Catatonia Lives

Despite all the criticism of DSM-5, the new classification of psychiatric diseases has one triumph to report: bringing back the diagnosis of catatonia as an almost independent disease entity. The new DSM has a numbered place for “catatonia associated with another mental disorder (catatonia specifier).” (APA 2013 p. 89).

This means that if you have depression with catatonia, the catatonia will be noted; or autism with catatonia ditto. The code is 293.89. This is a big deal.

Why is it such a big deal? After all, German psychiatrist Karl Kahlbaum first coined the term catatonia in 1874. Since then, catatonia has become readily treatable, with benzodiazepines (often lorazepam) and with shock treatment (electroconvulsive therapy or ECT). Often, the other symptoms will clear at the same time as the catatonia lifts.

Some readers may not know what catatonia is. It’s a “psychomotor disorder,” meaning it affects movement and mind at the same time. The classical catatonic symptom would be the alternation of stupor and agitation. If you see this, the diagnosis “catatonia” should leap at once to the lips.

But it seldom does. Until recently, catatonia had been considered a subtype of schizophrenia. This meant that any patient exhibiting catatonic symptoms would get the diagnosis of catatonia only if he or she were considered simultaneously schizophrenic. This was so improbable in many cases that pediatric psychiatry developed a special diagnosis, stereotypic movement disorder, to pry catatonic children away from being called schizophrenic.

(Whether the pediatric psychiatrists realized that stereotypies, head-bangings and the like in children with autism and intellectual disability were catatonic in nature is unclear; the word catatonia does not appear in the pediatric “stereotypic movement disorder” section of DSM-5, which makes the entire document appear incoherent: We now accept catatonia in adults but not in children.)

What else? The stereotypical movements of catatonia are quite familiar clinically: repeated neck twitches, arm jerks, and other repetitive movements. Mutism is a classic catatonic symptom. Ditto posturing, grimacing, echolalia (mocking another’s speech), and negativism. Negativism, by the way, is not a motor symptom; it just means refusing to do what your medical attendants want, such as refusing to eat, refusing to toilet (then letting go in bed), and the like. In autism and intellectual disability, catatonia may take the form of a devastating symptom called self injurious behavior or SIB.

All these symptoms are common in psychiatry, and in the rest of medicine, occurring as they do in infectious illness and other medical conditions. But they remained astonishingly unrecognized (apart from schizophrenia) until Max Fink, professor of psychiatry at Stony Brook, and Michael Alan Taylor, professor of psychiatry at the University of Michigan, wrote a book about catatonia in 2002 that remained widely unread (Fink & Taylor 2002).

Surprised to see that truth-telling had little impact on his fellow psychiatrists, Fink began a determined campaign to reintroduce catatonia to psychiatry, the capstone of which was a special issue of the Acta Psychiatrica Scandinavica in 2013 on “rediscovering catatonia: the biography of a treatable syndrome.” By this time, the DSM-5 task force had decided to include semi-autonomous catatonia in the new edition of the manual, and the special issue of Acta was more a victory lap than a milestone. But it was a victory for Fink, and the team that he led, to effect a major change in the nature of psychiatric diagnosis.