Clinical Practice to Change with Divorce of Catatonia and Schizophrenia

GUEST EDITORIAL

Clinical Practice to Change With Divorce of Catatonia and Schizophrenia

Max Fink, MD

atatonia is a motor dysregulation syndrome of acute onset that is marked by stupor, mutism, C negativism, refusal of food, posturing, rigidity, and repetitive speech and movement. It follows a mild systemic illness, more often in the young. Some forms are malignant with high fever, delirium, tachycardia, hypertension, and sweating, occasionally leading to death. For all the 20th century, in each revision of the classification of psychiatric disorders, catatonia has only been designated as a type within the poorly conceived concept of ‘‘schizophrenia’’. Effective treatments for catatonia, sedative anticonvulsant agents and induced seizures (electroconvulsive therapy [ECT]), were devel- oped in the 1930s. Although they were dramatically effective for catatonia, they offered little benefit for schizophrenia. The diagnostic limitation of catatonia only as a type of schizophrenia blocked catatonic patients from effective treatments. Indeed, prescribing neuroleptic drugs for catatonic patients not only offered inadequate treatments but also subjected them to the risks of precipitated malignant catatonia labeled ‘‘neuroleptic malignant syndrome.’’ The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), divorce of catatonia from schizophrenia ben- efits both patients and clinicians.1,2 Catatonia was delineated by the German psychiatrist Karl Kahlbaum from among the patients in his sanitarium in 1874. He described 26 case examples in a small book titled ‘‘Die Katatonie oder das Spannungsirresein’’V‘‘Catatonia or the tension insanity’’.3 Catatonia was described in patients with thought, mood, and speech disorders and those having the systemic diseases of tuberculosis, neurosyphilis, and epilepsy. Patients were unusually fearful and anxious. He did not connect the syndrome to psychosis or dementia. Psychiatrists in Europe and the United States, with Kahlbaum’s descriptions in hand, quickly recognized similar cases. In1893, Emil Kraepelin, then devising a grand classification scheme for behavior and mood disorders, incorporated Kahlbaum’s catatonia as a specific marker for ‘‘dementia praecox.’’4 Although Kraepelin recognized catatonia in patients having manic-depressive insanity, he pigeonholed catatonia as a principal diagnostic sign of dementia praecox only. When Eugen Bleuler reshaped dementia praecox into ‘‘schizophrenia’’ in his 1911 textbook, catatonia remained its main sign.5 Although the subsequent literature reflected 2 points of view, catatonia as an independent clinical syndrome and as a singular sign of schizophrenia, the first official diagnostic classification by a committee of the American Psychiatric Association in 1952 cited catatonia only as a type of schizophrenia. Official revisions of the classification in 1968 and 1980 as well as the World Health Association’s International Classifications of Diseases followed suit. For almost all the decades of the 20th century, catatonia has been regarded as a form of schizophrenia, and patients were prescribed interventions deemed effective for that illness. In the 1970s, clinicians increasingly reported catatonia in patients with depressive and manic mood disorders, the epilepsies, and in systemic medical disorders.6,7 Catatonia was only occasionally recognized as a unique syndrome, and by 1981, the question was raised, ‘‘where had all the catatonics gone?’’ The answer was complex, based in large part on the hiding of catatonia within schizophrenia and in part on the speed with which the signs of catatonia were resolved by available treatments. By 1930, injections of sodium amobarbital quickly relieved catatonia, and clinicians working in acute psychiatric centers aborted catatonia as soon as it was identified.8 In 1934, the acute benefit of induced seizures to relieve catatonia was demonstrated,9 and by the 1940s, electrically induced seizures (ECT) became the almost universal treatment of the severe psychiatric ill, especially those with catatonia. Soon after potent neuroleptic drugs were introduced to clinical use in the 1950s, a neurotoxic syndrome was recognized with dominant signs of catatonia accompanied by high fever, hypertension, and tachycardia, occasionally progressing to death.10 Labeled the ‘‘neuroleptic malignant syndrome,’’ the first reports hazarded treatments based on the belief that neuroleptic drugs inhibited the brain’s

From the Departments of Psychiatry and Neurology, Stony Brook University, Long Island, NY. Reprints: Max Fink, MD, Emeritus, Departments of Psychiatry and Neurology Stony Brook University, PO Box 457, St James, NY 11780 (e-mail: [email protected]; [email protected]). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0271-0749 DOI: 10.1097/JCP.0b013e3182905267

Journal of Clinical Psychopharmacology & Volume 33, Number 3, June 2013 www.psychopharmacology.com 287

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Guest Editorial Journal of Clinical Psychopharmacology & Volume 33, Number 3, June 2013 dopaminergic transmitter system. Dopamine agonists (eg, bro- and adolescents. The signs of catatonia and the methods of eval- mocriptine) and muscle relaxants (eg, dantrolene) were pro- uation found in catatonia rating scales offer a useful basis for ef- moted. Those clinicians who recognized the signs of catatonia in fective recognition.1,2 NMS applied the known treatments for catatoniaVbarbiturates, The association of catatonia with the animal fear response benzodiazepines, or ECTVwith rapidly appreciated success labeled ‘‘tonic immobility’’ is an intriguing explanation for the when the neuroleptic drug prescription was also discontinued. onset of the syndrome and its resolution with sedative anxiolytic These treatments successfully relieved NMS more effectively agents. When Kahlbaum described catatonia, he reported that than did the prescription of bromocriptine and dantrolene.1 his patients were unduly fearful. The evidence for the associa- Once the tie of catatonia to schizophrenia was questioned, tion of catatonia with the animal fear response is compelling.12 other forms of catatonia were identified. Benign stupor, malig- Our clinical guidelines identify and differentiate very het- nant catatonia, delirious mania, and the toxic serotonin syn- erogeneous populations of schizophrenia, bipolar disorder, major drome were brought under the catatonia umbrella.1 depression, and a glossary of childhood disorders. We accept A limited recognition of catatonia outside schizophrenia 30% to 50% reduction in the number and severity of symptoms was afforded in the 1994 Diagnostic and Statistical Manual of as ‘‘improvement’’ when treating patients with these syndromes. Mental Disorders, Fourth Edition, classification by the addition Full relief is rarely attained. By contrast, the proper application of a distinct class of ‘‘293.89Vcatatonia secondary to a medical of the known treatments for catatonia assures the full and rapid condition.’’ In the following years, malignant forms of catatonia resolution of all its signs. This note alone distinguishes catatonia were often reported in patients with systemic diseases of lupus from other identified behavior disorders and should encourage erythematosus and anti-N-methy-D-aspartate receptor enceph- the education of practitioners to identify catatonia early in the alitis, and most recently in patients with the self-injurious be- differential diagnosis of patients with peculiar movements, es- haviors in autism spectrum disorders.1 pecially in the young. The DSM-5 revised classification deletes the catatonia type of schizophrenia (295.2), adds a new class of ‘‘Catatonia AUTHOR DISCLOSURE INFORMATION Not Elsewhere Classified (299.89),’’ retains the medical disease The author declares no conflicts of interest. association of catatonia introduced in DSM-IV (293.89), and ac- cepts catatonia as a specifier of 10 psychiatric diagnoses.1 The authors do not justify this complexity but sign off with the ex- REFERENCES pectation that clinical experience will clarify their formulation. 1. Fink M. Rediscovering catatonia: the biography of a treatable The DSM diagnoses are made by the presence of a defined syndrome. Acta Psychiatr Scand. 2013;127(suppl 441):1Y50. number of symptoms and signs from a checklist for each di- 2. Fink M, Taylor MA. Catatonia: A Clinician’s Guide to Diagnosis and agnosis. The DSM-5 catatonia diagnosis is made by the pres- Treatment. 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Catatonia, a prospective clinical study. Arch Gen (or ECT in malignant cases) validates the diagnosis. Psychiatry. 1976;33:579Y581. In patients with verified diagnoses, administering high doses of benzodiazepinesV6 to 20 mg lorazepam daily, for exampleV 7. Morrison JR. Catatonia: retarded and excited types. Arch Gen Y effectively relieves catatonia in more than 80% of subjects.2 The Psychiatry. 1973;28:39 41. remainder is relieved by ECT. For those with malignant catatonia, 8. Bleckwenn WJ. The production of sleep and rest in psychotic cases. ECT is effective, although daily treatments may be necessary. Arch Neurol Psychiatry. 1930;24:365Y372. It is useful to recall this history because clinicians today 9. Gazdag G, Bitter I, Ungvari GS, et al. Laszlo Meduna’s pilot studies are indoctrinated in the Kraepelinian dictum that ‘‘catatonia = with camphor induction of seizures. J ECT. 2009;25:3Y11. schizophrenia.’’ This universally adopted formula impedes our 10. Caroff SN. The neuroleptic malignant syndrome. J Clin Psychiatry. ability to recognize catatonia as an independent syndrome. The 1980;41:79Y83. reflex prescription of neuroleptics to every case of catatonia is no longer acceptable clinical practice. 11. Taylor MA, Fink M. Catatonia in psychiatric classification: a home of In systematic surveys, catatonia is found in 10% of patients its own. Am J Psychiatry. 2003;160:1233Y1241. on psychiatry, neurology, and emergency department units in ac- 12. Moskowitz A. ‘‘Scared Stiff’’: catatonia as an evolutionary-based fear ademic general hospitals. It is increasingly identified in children response. Psycholog Rev. 2004;111(4):984Y1002.

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