Catatonia from the first descriptions to DSM 5 – Journal of

by F Luchini · 2015 · Cited by 14 — Catatonic Disorder due to a General Medical Condition;. 2. Schizophrenia-Catatonic Subtype;. 3. Episode Specifier for Major Mood Disorders without specific

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145Journal of Psychopathology 2015;21:145-151 Summary AimsThis paper aims to provide an update to clinicians regarding the changes of the diagnostic criteria of catatonia in DSM 5. MethodsThe authors have made a review of the literature concerning catatonia using the keywords mentioned below; the various ver -sions of DSM have been also consulted. ResultsAlthough catatonia has historically been associated with schizo -phrenia, it occurs more frequently in conjunction with mood dis -orders or somatic diseases. Therefore, since the fourth edition of the DSM, catatonia has been both a specifier for affective episodes and it has been pos -sible to make diagnosis of catatonia due to a general medical condition. In DSM 5 four changes have been made: 1) the catatonia is de – scribed in the whole manual, regardless of the condition which appears to be associated with, by the same type and number of criteria, 2) it is a specifier both of schizophrenia and affective epi – sodes (the catatonic subtype of schizophrenia has been removed), 3) it is used as a specifier for other psychotic spectrum disorders, and 4) finally, there is the category ﬁNOSﬂ that allows the rapid diagnosis where the etiology is not immediately identifiable. DiscussionThese changes will improve the recognition of catatonia within the various psychiatric disorders and they will facilitate the treatment. Key words Catatonia from the first descriptions to DSM 5 F. Luchini, N. Bartolommei, A. Benvenuti, M. Mauri, L. Lattanzi U.O. Psichiatria, Dipartimento di Medicina Clinica e Sperimentale, Azienda Ospedaliero-Universitaria Pisana Correspondence Lorenzo Lattanzi, Dipartimento di Medicina Clinica e Sperimentale, Sezione di Psichiatria, Università di Pisa, Azienda Ospedaliero-Universitaria Introduction – and alternating manic, depressive and psychotic phases, with an eventual deteriorative course 1. In the early years – dementia praecox 2. – years, the term ﬁcatatoniaﬂ was considered a synonymous in the scientific literature of the twentieth century, condi – tioning the first editions of the ICD and of the DSM clas-sifications . Catatonia in the diagnostic classification systems that catatonic syndromes could complicate the course not liver failure, ketoacidosis, vitamin B12 deficiency), endo – – -ia)˜.For these reasons the authors of the last versions of the most important diagnostic classification systems changed their approach to catatonia. In particular the International Classification of Disease catatonic disorderﬂ while the DSM-IV 7 – 1. Catatonic Disorder due to a General Medical Condition; 2. 3. single manic episode; most recent episode manic; most recent episode depressed; most recent episode mixed – single episode or recurrent ).

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146 , -velopmental disorders ;4. the manual did not permit a diagnosis when the link -der is not immediately evident, as it happens in the initial stages of a clinical evaluation. Clinical experi -ence and research data have highlighted the impor -tance of early diagnosis of catatonia, especially for the therapeutic-prognostic implications ﬁidiopathic catatoniaﬂ is often used in these cases , the DSM-IV. Catatonia as an autonomous diagnostic category According to some authors the most important limit of DSM-IV approach is that catatonia is not recognized as a specific syndrome – a. catatonia is common, though not always correctly ; b. Catatonia Rating Scales, as the Bush-Francis Catato – nia Rating Scale , can help in identifying catatonic symptoms. Factor analytic studies have delineated – of catalepsy, posturing, mutism and negativism and a ;c. – searchers as a generally cyclic disorder, with episodes response to specific treatments in most cases prevents the worse outcome; d. -ders. Considering catatonia as an independent syn-drome would definitely separate the diagnosis from schizophrenia present a diagnosis of schizophrenia and, according – five groups of symptoms for the diagnosis of catatonia as -tive episode, while for the diagnosis of ﬁcatatonia due to of only one of the five sets of symptoms. recognition and assessment of catatonia, some authors 1. DSM IV criteria remain vague, leading to a discrepan – – and the relative rarity of the diagnosis of catatonia˜ 22. ;2. catatonic schizophrenia, as formulated in the DSM- – 25-27 acute psychosis catatonic symptoms were recog – -cal practitioners˜ 21; 3. 7. Actually catatonia is also present in other psychiatric disorders. Individual case reports and extensive clinical case se -ries report the presence of catatonia in the context TABLE I. I criteri diagnostici per catatonia nel DSM-IV (APA, 1994). – commands or maintenance of a rigid posture against at- – mannerisms or prominents grimacing

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147 g. – symptoms and specific alterations of the striatal-tha – lamic-cortical circuit, involving the frontal and pari – efficacy of BDZ seems to suggest an impairment of the GABAergic system; indeed, some authors reported – with catatonia. Since this area has direct connections with the amygdala, its involvement may explain the – -tivity in these areas may results in the reappearance of of a hyperactivity of glutamatergic circuits, which would lead to a dysfunction of the posterior parietal – such as posturing and alteration of the position of the the use of antagonists of NMDA receptors . Finally, – -sion would compromise the thalamocortical circuit. For these reasons Northoff et al. 51 have recently sug – impairment of the GABAergic system with a second -ary involvement of the dopaminergic transmission dysregulationﬂ). Among the main supporters of a ﬁcatatonic syndromeﬂ, , proposed to consider catatonia as -pened for the delirium – Kahlbaum syndrome – – – – tion, altered state of consciousness and delirium. It re- -sociated with mood disorders, particularly with severe – cesses mental health services with catatonic features – of mixed episodes, greater severity of manic symp – toms, and longer periods of hospitalization. Finally, catatonia usually has a poor response to antipsychot – clinical picture, facilitating the development of the malignant form ;e. period of 5 minutes, an additional dose of 1 mg is of patients there is a reduction in stiffness, the ap-pearance of spontaneous movements and recovery of -;f. once diagnosed, catatonia responds to specific treat- schizophrenia, has prompted the use, potentially harmful, of antipsychotics. On the other hand, if not – -TABLE II. Il trattamento della catatonia .BDZ i.v. catatonic symptoms. In these cases the overall response rates ECT BDZ i.v. + ECT – as they can rise the seizure threshold. GABA-A agonist zolpidem and NMDA antagonists – Antiepileptics harmful

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148DSM 5 and suggestions proposed in the field of catatonia during account only some of them. A great effort was spent to diagnosis of catatonia. Compared to the previous version of the manual, the DSM 5 introduces four key changes a. criteria for catatonia are the same throughout the – unidentified medical condition. In order to facilitate b. c. specifier for four additional psy- – hypertension, tachycardia, tachypnea, diaphoresis), increased enzyme of muscle necrosis, reduction of circulating iron, leukocytosis. Somatic complications – – authors included in this group also the Neuroleptic Malignant Syndrome and the Serotonin Syndrome . – ondary to a general medical condition or toxic state; c) secondary to a neurological disorder, d) secondary to a psychotic disorder. poor specificity of DSM-IV diagnosis. First of all they criti -cized the fact that, according to DSM-IV criteria, the non- echophenomena are specific catatonic features, exces – – symptoms last at least one hour in order to facilitate reli- and the application of appropriate treatments.TABLE III. . I criteri diagnostici di Fink e Taylor raccomandati per la catatonia (adattato da Fink e Taylor, 2003) 13.A. associated with at least one two or more occasions TABLE IV. Definizione della catatonia nel DSM 5 (APA 2013). the gravity) – – ronment) – stimuli or instructions) posture against gravity) movements) – iner) examiner)

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149 55 have summarized the ar – – – phrenia, mania) associated with catatonia have a greater -ample, patients with recurrent depression presenting an episode with catatonic features not necessarily manifest applies to schizophrenic patients, who may show cata -tonic symptoms during a period of illness and not in the – – sification of catatonia as an independent diagnosis could lead to an artificial increase of the percentage of comor – – cal picture in different clinical contexts, however differ – associated mental disorder and not to a specific set of – associated with chronic schizophrenia compared to other diagnosis 56-58. Moreover, the use of atypical antipsychot -ics, although generally not recommended in catatonia, psychotic disorders, thanks to their dopamine-stimulating property in the cortical prefrontal area 56 57. In the final evaluation has therefore prevailed the opin – correct the deficiencies of DSM-IV and improve clinical diagnosis .Conclusions – ing the DSM 5 task force, while not yet recognizing cata – tonia as an independent syndrome, has corrected those theories that affected negatively medical care and re – encourages clinicians to assess catatonic symptoms and signs in the most various mental disorders and to start immediately the most proper treatment even when the when an incomplete knowledge of the clinical picture or particularly complex diagnostic procedure do not consent to identify immediately the medical disorder associated with catatonia;when catatonic symptoms occur in the context of an autistic spectrum disorder and other developmental disorders . In these cases the diagnosis of catatonia-NOS allows to d. otherwise specified-NOSﬂ is added, to facilitate the diagnosis in patients with psychiatric conditions other than schizophrenia and mood disorders or when the underlying general medical condition is not immedi – ately recognized. The ongoing debate criticized . According to some authors, the two catego -ries of ﬁCatatonia due to general medical conditionﬂ and ﬁCatatonia NOSﬂ easily overlap in clinical practice, while the excessive enlargement of the diagnosis of Catatonia -ment, it would lead clinicians to neglect the search for a detailed diagnosis of the underlying condition. Moreover – dependent diagnostic category for catatonia, completely authors of the DSM 5. Different authors suggested that research. A specific diagnostic code would help the rec – research on nosology, treatment and outcome 18. Catatonia is still included in the ﬁschizophrenia spectrum somehow confounding when the syndrome is considered a specifier for other mental disorders or medical conditions. TABLE V. Possibile diagnosi di catatonia (APA 2013). 1. Catatonia due to a general medical condition a. Schizophrenia c. Schizophreniform disorder d. Brief psychotic disorder – -der, other mental disorders) Use the same set of criteria for the diagnosis of catatonia across the DSM- 5

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150 17 -view 18 The catatonia conun – . Asian J Psychiatr Daniels J. -relates. -pression: prevalence, clinical correlates, and validation of a scale 21 -peared or under-diagnosed? 22 Nosological status and definition of schiz -ophrenia: some considerations for DSM 5. Asian J Psychia – Are we wit -nessing the disappearance of catatonic schizophrenia? The subtypes of schizophrenia . Shanghai Arch Psy – 25 Another view of schizophrenia subtypes: a report from the inter -national pilot study of schizophrenia . Arch Gen Psychiatry 26 Subtypes of schizophrenia: a cluster analytic approach 27 Nosological status and definition of schiz -ophrenia: some considerations for DSM 5 . Asian J Psychia – 28 the catatonic syndrome Peralta V, Cuesta MJ, Serrano JF, et al. The Kahlbaum™s syn – drome: a study of its clinical validity, nosological status and relationship with schizophrenia and mood disorder . Compr A retrospective study of 34 catatonic patients: analysis of clinical care and treatment -cence -ders Cornic F, Consoli A, Cohen D. – dren and adolescents. sight among different pediatric disorders: a review article . Francis A, Fink M, Appiani F, et al. and Statistical Manual of Mental Disorders, Fifth Edition . J start immediately a correct treatment without unneces-sary and harmful delays. Future studies will indicate if this approach to catatonia really help clinicians in the managing and treatment of this severe and sometimes fa -tal syndrome. References 1 Bal- 2 Dementia praecox and paraphrenia, 1919 . – Dementia praecox, or the group of schizophre -nias, 1911 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – 1st Edition (DSM-I). – 5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – 2nd Edition (DSM-II). – 6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – 3rd edition (DSM-III). – 7 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders – 4th Edition (DSM-IV). – 8 Manual of the international statistical classification of diseases, injuries, and causes of death, volume 1. mental and behavioral disorders: clinical descriptions and The catatonic syndrome 11 12 Organic factors in˜catatonia . Br J -sis and treatment Peralta V, Cuesta MJ. The relationship between syndromes of the psychotic illness and familial liability to schizophrenia and major mood disorders 15 Prevalence and clinical sig -nificance of catatonic symptoms in mania . Compr Psychia – 16 Schizophrenia with prominent catatonic features (‚catatonic schizophrenia ): I. Demographic and clinical correlates in the chronic phase .

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