Catatonia is a motor dysregulation syndrome.It is characterised by acute onset of stupor, mutism, negativism, posturing, rigidity, and repetitive speech and movement. Historically, catatonia was considered as a sub type of schizophrenia. Sedative and seizure treatments were dramatically effective for catatonia though they offered little benefit for schizophrenia as such. Being understood only as a sub type of schizophrenia was a limitation, as it prevented other catatonic patients from effective treatments. Giving antipsychotics to patients with catatonic symptoms had the risk of precipitating malignant catatonia (NMS).
Max Fink’s guest editorial welcome the changes made In DSM 5. DSM-5 deletes the catatonia type of schizophrenia (295.2), adds a new class of ‘‘Catatonia Not Elsewhere Classified (299.89),’’ retains the medical disease association of catatonia introduced in DSM-IV (293.89), and accepts catatonia as a specifier of 10 psychiatric diagnoses. Catatonia is now completely divorced from schizophrenia.
When German psychiatrist Karl Kahlbaum described catatonia, he didn’t connect that to psychosis. Emil Kraepelin incorporated Kahlbaum’s catatonia as a specific marker for ‘‘dementia praecox.’’, which remained so when Eugen Bleuler reshaped dementia praecox into ‘‘schizophrenia’’. Subsequent literature reflect two point of views -catatonia as an independent clinical syndrome vs catatonia as a sign of schizophrenia. Diagnostic systems (historically) considered catatonia as a form of schizophrenia, and patients were prescribed interventions deemed effective for that illness. However, clinicians increasingly reported catatonia in disorders other than schizophrenia and this lead to DSM 4 first recognising this by including category ‘catatonia secondary to a medical condition’. New DSM has taken the next step. .The DSM-5 catatonia diagnosis is made by the presence of 3 or more signs from a 12-item checklist.Max Fink is critical of the restricted diagnostic criteria for catatonia specifier.
Author consider that a presumptive diagnosis of catatonia is to be made by the presence of 1 or 2 motor signs for 24 hours or longer.The diagnosis of catatonia is verified by the quick relief afforded by the intravenous administration of 1 or 2 mg of lorazepam, 2.5 to 5 mg of diazepam, or the oral administration of 7.5 mg of zolpidem. When the diagnosis is verified, successful treatment with high doses of benzodiazepines (6 to 20 mg lorazepam daily) (or ECT in malignant cases) validates the diagnosis. High dose sedatives relieves catatonia in more than 80% of subjects.The remainder is relieved by ECT.
Looking back, Max Fink think that the Kraepelinian dictum that ‘‘catatonia = schizophrenia ’’ impeded our ability to recognize catatonia as an independent syndrome and in his opinion the reflex prescription of neuroleptics to every case of catatonia is no longer an acceptable clinical practice.
Fink M. J Clin Psychopharmacol. 2013 Jun;33(3):287-8