Review
Catatonia in DSM-5

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Abstract

Although catatonia has historically been associated with schizophrenia and is listed as a subtype of the disorder, it can occur in patients with a primary mood disorder and in association with neurological diseases and other general medical conditions. Consequently, catatonia secondary to a general medical condition was included as a new condition and catatonia was added as an episode specifier of major mood disorders in DSM-IV. Different sets of criteria are utilized to diagnose catatonia in schizophrenia and primary mood disorders versus neurological/medical conditions in DSM-IV, however, and catatonia is a codable subtype of schizophrenia but a specifier for major mood disorders without coding. In part because of this discrepant treatment across the DSM-IV manual, catatonia is frequently not recognized by clinicians. Additionally, catatonia is known to occur in several conditions other than schizophrenia, major mood disorders, or secondary to a general medical condition. Four changes are therefore made in the treatment of catatonia in DSM-5. A single set of criteria will be utilized to diagnose catatonia across the diagnostic manual and catatonia will be a specifier for both schizophrenia and major mood disorders. Additionally, catatonia will also be a specifier for other psychotic disorders, including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. A new residual category of catatonia not otherwise specified will be added to allow for the rapid diagnosis and specific treatment of catatonia in severely ill patients for whom the underlying diagnosis is not immediately available. These changes should improve the consistent recognition of catatonia across the range of psychiatric disorders and facilitate its specific treatment.

Introduction

The current status of catatonia in the fourth edition of the Diagnostic and Statistical Manual for mental disorders (DSM-IV, American Psychiatric Association, 1994) is best understood from a historical perspective. It was first introduced as a distinct psychiatric syndrome by Karl Kahlbaum (1973) in the 1870s. Subsequently in the early 1900s, it was combined with hebephrenia and dementia paranoides into a single entity (dementia praecox) by Emil Kraepelin (1971) and the presence of catatonia became synonymous with dementia praecox or schizophrenia (Bleuler, 1950). The Kraepelin–Bleuler view of catatonia as a subtype of schizophrenia became prevalent and was reflected in the first three editions of DSM (American Psychiatric Association, 1952, American Psychiatric Association, 1968, American Psychiatric Association, 1980) where the only mention of catatonia was as a subtype of schizophrenia. Findings in the 1970s and 1980s, however, revealed the presence of catatonia in a number of neurological and other medical disorders (Gelenberg, 1976), and “organic catatonia” or “catatonia secondary to a general medical condition” was added as a new category in DSM-IV. Additional findings in the 1970s and 1980s revealed that a significant proportion of catatonia occurred in the context of major mood disorders (Abrams and Taylor, 1976, Taylor and Abrams, 1977) and catatonia was also added as an episode specifier of major mood disorders in DSM-IV (American Psychiatric Association, 1994).

Currently, the presence of catatonia is recognized in three contexts in DSM-IV:

  • 1.

    Catatonic Disorder due to a General Medical Condition (ICD-9 code 293.89)

  • 2.

    Schizophrenia — Catatonic Subtype (295.20)

  • 3.

    Episode specifier for Major Mood Disorders (296.xx) without specific numerical code:

    • a.

      Bipolar 1 Disorder — Single manic episode (296.00)

    • b.

      Bipolar 1 Disorder — Most recent episode manic (296.40)

    • c.

      Bipolar 1 Disorder — Most recent episode depressed (296.50)

    • d.

      Bipolar 1 Disorder — Most recent episode mixed (296.60)

    • e.

      Major Depressive Disorder, Single episode (296.20)

    • f.

      Major Depressive Disorder, Recurrent (296.30).

Some experts consider neuroleptic malignant syndrome (333.92), an adverse effect of antipsychotic medications, as a form of malignant catatonia (Fink, 1997, Lee, 2007).

A diagnosis of catatonia in DSM-IV requires that the clinical picture be dominated by:

  • a.

    Motoric immobility, as evidenced by catalepsy or stupor

  • b.

    Excessive motor activity

  • c.

    Extreme negativism or mutism

  • d.

    Peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing

  • e.

    Echolalia or echopraxia.

Whereas the DSM-IV definition of catatonia as a subtype of schizophrenia or episode specifier for major mood disorders explicitly requires the presence of at least two of these five sets of symptoms, there is no such requirement for its definition in “Catatonic disorder due to a general medical condition”. Of interest, the current edition of the International Classification of Disease (ICD-10, World Health Organization, 1992) recognizes catatonia only in two contexts, i.e., Organic Catatonic Disorder (ICD-10 code F06.1) and catatonic schizophrenia (F20.2).

Section snippets

Summary of new data and limitations in DSM-IV treatment of catatonia

Studies over the past two decades confirm the occurrence of catatonia in the context of schizophrenia, major mood disorders, and due to a range of general medical conditions (Peralta et al., 1997, Brauning et al., 1998, Ungvari et al., 2005, Weder et al., 2008). The continued importance of identifying the presence of catatonia in these different contexts is supported by its familial aggregation and co-aggregation with schizophrenia and major mood disorders (Peralta and Cuesta, 2007), clear

Changes for DSM-5

Following an extensive review of the literature and consultation with several experts, a series of changes have been made in the DSM-5 formulation of catatonia to address the identified gaps in the DSM-IV treatment of catatonia. The revision process placed particular emphasis on clinical utility and applicability and utilized all available research evidence to build on the strengths of the DSM-IV approach to improve diagnostic practice. While DSM-5 will retain the DSM-IV entities of catatonia

Summary

Changes made in the treatment of catatonia in DSM-5 include a consistent treatment of catatonia across the diagnostic manual, with a common set of criteria and its designation as a specifier for both schizophrenia and major mood disorders. Additionally, catatonia can also now be a specifier for other psychotic disorders, including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. The new residual category of catatonia not

Role of funding source

The authors do not have to declare any funding support for this manuscript.

Contributors

The DSM-5 Psychosis Workgroup developed the proposal. Rajiv Tandon drafted the manuscript and all the other authors provided comments on the basis of which the manuscript was revised. All authors have approved the final manuscript.

Conflict of interest

The authors have declared all relevant conflicts of interest regarding their work on the DSM-5 website to the APA on an annual basis. Complete details are posted on the public website: http://www.dsm5/Meetus/Pages/PsychoticDisorders.aspx.

Acknowledgment

The authors do not have to declare any funding or administrative support for this manuscript.

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