Max Fink MD Publishes New Book on Rediscovering Catatonia

In his latest book, titled Rediscovering catatonia: the biography of a treatable syndrome, Professor Emeritus Max Fink argues for the recognition of catatonia as an independent diagnostic category by tracing the syndrome from its first description in 1874 through its current status in the proposed DSM-5.

The “biography” of catatonia takes the reader back to a nineteenth century asylum filled with “the cacophony of cries and the pungent odors of urine, sweat, and the medicine paraldehyde” where the director, Karl Kahlbaum, first identified catatonia. “The patients were immobile and posturing, remaining in one position for hours; or moving continuously, pacing or hitting a wall or themselves… repeating words or phrases over and over again.” Because Kahlbaum lacked an effective treatment, he was able to observe the entire syndrome: its sudden onset, progressive course and debilitating outcome. Catatonia looked to Kahlbaum like “an immobility induced by severe mental shock.”

While Kahlbaum’s description won early acceptance by many clinicians worldwide, catatonia became submerged as a type of dementia praecox in the textbooks of the influential German psychiatrist Emil Kraepelin and later as a subtype of schizophrenia in the diagnostic scheme of Paul Eugen Bleuler. It has remained hidden there ever since, despite the publication throughout the 20th century of articles identifying catatonia in patients with diseases other than schizophrenia. Interest in catatonia waned once it could be quickly relieved by an injection of sodium amobarbital (Amytal).

When neuroleptic drugs were introduced in the 1950’s the association between catatonia and schizophrenia led psychiatrists to prescribe them to people with catatonia, often with disastrous results. A review article in 1980 identified the life-threatening "neuroleptic malignant syndrome", the acute onset of catatonic symptoms accompanied by high fever and cardiovascular changes. The severity of the syndrome, together with the discovery that it could be relieved by the administration of lorazepam or with ECT, led to a renewed interest in catatonia and a growing recognition of its independence from schizophrenia.

In its rediscovered state, catatonia came to be recognized in patients diagnosed with delirious mania, autism spectrum disorders and mental retardation. Dr. Fink lists additional syndromes that warrant consideration as variations of catatonia, including Tourette’s syndrome, anti-NMDAR encephalitis, obsessive-compulsive disorder and akinetic mutism.

Although it has been known for more than 50 years that catatonic patients respond well to barbiturates and to ECT while schizophrenic patients do not, the official diagnostic manual of the American Psychiatric Association continued to include catatonia only as a type of schizophrenia. The inclusion of ‘catatonia secondary to a medical disorder’ in the 1994 DSM-IV was a victory of sorts, but it had little influence on clinical practice.

When the APA began to plan for the DSM-5, a group of scholars and clinicians familiar with catatonia successfully advocated for the deletion of catatonia as a type of schizophrenia and the addition of a new independent class. They argued that the traditional scheme increased the risk of inducing neuroleptic malignant syndrome and obscured the fact that catatonia is easily treatable.  The APA DSM-5 Work Group eliminated the catatonia type of schizophrenia and added a new class of ‘catatonia not elsewhere classified’ with an independent  numeric code. The main issue now is how the new classifications will be treated in psychiatric textbooks and official treatment guidelines. The fact that 80% of patients with catatonia respond well to benzodiazepines is positive, but the fact that the remaining 20% are best treated with ECT is limited by the prejudice against its application.

Dr. Fink next considers the possible origins of catatonia in the fear response described by psychologists as "tonic immobility."  If catatonia is a relic of an epoch when humans froze in fear to escape the notice of aggressive animals, it should be regarded as an exaggeration of the normal biological state and attention should be paid to the stress aspects of the patient's history.

 A concluding discussion examines parallels between catatonia and melancholia in the diagnostic manuals. Despite its long history, melancholia is not given a separate category in the DSM classification, but treated as a specifier of mood disorders. The fact that both catatonia and melancholia are rapidly resolved by ECT and are marked by similar hormone abnormalities suggests that there may be a connection between them.

The book was published as Volume 127, Supplement 441 to the journal Acta Psychiatrica Scandinavica in January 2013.