Catatonia


Catatonia
   Catatonia is motor abnormalities in association with severe disorders of mood and thought. Catatonic excitement means an increase in spontaneous and purposeless movements; it is a feature of manic illness among other disorders. Catatonic stupor is a decrease in reactivity to the environment with a reduction of movements and is a feature of depressive illness among others. Catatonia can also be seen as an independent disease. The term "catatonia" was coined by Karl Ludwig Kahlbaum in an 1874 monograph (Die Katatonie, oder das Spannungsirresein), but he had used it in public lectures since 1868. The phenomenon had, however, been long familiar in psychiatry and was recognized as part of the immobile apathy traditionally called melancholia attonita (attonita_thunderstruck).
   Emil Kraepelin at first accepted Kahlbaum’s view that catatonia was an independent illness. He said in the fourth edition (1893) of his textbook, Psychiatry (Psychiatrie), that Kahlbaum’s own classification was overly diverse in terms of cause, clinical picture, and prognosis. "Nonetheless on the basis of clinical experience I feel justified in selecting out a certain group of cases from the category ‘catatonia’ as a distinctive disease. We are talking here about the acute or subacute forms of distinctive kinds of excitement, that then pass into stupor or dementia with confused delusions and sporadic hallucinations" (pp. 444–445). Here, he made catatonia a form of the "psychic processes of degeneration" alongside dementia praecox.
   Yet, in the sixth edition in 1899, Kraepelin changed his mind: catatonia was a subform of dementia praecox. Among the clinical manifestations of dementia praecox, he said, were the hebephrenic forms, the paranoid forms, and the catatonic forms. As he noted in the eighth edition of his textbook in 1913, the last edition he was to complete himself, "On the basis of course, namely of outcome, and apparently on the basis of autopsy findings, there remain no distinctive differences [between catatonia and dementia praecox]; thus we are justified in seeing Kahlbaum’s catatonia chiefly as a distinctive kind of course of dementia praecox" (vol. III, 6th ed. [2], p. 809). For Eugen Bleuler as well, catatonia was one of the subdivisions of "the schizophrenias" (alongside the paranoid, hebephrenic, and schizophrenia-simplex subdivisions).
   As he said in his Textbook of Psychiatry (Lehrbuch der Psychiatrie) in 1916,
   "Following acute catatonic attacks a tolerable condition may again recur; the cases that begin furtively all have a bad prognosis without any remissions that are worth mentioning" (A. A. Brill’s 1924 English translation of the fourth German edition, p. 417). Kraepelin and Bleuler had thus hijacked Kahlbaum’s catatonia and buried it in schizophrenia (where it has been ever since).
   In 1930, William J. Bleckwenn (1895–1965), assistant director of the Wisconsin Psychiatric Institute, noted in the Journal of the American Medical Association (JAMA) that intravenous injections of amobarbital relieved catatonia. Under the category "schizophrenia," he wrote, "The catatonic patient has shown some extremely interesting and rather striking responses." "Periods of from four to fourteen hours of a ‘normal lucid interval’ have been a constant result of the treatment" (p. 1169). These observations took catatonia out of the concept of "psychological defenses"; some observers view Bleckwenn’s procedure as the real beginning of psychopharmacology.
   As for the recent history of catatonia, DSM-III continued the Kraepelinian tradition of seeing catatonia as a kind of schizophrenia. In 1980, the existence of a "catatonic type" of schizophrenia, marked by "stupor, negativism, rigidity, excitement, or posturing," was noted in the Manual (p. 190). DSM-IV in 1994 extended the possibility of catatonic symptoms to mood disorders, adding the term as a "specifier": "when the clinical picture is characterized by marked psychomotor disturbance that may involve motoric immobility, excessive motor activity, extreme negativism, mutism" (p. 382). In the 1970s, interest in catatonia as independent of schizophrenia began to revive with the report in 1973 of James R. Morrison, then at the University of Iowa, in the Archives of General Psychiatry that catatonia occurred in about 10% of a series of 2500 patients admitted to the inpatient service of the Iowa State Psychopathic Hospital during the years 1920–1971 with a diagnosis of schizophrenia. He found that catatonia was also quite common in mood disorders: "It would appear that approximately one quarter of patients who have been diagnosed as catatonia, excited type, in fact may suffer from an affective disorder" (p. 41). In 1976 in the Archives of General Psychiatry,
   Richard Abrams (1937–) and Michael Alan Taylor (1940–), using data collected while they were at New York College of Medicine (Metropolitan Hospital), showed that two thirds of a series of consecutive inpatients with signs of catatonia in fact had a mood disorder, usually mania.
   In 2003, Taylor, now at the University of Michigan, and Max Fink recommended in the American Journal of Psychiatry that catatonia be considered an independent syndrome in its own right: "[It] is found in about 10 percent of acutely ill psychiatric inpatients and is more commonly observed in persons with mood disorder than in those with schizophrenia. It is found in many conditions and presents mainly as retarded-stuporous or excited-delirious forms" (p. 1233). This contradicts the commonly held view that catatonia is "rare." (Interested readers will find an overview in Fink and Taylor, Catatonia: A Clinician’s Guide to Diagnosis and Treatment [2003].) (On periodic catatonia see Psychosis: Emergence [1932].)

Edward Shorter. 2014.

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