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REVIEW ARTICLE

Catatonia from its creation to DSM-V: Considerations for ICD

Max Fink
Departments of Psychiatry and Neurology, Stony Brook University, Long Island, New York, USA

ABSTRACT

Catatonia was delineated only as a type of schizophrenia in the many American Psychiatric Association DSM
classifications and revisions from 1952 until 1994 when “catatonia secondary to a medical condition” was added. Since
the 1970s the diagnosis of catatonia has been clarified as a syndrome of rigidity, posturing, mutism, negativism, and other
motor signs of acute onset. It is found in about 10% of psychiatric hospital admissions, in patients with depressed and
manic mood states and in toxic states. It is quickly treatable to remission by benzodiazepines and by ECT. The DSM-V
revision proposes catatonia in two major diagnostic classes, specifiers for 10 principal diagnoses, and deletion of the
designation of schizophrenia, catatonic type. This complex recommendation serves no clinical or research purpose and
confuses treatment options. Catatonia is best considered in the proposed ICD revision as a unique syndrome of multiple
forms warranting a single unique defined class similar to that of delirium.

Key words: Catatonia, malignant catatonia, neuroleptic malignant syndrome, delirious mania, tourette syndrome, NMDAR
encephalitis, barbiturates, benzodiazepines, ECT, ICD, DSM

INTRODUCTION BIRTH OF CATATONIA

Committees of the American Psychiatric Association are
actively revising the classification of psychiatric disorders.
The fifth major edition is expected in 2013, with the
fourth having been published in 1994. The political,
financial, social and medical implications of the decisions
are extensive. With almost universal government-
supported health insurance, defined conditions become
the basis for physician and hospital reimbursements, for
pharmaceutical labeling and sales and for professional
educational texts. Earlier editions of the classification were
translated into many languages and adopted in many
countries.
The impact is not limited to the United States, since the
World Health Organization International Classification of
Diseases (ICD) has followed the DSM model closely and is
also undergoing revision.
Address for correspondence: Dr. Max Fink,
Departments of Psychiatry and Neurology, Stony Brook
University, Long Island, P.O. Box 457, St. James,
New York, 11780, USA.
E-mail: max.fink@sunysb.edu
In the 19th century, European physicians sought to identify
specific diseases among the many forms of disturbed
behaviors that filled their sanitaria. They applied a medical
model of diagnosis – the observation of symptoms,
examination for physical signs, recording the course of
illness to make a diagnosis, testing treatments and predicting
prognosis. Many forms of mutism, posturing, stupor and
excitement were labeled as catalepsy and stupor. The
catatonia story, however, began in East Germany in 1874.
In 1863, the German psychiatrist Karl Kahlbaum published
a multi-fold classification of psychiatric disorders based on
similarities of age of onset, symptoms, course and outcome.
He conceived of five principal classes, each with multiple types,
and gave each a unique name. The descriptions were hard
to understand, the names were innovative, his colleagues
did not accept this complex system and it disappeared.
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How to cite this article: Fink M. Catatonia from its creation DOI:
to DSM-V: Considerations for ICD. Indian J Psychiatry
10.4103/0019-5545.86810
2011;53:214-7.

214 Indian Journal of Psychiatry 53(3), Jul-Sep 2011

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Fink: Catatonia in ICD
Ewald Hecker, a colleague at his private sanitarium in
East Germany, focused interest on hebephrenia, a single
syndrome that he described in 1871 in an essay of 35 pages,
with seven illustrative case histories. The clear delineation
of a single illness of hebephrenia made it possible for other
observers to quickly verify his description and identify
clinical cases.
Three years later, Kahlbaum described and named a motor
dysregulation syndrome “Die Katatonie” in a 104-page
essay with 26 case vignettes.[1] Kahlbaum clustered 17
motor abnormalities into a single syndrome in patients
suffering from disorders in mood, psychosis, neurosyphilis,
tuberculosis and epilepsy. He described catatonia so well that
within a few years his description was repeatedly verified.
Emil Kraepelin was among the authors who recognized
both catatonia and hebephrenia in his population of chronic
mentally ill. He, too, described his own syndrome that began
in adolescence and progressed relentlessly to dementia. He
adopted both catatonia and hebephrenia as cornerstones of
his scheme of dementia praecox.
Kraepelin next recognized manic-depressive insanity as a
disorder of mood with fluctuating life course that did not
necessarily progress to dementia. Although he identified
catatonia among these patients, he catalogued it as a
principal sign of dementia praecox.
By1908, Eugen Bleuler had recast Kraepelin’s nosology
within a framework of the newly fashionable psychodynamic
theory. He renamed dementia praecox as “schizophrenia”
and accepted catatonia as one of its forms. For the next
century, through multiple classification schemes, catatonia
remained firmly within schizophrenia. In each era, clinicians
applied the popular treatments for this condition. Although
catatonia was recognized outside schizophrenia, official
formulations did not accept these descriptions. Catatonia
meant schizophrenia.
WHAT IS CATATONIA TODAY?
Catatonia is now recognized as a motor and mood
dysregulation syndrome that is found among men and women
of all ages.[2] We closely follow Kahlbaum’s description.
Onsets are often acute, manifested in repetitive behaviors,
stupors and frenzied and delirious states. Some forms
are malignant, leading to death. Before Kahlbaum named
catatonia, a syndrome of catalepsy had been described as
muscular rigidity, fixed posturing and insensitivity to pain.
Kahlbaum added echophenomena, grimacing, mannerisms,
mutism, perseveration, posturing, negativism, rigidity,
stereotypies and staring as characteristic motor signs. He
saw catatonia as a psychiatric illness.
Kahlbaum had no effective treatment. In 1930, William
Indian Journal of Psychiatry 53(3), Jul-Sep 2011
Bleckwenn in Wisconsin described the immediate
relief afforded by high doses of sodium amobarbital. In
recent decades, amobarbital has been replaced by the
benzodiazepines (mainly lorazepam and diazepam) as
effective treatments.
In 1934, Ladislas Meduna in Budapest treated schizophrenia
patients by inducing seizures with intramuscular
injections of camphor-in-oil and then with intravenous
pentylenetetrazol. His first trials were in the patients who
were mute, negativistic, posturing, refusing food and
requiring tube feeding. These patients met the criteria for
the catatonic type of schizophrenia.
Some patients recovered with a few seizures and in
1937, Meduna published “Die Konvulsionstherapie der
Schizophrenie,” describing greater than 50% remission
rates in 110 patients.[3] At that time, schizophrenia was
considered to be an immutable inherited genetic disorder
and Meduna’s reports were rejected as fantasy. Clinicians
who were faced with the many chronically ill mad persons
who filled large sanitaria, however, welcomed an effective
treatment. By the early 1940s, the relief afforded the
psychoses by induced seizures was verified. An electrical
method (electroconvulsive therapy, ECT), a more assured
method of seizure induction, quickly replaced chemical
inductions of seizures. ECT is the definitive treatment of
catatonia today.[4]
INCREASING RECOGNITION OF CATATONIA
Despite the official tie of catatonia to schizophrenia in the
classification, in textbooks and in clinical teaching, young
clinicians in the 1970s identified catatonia to be common
among patients with mood disorders, especially in the
excited states of mania. By 1980, the acute onset of fever,
rigidity and autonomic signs was recognized as a toxic
response to neuroleptics in the “neuroleptic malignant
syndrome” (NMS). The syndrome was first related to
malignant hyperthermia (MH), but treatments for MH failed
to bring relief. Comparisons of NMS to the malignant form
of catatonia (MC) found the two to be indistinguishable.
When the treatments for MC were applied, NMS resolved.
NMS is now considered and treated as a variant of catatonia.
Excited states of delirious mania next met catatonia
symptom criteria for which treatments for catatonia are
effective. Delirious mania is a catatonia variant.
Children and adolescents with autism spectrum disorders
exhibit many signs of catatonia. Their repetitive self-
injurious behavior (SIB) is a feature among the negativism,
posturing, staring and mutism common to these patients.
Although the use of ECT in adolescents, especially those
with neurodevelopmental defects, was considered risky and
unethical, treatment trials found that the catatonia features,
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Fink: Catatonia in ICD
including SIB, resolved. The latest reports find the children
to be very tolerant of benzodiazepines and, for effective
treatment, high doses are needed. SIB is considered a sign
of catatonia.
Patients with tics diagnosed as suffering from Gilles de la
Tourette syndrome meet the criteria for catatonia. These
patients respond to ECT, suggesting that systematic studies
of catatonia are warranted.
Today, a fashionable syndrome of anti-N-methyl-D-aspartate
receptor encephalitis is sweeping the United States today.
The detailed descriptions find that more than 70% of the
patients meet the criteria for catatonia. Enthusiasts drive the
discussion to unproven intravenous immunoglobulin (IVIG)
replacement therapy, and to the search for ovarian tumors,
but once the association with catatonia is recognized and
its effective treatments applied, the syndrome will be seen
as a treatable form of catatonia, much as NMS and SIB are
now recognized.
CATATONIA IN THE DSM CLASSIFICATIONS
In the DSM classifications, psychiatric disorders are
identified by cross-sectional symptoms and course of
illness. Data from physical examination, laboratory tests
and prior treatment responses are not considered. This
attitude eliminates a useful criterion for catatonia. When
the presence of two or more catatonia signs for more than
24 h points to catatonia, a reduction of 50% or more in
catatonia signs after an intravenous dose of a barbiturate or
benzodiazepine verifies the syndrome. The test is reported
positive in 50–80% of the patients who meet clinical signs of
catatonia.[2] Excluding such a test is arbitrary and is equivalent
to excluding the findings in an electroencephalogram for a
seizure disorder or a serologic test for syphilis.
The 1980 DSM-III classification identified catatonia only
as a type of schizophrenia, coded as 295.2. Because
“schizophrenia” is the dominant code, neuroleptics are
prescribed and the effective treatments for catatonia of
barbiturates and ECT are not considered. By 1994, the DSM-
IV committees recognized catatonia outside schizophrenia
and added “catatonia secondary to a medical disorder” to
acknowledge catatonia in neurotoxic syndromes, coded as
293.89. In the interim, catatonia scholars had documented
the broader representation of catatonia outside
schizophrenia and medical disorders, calling for it to be
recognized as a syndrome of its own, similar to delirium
and dementia.[5,6] The proposal called for the recognition of
catatonia as a defined syndrome with a single numeric code
and with four types for descriptive purposes: an inhibited
form described as the Kahlbaum syndrome, an excited
form of delirious mania, a malignant form that includes the
neuroleptic malignant syndrome and a form associated with
systemic illnesses.[2,5]
216
The argument for catatonia as an independent syndrome in
the DSM-V classification was formally presented in a critique
of the Kraepelin formulation.[7] In invited discussions of these
views, Rosebush and Mazurek consider the treatment for
catatonia to differ significantly from that of schizophrenia,
supporting the call for an independent syndrome.[8] Ungvari
and his colleagues argue that the position of catatonia
within schizophrenia is verified by many studies, and the
connection should be maintained.[9] The DSM-V Psychosis
Work Group’s hesitancy is described by Heckers, Tandon
and Bustllo in the same journal.[10]
THE DSM-V FORMULATION OF CATATONIA
The DSM-V recommendations for catatonia proposed by the
DSM-V Psychosis Work Group were posted on the website
www.dsm5.org on January 18, 2011. Four principal changes
are recommended.
1. “Schizophrenia, catatonic type (295.2)” is to be
eliminated, ending the direct tie of catatonia with
schizophrenia.
2. Catatonia is recognized as a specifier across the 10
principal primary diagnoses of the system, including
schizophrenia, major depression and bipolar disorder
and their related subtypes. Recognition of the catatonia
specifier is to be coded by using a fifth digit (xxx.x5).
3. Catatonia in a general medical condition (293.89) is to
be maintained.
4. A new class of catatonia NOS (298.99) is recommended
for those cases that exhibit the motor, mood and
systemic signs of catatonia, but in whom the underlying
pathology cannot be confirmed.
What is the anticipated impact of these proposed changes?
Specifiers, including catatonia, were adopted in DSM-IV
without numeric codes, discouraging their use in the clinic
and in research. Physicians find a single diagnosis sufficient
to support the care that they select for each patient. The
DSM-V consideration of a fifth digit for the catatonia
specifier would be an improvement, but the concept of
specifiers for at least 10 principal diagnoses concept serves
no clinical purpose and confuses treatment options.
Catatonia secondary to a medical disorder and catatonia
NOS will justify the testing and treatment of catatonia as a
principal intervention. Because all forms of catatonia are of
systemic origin, it is probable that the code 293.89 will have
limited use, and the less restrictive “Catatonia NOS” will be
applied for all forms of catatonia.
CONCLUSION
More than 135 years after its birth, catatonia is now
recognized as an identifiable and treatable syndrome. Its
characteristics are well defined, a simple test verifies the
diagnosis and the treatments of high-dose benzodiazepines
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Fink: Catatonia in ICD

and ECT are remarkably effective and safe. The labels of “not
otherwise specified” and “secondary to a medical disorder”
and the suggested use as a specifier add unnecessary
redundancy and confusion. Catatonia warrants the proposed
separation from schizophrenia and establishment as an
independent syndrome in the classification of psychiatric
illnesses with a single numeric code.
REFERENCES
1. Kahlbaum KL. Die Katatonie oder das Spannungsirresein: eine klinische
Form psychischer Krankheit. Berlin: Verlag August Hirshwald, 1874.
Translated: Kahlbaum, K: Catatonia. Baltimore: Johns Hopkins University
Press, 1973.
2. Fink M, Taylor MA. Catatonia: A Clinician’s Guide to Diagnosis and
Treatment. Cambridge UK: Cambridge University Press; 2003.
3. Meduna L. Die Konvulsionstherapie der Schizophrenie. Halle A.S: Carl
Marhold Verlagsbuchhandlung; 1937. p. 121.
4. Fink M, Taylor MA. Catatonia syndrome: Forgotten but not gone. Arch Gen
Psychiatry 2009;66:1173-7.
5. Taylor MA, Fink M. Catatonia in psychiatric classification: A home of its
own. Am J Psychiatry 2003;160:1233-41.
6. Francis A, Fink M, Appiani F, Bertelsen A, Bolwig TG, Bräunig P, et al.
Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition. J ECT 2010; 26: 246-7.
7. Fink M, Shorter E, Taylor MA. Catatonia is not schizophrenia: Kraepelin’s
error and the need to recognize catatonia as an independent syndrome in
medical nomenclature. Schizophr Bull 2010:36:314-20.
8. Rosebush PI, Mazurek MF. Catatonia and its treatment. Schizophr Bull
2010:36:239-42.
9. Ungvari G, Caroff SN, Gerevich J. The catatonia conundrum: Evidence of
psychomotor phenomena as a symptom dimension in psychotic disorders.
Schizophr Bull 2010:36:231-8
10. Heckers S, Tandon R, Bustillo J. Catatonia in the DSM- Shall we move or
not? Schizophr Bull 2010:36:205-7.
Source of Support: Nil, Conflict of Interest: None declared

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