–‹‘„‡–™‡‡’•› Š‘‘–‘””‡–ƒ”†ƒ–‹‘ƒ†ƒ‰‹–ƒ–‹‘ǤŠ‡™ƒ•‹•‘Žƒ–‹˜‡–‘Š‡””‘‘
ƒ††‹†‘–‹–‡”ƒ –‡ƒ‹‰ˆ—ŽŽ›™‹–Š’‡‡”•‘”•–ƒˆˆǤ—‡–‘–Š‡ˆ‘ŽŽ‘™‹‰‘„•‡”˜‡†
•›’–‘•ǡŠ‡”†‹ƒ‰‘•‹•™ƒ• Šƒ‰‡†–‘ƒŒ‘”†‡’”‡••‹˜‡†‹•‘”†‡”™‹–Š’•› Š‘–‹ 
ˆ‡ƒ–—”‡•Ǥ ƒŽ‘’‡”‹†‘Žͷ‰–™‹ ‡†ƒ‹Ž›ƒ†•‡”–”ƒŽ‹‡—’–‘ʹͲͲ‰†ƒ‹Ž›„”‘—‰Š–ƒ„‘—–ƒ
‹Ž††‡ ”‡ƒ•‡‹——•—ƒŽ„‡Šƒ˜‹‘”•„—–Ž‹––Ž‡‹’”‘˜‡‡–‘ˆ†‡’”‡••‹˜‡•›’–‘•Ǥ–
ƒ’’”‘š‹ƒ–‡Ž›‘‡‘–Š‹–‘Š‘•’‹–ƒŽ‹œƒ–‹‘ǡŠ‡”†‹ƒ‰‘•‹•™ƒ•”‡˜‹•‡†–‘ƒŒ‘”
†‡’”‡••‹˜‡†‹•‘”†‡”™‹–Š’•› Š‘–‹ ƒ† ƒ–ƒ–‘‹ ˆ‡ƒ–—”‡•†—‡–‘—–‹•ǡ”‡ˆ—•ƒŽ–‘‡ƒ–ǡ
†”‹‘”ƒ––‡†–‘’‡”•‘ƒŽŠ›‰‹‡‡ǡ’‡”‹‘†•‘ˆ•–ƒ”‹‰™‹–Š‹‹ƒŽ„Ž‹‹‰ǡƒ†
‡‰ƒ–‹˜‹•ǤŠ‡—•ŠǦ ”ƒ ‹•ƒ–ƒ–‘‹ƒƒ–‹‰ ƒŽ‡™ƒ•’‡”ˆ‘”‡†™‹–Šƒ• ‘”‡‘ˆ
ʹͳǤŠ‹Ž‡ƒ–‹’•› Š‘–‹ •ƒ›’‘–‡–‹ƒŽŽ›™‘”•‡ ƒ–ƒ–‘‹ƒ‹•‘‡’ƒ–‹‡–•ǡŠƒŽ‘’‡”‹†‘Ž
†‹†‘–‡šƒ ‡”„ƒ–‡ ƒ–ƒ–‘‹ •›’–‘•‹–Š‹• ƒ•‡Ǥ ‡”–”‡ƒ–‹‰–‡ƒ“—‡•–‹‘‡†™Š‡–Š‡”
–Š‡‘”‹‰‹ƒŽ‘††„‡Šƒ˜‹‘”•™‡”‡‘–’•› Š‘–‹ ˆ‡ƒ–—”‡•„—–ƒ –—ƒŽŽ›–Š‡’—”’‘•‡Ž‡••
•–‡”‡‘–›’‡†ƒ‰‹–ƒ–‹‘‘ˆ‡š ‹–‡† ƒ–ƒ–‘‹ƒǤŽ‡ –”‘ ‘˜—Ž•‹˜‡–Š‡”ƒ’›ȋȌ–”‡ƒ–‡–•
™‡”‡–Š‡‹‹–‹ƒ–‡†–‘ƒ††”‡••„‘–Š†‡’”‡••‹‘ƒ† ƒ–ƒ–‘‹ ˆ‡ƒ–—”‡•Ǥ

™ƒ•ƒ†‹‹•–‡”‡†™‹–Š”‹‰Š–—‹Žƒ–‡”ƒŽŽ‡ƒ†’Žƒ ‡‡––‘‹‹‹œ‡ ‘‰‹–‹˜‡‡ˆˆ‡ –•Ǥ
‘„•–‡–”‹ ƒŽ—”•‡ƒ••‹•–‡†™‹–Š ‘–‹—‘—•ˆ‡–ƒŽŠ‡ƒ”–”ƒ–‡‘‹–‘”‹‰’Ž—•—–‡”‹‡ƒ –‹˜‹–›
‘‹–‘”‹‰ˆ‘”ʹͲ‹—–‡•’”‡Ǧƒ†͸Ͳ‹—–‡•’‘•–ǦǤŠ‡™ƒ•ƒŽ•‘ Š‡ ‡†’‘•–Ǧ

ʹ
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


͵
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 –‘”‡†

Ͷ
‹–‘”‹•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™ƒ ǡ‡–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‹‰ǡ ƒ›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”‘™ ǡ ƒ•‘ 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‹ǡ ƒ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 Gest. Diagnosis Treatment Catatonic

Age Age Symptoms

Kraepelin, 1 29 NR “katatonia” Supportive care Mutism,

1905 stupor,
echolalia,
catalepsy,
stereotypy,
negativism

Bleckwenn, 1 30 NR “Catatonic Sodium Mutism,

1930 dementia amobarbital stupor,
praecox” negativism,
withdrawal

Sobel et al, 33 NR Pre- “agitation or ECT NR

1960 partum catatonia”

Brown et al, 1 27 36 subarachnoid supportive care waxy flexibility,

1973 hours hemorrhage mutism
PP

Morrant et 1 29 9 wks Schizophrenia vs. Chlorpromazine, Posturing,

al, 1984 PP encephalitis vs. haloperidol, excitement,
NMS vs. other antibiotics stupor
infection

Brockington 1 NR 8 wks postpartum chlorpromazine negativism

et al, 1990 PP psychosis amitriptyline, ECT mutism

Bach Y Rita 1 22 1.5 postpartum ECT waxy flexibility,

et al,1992 wks psychosis posturing,
PP negativism

Ranzini et 1 28 21 wks puerperal delivery akinetic

al, 1996 psychosis stupor,
mutism

Polster et 1 29 23 wks schizophrenia lorazepam, PMR, poverty

al,1999 loxapine, of speech
 nortriptyline, ECT

Lai et al, 4 25-38 0.5-2 MDD, IV lorazepam stupor,

2004 wks schizophrenia, mutism,
PP psychosis due to immobility,
GMC negativism

Espinola- 1 22 21 wks puerperal ECT, IV muscular

Nadurille et psychosis vs. lorazepam, rigidity,
al, 2007 NMS clozapine mutism

Kitabayashi 1 19 2 wks atypical PRES Midazolam, catatonic

et al, 2007 PP etizolam, ethyl stupor
loflazepate

Yu et al, 1 29 11 wks paraneoplastic ECT, steroids, stereotypies

2011 PP encephalitis plasmapheresis
rituximab

McCarthy et 1 32 8 wks NMDA receptor plasma exchange stereotypies,

al, 2012 encephalitis waxy flexibility

Strain et al, 1 18 22 wks postpartum lorazepam, mutism,

2012 PP psychosis olanzapine, ECT negativism

Kar et al, 1 27 2 wks cerebrovasculo-c IV lorazepam, mutism,

2013 PP oagulopathy risperdal, apathy,
ECT disorganized
behavior

Durand et al, 1 42 31 wks schizophrenia haloperidol, mutism,

2013 with catatonia lorazepam psychomotor
retardation

Babu et al, 13 NR PP NR ECT “catatonic

2013 agitation”
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