Catatonic syndrome

A psychiatric phenomenon, a special form of insanity, first described as an independent disease by K. Kohlbaum at the end of the 19th century. He also came up with the name: catatonia, which comes from the ancient Greek κατατείνω – to strain. The main manifestation of this condition is a violation of the tone of the body's muscles, their tension in combination with volitional disorders.

Later, catatonic syndrome was attributed to schizophrenic psychosis. It is now known that catatonia can develop, in addition to schizophrenia, with many mental disorders, as well as neurological and general diseases and intoxications, neoplasms and brain injuries.

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Epidemiology

The prevalence of catatonia among the world's population is unknown, and various studies report completely inconsistent data.

There is evidence that approximately 5-10% of schizophrenics develop symptoms of catatonia. And although catatonic manifestations are still considered in the context of schizophrenia, in some modern studies among the patients with catatonic syndrome included in the sample, for nine to ten people with affective disorders, there was only one schizophrenic.

It is estimated that among young people with autism spectrum disorders, symptoms of catatonia are found in every sixth to eighth person.

According to various sources, 10 to 17% of patients with catatonia are kept in psychiatric hospitals. The role of ethnic factors in the development of this syndrome is unknown.

The incidence of catatonia in female and male patients is almost the same, but idiopathic catatonia is more common in women.

Catatonic syndrome of people from the risk group can occur at any age, however, in children and the elderly much less often than in the younger generation. Basically, catatonia manifests itself in schizophrenics at the beginning of the manifestations of the main disease from 16 to 40 years.

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Causes catatonia

It is currently not known exactly what processes occurring in the brain cause a catatonic state. However, even intrauterine abnormal development of the cerebral cortex in the fetus can lead to schizophrenia and other mental disorders. Hereditary predisposition is not excluded.

Symptoms of catatonia are observed in people with functional disorders of cortical and subcortical glutamatergic connections, disturbance of the balance between excitation and inhibition, functional deficiency of γ-aminobutyric acid, and blockade of postsynaptic dopamine receptors.

Also, during autopsy of deceased persons with catatonic syndrome, structural anomalies of the frontal elements of the brain (fossa cerebri, middle and inferior frontal convolutions) were revealed.

Catatonia is not an independent nosological entity. In addition to congenital anomalies and obstetric pathologies, acquired organic disorders resulting from diseases, injuries and intoxications are considered among the causes of this syndrome.

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Risk factors

The so-called catatonic spectrum of diseases has been identified, in which the development of catatonia is most likely.

First of all, these are mental disorders, with emotional disorders ( affect ) coming to the forefront, especially deep depression and mania, even ahead of schizophrenia. This spectrum of diseases includes post-traumatic and postpartum psychoses, hysterical neurosis, autistic disorders. Catotonic syndrome is observed in mentally retarded patients and children with mental development disorders.

People who have suffered encephalitis, stroke, traumatic brain injury, epilepsy, brain tumors, and Tourette's disease have a fairly high risk of developing a catatonic state.

Some congenital and acquired metabolic disorders leading to sodium or cyanocobalamin deficiency, copper excess ( Wilson-Konovalov disease ), and early childhood amaurotic idiocy are considered risk factors for this syndrome.

Chronic endocrine and autoimmune pathologies, oncological diseases, Werlhof's disease, AIDS, typhoid fever can lead to the development of catatonia. This condition can also be a consequence of hypoxia, heat stroke, severe diseases suffered in childhood, in particular, rheumatic fever.

Catatonic syndrome develops in drug addicts as a consequence of carbon monoxide and exhaust gas intoxication, as a side effect of a therapeutic course of dopamine receptor blockers (neuroleptics), anticonvulsants, glucocorticosteroids, the antibiotic ciprofloxacin, disulfiram (a drug for treating alcoholics), muscle relaxants with the active ingredient cyclobenzaprine. Sudden withdrawal of the antipsychotic clozapine, anticonvulsants and dopaminomimetics, benzodiazepine drugs can cause this condition.

In some cases, it was never determined what triggered the development of catatonia – idiopathic catatonic syndrome.

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Pathogenesis

The mechanism for the development of this condition also falls within the realm of speculation, and there are several of them.

Since a pronounced therapeutic effect in the treatment of catatonia is observed when using benzodiazepine drugs, it is assumed that the basis of the disorder of psychomotor functions is a deficiency of γ-aminobutyric acid (GABA), which is the main neurotransmitter of inhibition processes in the cerebral cortex. Benzodiazepines normalize the functions of the basal nuclei, affecting GABA receptors, increasing the affinity of the acid to neurons of the brain. Another similar assumption concerns the increased activity of the excitatory transmitter - glutamate.

Attempts to treat catatonia with neuroleptics have failed to achieve success, and even worsening of the patients' condition has been observed. Based on this, there is a hypothesis that catatonia occurs due to an immediate and massive blockade of dopaminergic receptors. Moreover, treatment with dopamine stimulants is usually successful, and electroconvulsive therapy (electroshock) also promotes the release of dopaminergic receptors.

Withdrawal syndrome from the atypical neuroleptic Clozapine manifests itself as catatonia, the cause of which is associated with the release of cholinergic and serotonergic receptors, due to which the activity of these systems increases.

In patients with chronic catatonic syndrome, accompanied by severe speech dysfunction, PET tomograms reveal bilateral metabolic disturbances in the upper part of the thalamic zone of the diencephalon and the frontal lobes of the cerebral cortex.

Researchers identify a special type of autistic catatonia observed in individuals with mental development disorders, the pathogenesis of which includes a deficiency of γ-aminobutyric acid, disorders in small structures of the cerebellum, and a hereditary predisposition due to the presence of a gene on the long arm of chromosome 15.

Non-convulsive epileptic seizure in the form of catatonic syndrome (ictal catatonia) is considered to be caused by damage to the visceral brain ( limbic system ).

These hypotheses are based on real observations of patients, their reaction to drugs and diagnostic tests. Another assumption is based on the fact that catatonic syndrome is currently observed in patients with mental and general diseases who are in a severe (pre-death) condition. Catatonic stupor is considered a reaction of horror caused by a sense of imminent death. Prey animals fall into a similar state when they encounter a predator.

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Symptoms catatonia

The first signs of impending catatonia create the impression of an abnormal increase in the characteristics characteristic of the individual. In the prodromal period, the patient is more withdrawn than usual, spends almost all his time alone, and is irritated by attempts to involve him in any common activities. He often complains of difficulty falling asleep, headaches, weakness, and the inability to perform any purposeful actions.

Later, the mood changes significantly, anxiety appears, various delusional thoughts and visions, numbness of the limbs and the whole body, the perception of reality is transformed, negativity increases, the patient may completely refuse to move and eat.

Many symptoms of catatonic syndrome have been described, some of them are characteristic of different mental disorders, a full complex of symptoms in one patient is not necessary. The features of clinical signs depend on the type of syndrome and the age of the patient.

During the catatonic state the following may be observed:

• stupor - a combination of complete immobility and the absence of any kind of contact with the patient (mutism), although in principle the patient retains the ability to speak, sometimes there is one of the symptoms - immobility or mutism;
• negativism - the patient resists attempts to give his body a different position, while muscular resistance is equal in strength to external efforts;
• disgust towards others, medical personnel (aversion) – the patient does not respond to the appeal, turns away, demonstrating with his whole appearance a reluctance to make contact;
• catalepsy (waxy flexibility) - an abnormally long period of maintaining a fanciful, extremely uncomfortable position, which the doctor can give the patient; in addition, the patient himself often takes strange uncomfortable positions and remains in them for a long time;
• submission brought to automatism - the patient does absolutely everything with extraordinary precision, the body pliably takes any, even the most uncomfortable position without resistance, but again returns to its original position when it is not touched (unlike catalepsy);
• the “air cushion” sign – the patient lies with his head raised above the surface of the bed, as if on an invisible pillow, for quite a long time – a typical position for catatonia;
• ambitendent – a demonstration of peculiar ambitions; the patient, while agreeing, still does not want to obey, for example, he extends his hand to the doctor, but at the last moment pulls it back;
• verbigeration – repetition of the same speech stereotypes: phrases or sentences, words (palilalia), individual syllables (logoclonia);
• logorrhea - monotonous, continuous, incoherent muttering;
• echolalia – the patient echoes all the sounds pronounced by the doctor;
• echopraxia – repeating someone else’s movements;
• thought and movement blocking - sudden cessation of speech or movement;
• Stereotypes and motor perseverations – constant repetition of identical meaningless movements.

Patients have wide-open eyes, they grab the doctor's hand during examination, the nurse or relatives, not allowing them to touch them. A characteristic feature is an instant transition from a stuporous state to an excitable one and vice versa, while the movements are impulsive, absurd and meaningless (jumps, somersaults, attacks). Speech excitation is manifested by swearing, singing, indistinct muttering. Both motor and speech excitation are characterized by endless repetitions of grimaces, jumps, shouts. Some patients are mannered - they greet and bow all the time. Sometimes the transition from an excited state to an inhibited one and vice versa occurs gradually.

In most cases, patients are satisfactorily oriented in time and space, but confusion of consciousness, speech, hallucinations, very varied, instantaneous or with gradual development, also occur.

Severe stages are characterized by symptoms such as mutism and immobility, sharp negativism, bizarre postures, reluctance to eat, prolonged muscle rigidity, and increasing speech disorders.

Often, an excited state with delirium and hallucinations is followed by a short-term normalization of the state, occasionally so long that it borders on recovery.

However, catatonic stupor of varying depth and duration develops even more frequently. It can be chronic with frequent and sudden emotional outbursts, accompanied by senseless escapades.

Sometimes the syndrome occurs in the form of catatonic seizures, expressed in the periodic alternation of stupor and excitement.

Symptoms of vascular innervation disorder are striking: the patient's pale face can instantly turn red, sometimes some part of the body turns red - the forehead, one cheek, ear, neck. Patients lose weight, they have persistent sleep disorders. Other somatic symptoms accompanying catatonia are arrhythmia, increased sweating and salivation, rashes resembling urticaria, fluctuations in body temperature (morning and evening), constriction - enlargement of the pupils and variability of their reaction, shallow breathing.

Chronic catatonia in mental illnesses, particularly in schizophrenics, generally leads to progression of mental retardation. At the same time, it is precisely in the catatonic form of schizophrenia that long-term remissions after the syndrome in 15% of patients are practically similar to their recovery.

Catatonia in a child most often has symptoms of rhythmic motor stereotypes - grimacing, running in circles, monotonous movements of the arms, legs, body, running or walking on tiptoes, on the outer or inner side of the foot, etc. Movements and actions are characterized by impulsiveness, mutism, echopraxia, echolalia and other speech disorders are often observed. Often, a child may have regressive catatonia - he begins to completely copy the behavior of animals (licking himself and objects, eating without the help of cutlery, etc.).

It should be taken into account that catatonic syndrome does not always go through all the described stages of development and in different cases their random order is observed.

Psychomotor disturbances in catatonic syndrome are classified as agitation and stupor.

An excited state is characterized by psychomotor activity and is divided into the following forms:

• pathetic excitement (while maintaining consciousness) - increases gradually, in the highest phase - moderate manifestations; patients are mannered, pathetic, there is an elevated background of mood, in the form of exaltation, and not hyperthymia; pathetic poses and gestures are noted, there may be echolalia; then the excitement increases, and the patient begins to openly fool around, impulsive actions appear, reminiscent of hebephrenia;
• impulsive excitement has an acute onset, develops suddenly and rapidly, in most cases the patient's actions are harsh and destructive, antisocial in nature; speech disorders (verbigeration) are observed;
• the peak of the previous form, reaching the point of frenzy, some experts distinguish as a third variant - silent excitement, when the patient, without uttering a sound, destroys everything around him, splashing out aggression on those around him and even on himself.

In stupor, the patient's muscles are almost always tense and stiff, sometimes to the point of impossibility of even passive movements. A patient in a substuporous state is sedentary and slow, while in a stuporous state he lies, sits or stands motionless. The patient is silent, his face is like a frozen mask, facial expressions are often absent, sometimes the movements of the facial muscles correspond to the affective state - the patient wrinkles his forehead, squeezes his eyelids, tenses the muscles of the jaws and neck, stretches his lips like a "pipe". Patients can remain in a catatonic stupor for a long time, measured in weeks and months. There is a disorder of all functions, even instinctive ones, as well as symptoms of disorders of the somatic sphere and the autonomic nervous system: cyanosis and swelling of the extremities, hypersalivation, hyperhidrosis, seborrhea, hypotension. Three stuporous forms of catatonia are distinguished:

• cataleptic - the individual maintains a certain pose for a long period of time, often unnatural, which he has adopted himself or has been given by others (waxen flexibility), for example, lying on an "air cushion" with a blanket over his head; normal and loud speech does not cause a reaction, but may react to a whisper; under the influence of darkness and silence, stupor sometimes weakens and contact becomes possible for a while (this form is characterized by the presence of delirium and hallucinations);
• negativistic - motor retardation is combined with resistance to any attempts on the part of the patient to change his position, resistance can be active and passive;
• numbness - the peak of inhibition and stiffness of the muscles, often in the fetal position or on an “air cushion”, the lips are stretched into a tube.

Mutual transformations of one form of catatonic stupor or excitation into another have been noted, although such cases are rare. More common are transformations of an excited state into a stuporous one and vice versa, usually of the appropriate type, for example, pathetic excitation → cataleptic stupor, impulsive → negativistic or stupor with numbness.

Based on the presence or absence of a disorder of consciousness, catatonia is classified into the following types: empty, lucid, and oneiroid.

Empty is characterized by typical symptoms of the syndrome without delirium and hallucinations, as well as affects: monotonous iterations of movements, poses, phrases and words, catalepsy, echo symptoms, negativism - inert (the patient sabotages requests), active (the patient performs actions, but not those required), paradoxical (performs actions opposite to those required). This type of syndrome is sometimes observed in organic lesions of brain tissue (neoplasms, consequences of craniocerebral trauma, infections and intoxications).

Lucid (pure) catatonia is characterized by the presence of productive symptoms (delusions, hallucinations) without a disorder of consciousness. The individual's self-identification is not impaired, he remembers and can reproduce the events that actually occurred during the period of stupor.

Oneiroid catatonia is the course of this syndrome with delusional and manic episodes, hallucinations, and also accompanied by clouding of consciousness. It begins suddenly with a pronounced increase in psychokinetic arousal. The individual's behavior and facial expressions quickly change, and manic features appear. Movements are active, natural, flexible, delirium appears, speech activity and the lack of need for an interlocutor (schizophasia). The patient experiences bright and colorful events in a solitary world that absolutely do not correspond to reality - catatonic sleep, which is characterized by the presence of a plot and completeness. The individual himself feels like the main character of stories that happened exclusively in his mind. They are accompanied by fantastic excitement, with intense emotional coloring, instantaneous changes from chaotic excitement to a stuporous state. The patient's facial expressions, reflecting the excitement he experiences in catatonic sleep, are usually very expressive. After emerging from the syndrome, the patient does not remember any real events, but can describe his "dreams". Catatonic sleep lasts from several days to several weeks.

It is believed that lucid catatonia is characteristic only of schizophrenia, while oneiroid catatonia is more common in neoplasms of the basal parts of the brain, post-traumatic or acute epileptic psychoses, the consequences of severe infections and intoxications, and progressive paralysis.

Febrile catatonia is an acute mental disorder and is observed in schizophrenics and individuals with affective disorders. External manifestations resemble the oneiroid type, accompanied by the rapid development of not only psychopathological, but also somatic disorders. It can take a malignant course if therapeutic measures are not started immediately in the first hours of the syndrome development.

A specific symptom is a high body temperature, manifested as fever, there may be temperature jumps. In addition, the patient's pulse and breathing quickens, the skin becomes sallow-gray, facial features become sharper, eye sockets become sunken, the forehead becomes covered with beads of sweat, the gaze is not concentrated, the lips are dry, the tongue has a white or brownish coating.

The cause of the patient's death is the development of cerebral edema.

Regressive catatonia is most often observed in children. It manifests itself as copying the behavioral stereotypes of animals.

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Complications and consequences

The characteristics of catatonic syndrome are such that it can cause adverse consequences both for the patient and for those around him. This condition cannot be ignored; at the first signs of the syndrome, it is necessary to consult a doctor, and possibly even hospitalize the patient.

Most patients in an excited state are characterized by antisocial behavior, and can cause serious injuries to others and themselves, including fatal injuries.

Refusal to eat can lead to cachexia, dehydration of the body and death by starvation if the patient is not fed and watered forcibly through a tube. Long-term unnatural feeding is complicated by digestive system disorders, water-electrolyte imbalance, development of hypoglycemia and hypercapnia.

In patients with catatonic syndrome, as a result of prolonged lying in one (often unnatural) position, bedsores may appear, hypostatic pneumonia, venous thrombosis, pulmonary embolism, and pneumothorax may develop.

Failure to observe basic hygiene rules can lead to infection of the oral cavity and genitourinary organs.

Catatonia is often complicated by vegetative symptoms, hyperthermia, cardiac dysfunction, fluctuations in blood pressure, the appearance of muscle contractures, paresis and paralysis.

Malignant course of catatonic syndrome usually leads to death.

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Diagnostics catatonia

This condition is diagnosed by psychiatrists, relying on the patient's medical history and the results of objective examinations.

The basis for examining a patient is the presence of one or more symptoms of catatonic syndrome. The presence of prolonged motionless stay in one position (stupor), abnormal agitation, mutism, negativism, resistance or automatic submission, bizarre postures (wax flexibility), echo phenomena, muscular rigidity, verbigeration and autism are taken into account.

Laboratory tests are mandatory: blood - clinical, for glucose content, creatine phosphokinase, thyroid hormones, liver function tests, autoantibody content, heavy metals, HIV infection and the Wasserman reaction; urine - general and for the presence of narcotic substances, specific tests for kidney function. Bacteriological tests of blood and urine may be prescribed.

Instrumental diagnostics are prescribed based on the results of the examination and may include electrocardiography, ultrasound, electroencephalography, computed tomography and magnetic resonance imaging. If necessary, the patient is prescribed a spinal fluid puncture, and other more specific studies may be prescribed.

Catatonia is a condition that occurs in a variety of diseases. First of all, the doctor needs to identify treatable causes, which play a decisive role in choosing the treatment tactics.

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Differential diagnosis

Catatonic syndrome can develop in various pathological conditions, and their differentiation is of crucial importance in prescribing drugs to normalize the patient's condition.

First of all, it is assumed that the patient has schizophrenia, since catatonic syndrome is historically associated with this disease. Pathetic catatonia at the peak of symptom growth should be differentiated from such a subtype of this disease as hebephrenia - those suffering from this form of the disease behave childishly, grimace, grimace, their emotional background is unstable. For the diagnosis of catatonic schizophrenia (according to ICD-10), at least one of the main symptoms of catatonia (stupor / agitation, freezing in various poses / waxy flexibility / muscle rigidity, negativism / command automatism) should be recorded in the patient lasting at least two weeks.

For affective disorders, the diagnostic criterion is the most extreme manifestation - catatonic stupor. Catatonia is recognized as a related diagnosis for such affective disorders as obsessive-compulsive disorder, depression, mania, bipolar disorder.

Catalepsy (a condition in which a person holds any uncomfortable position for a long time and this position can be easily changed) is one of the symptoms of catatonia, but far from the only one. Cataleptic seizures are called sleep paralysis, and in most patients they pass quite quickly.

Malignant neuroleptic syndrome, caused by taking antipsychotics, is considered by many specialists to be a type of lethal catatonia. However, these two conditions have an important clinical difference - the onset of the first is marked by extreme psychotic excitement, and the second begins with severe extrapyramidal rigidity of the body's muscles. Their difference is of great importance, since in the first case, timely measures can save the patient's life.

Encephalography helps differentiate catatonia from nonconvulsive status epilepticus.

Catatonia is differentiated from muscle stiffness syndrome, severe negative symptoms in mental pathologies, malignant hyperthermia, Parkinson's disease, dementia, organic catatonic disorders and other hyper- and hypokinetic syndromes.

A comprehensive examination of the patient helps to determine whether catatonia is functional or organic, and to determine which department the patient should be hospitalized in to receive assistance – psychiatric or general somatic.

Treatment catatonia

Patients with catatonic syndrome almost always require hospitalization, in complex cases – intensive care, since they require constant care from nursing staff and monitoring of the functioning of vital organs.

Preference in the treatment of catatonia is given to drugs of the benzodiazepine series, the action of which is aimed at stimulating the inhibitory neurotransmitter γ-aminobutyric acid, the reduced activity of which is considered one of the causes of this condition. These substances have a calming and hypnotic effect, reduce mental agitation and have a relaxing effect on muscle tissue. They have a moderate anticonvulsant effect.

There is experience of treating patients with catatonia with the oral form of the drug Lorazepam of medium duration of action and intramuscular injections of Diazepam (prolonged action), with a rapid therapeutic effect (within two days) in most patients. Two of them achieved remission after a single dose. But half of the patients required electroshock therapy for further normalization of the condition.

Other researchers report an even more impressive effect of Lorazepam, with 80% of the study group experiencing a complete disappearance of signs of catatonia within just two hours of taking the drug.

Benzodiazepine drugs in low doses are effective in cases of catatonic stupor, as well as agitation. Organic catatonia also responds well to therapy with these drugs.

Patients resistant to benzodiazepine therapy are usually given electroconvulsive therapy. This method is used to treat patients with mental illnesses, including schizophrenics. It is effective in depression, organic and hysterical, as well as idiopathic catatonia. The number of electroshock sessions required for a particular patient does not depend on the causes of the catatonic syndrome. This radical method helps to increase dopamine levels.

Treatment of catatonia with dopamine, especially its malignant forms, is also practiced in psychiatry. In addition to electroconvulsive therapy, which is used in this case as emergency aid, treatment regimens include benzodiazepines, Bromocriptine (a dopamine receptor stimulator), and Dantrolene (a muscle relaxant).

Also, the antiparkinsonian dopaminergic drug amantadine has proven effective in the treatment of catatonia.

Neuroleptics are not used as a means of treating catatonia, even in schizophrenics, whose underlying disease is treated with these drugs.

However, in cases of resistance to the action of benzodiazepines (resistant catatonia), the patient may experience rapid and long-term remission after treatment with the atypical neuroleptic Risperidone.

Catatonic stupor, resistant to traditional treatment with benzodiazepines, responded to combination therapy with lithium drugs in combination with a neuroleptic.

The anticonvulsant drug for epileptics Finlepsin (Carbamazepine) has proven effective as an emergency treatment and in maintenance therapy for catatonic syndrome.

The benzodiazepine analogue Zolpidem had a rapid and beneficial effect on a patient with catatonia resistant to traditional means (benzodiazepines and electroconvulsive therapy). This drug selectively stimulates benzodiazepine receptors of the omega-1 subclass.

It does not have a relaxing effect on muscles and does not stop cramps, however, it has proven itself as a good sleeping pill, reducing the period of falling asleep and the latent phase of sleep, prolonging the total time and quality of sleep. In addition, the drug does not cause daytime sleepiness and addiction.

The modern treatments described have been researched and have evidence-based value.

Prevention

Catatonia can arise from various causes and it is impossible to prevent them all, however, it is quite possible to reduce the risk. It is necessary to take a responsible attitude towards your health and teach your children to do the same, not to use psychoactive substances, promptly treat mental and neurological diseases, increase stress resistance and strengthen the immune system. These measures include proper nutrition, physical activity and a positive outlook on the world.

If there is a sick person from the risk group in the family, then he must be protected from stress and traumatic situations, at the first signs of catatonia, you need to seek medical help. Modern medicine has a good arsenal of means to bring a person out of this state.

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Forecast

Researchers of this phenomenon (mostly Western psychiatrists) report favorable treatment outcomes for patients with catatonic syndrome, which arose for various reasons. Apparently, the prognosis in most cases depends on timely treatment, correctness and quality of treatment. Most patients responded to treatment quickly and came out of this state.

Many researchers report that patients with affective disorders (mania, depression) had a high frequency of subsequent catatonic episodes. Periodically occurring catatonia aggravates the course of affective disorders, reduces the cognitive functions of patients, their activity in solving everyday life problems.

In schizophrenics, catatonic symptoms are also an unfavorable factor.

The development of catatonic syndrome in adolescents and the elderly has more unfavorable consequences than in the young working population.

Overall, there is a high probability that the patient will be brought out of the acute catatonic stage, however, the long-term consequences and frequency of relapses are determined by the patient's primary diagnosis.

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