Abstract
Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) no longer classifies catatonia as a subtype of schizophrenia but instead defines it separately, with 12 identified psychomotor features. It is acknowledged that catatonia can occur in the context of neurodevelopmental disorders, psychotic, bipolar and depressive disorders and other medical conditions but that its essential feature is marked psychomotor disturbance. The latter may manifest as decreased motor activity, disturbed engagement during interview and examination, and peculiar or excessive motor activity (DSM5).
Catatonia was first described in 1862 by a German psychiatrist, Karl Ludwig Kahlbaum, who carefully examined and documented the symptoms of catatonia and noted its development in his patients. Based on his clinical observations, he was able to assort and group the signs of catatonia into a single entity, albeit derived from multifarious origins, and in so doing laid the foundations for his most influential work ‘Die Katatonie oder das Spannungsirresein’ (Catatonia or tension insanity). In this, Kahlbaum posited a multifactorial aetiology of catatonia and proposed that mood disorders were more often associated with catatonia than psychotic disorders, and that in general they tended to have a better prognosis (Kahlbaum, 1874).
In addition, he identified a sequenced symptomatic progression that began initially with mood symptoms, especially with ‘excitation’ (mania), but also sometimes with melancholia, which was then followed by oscillation between the two mood states before the ‘process’ deteriorated inexorably into ‘Melancholia attatonita’; a stuporous state that at times transiently switched back and forth into mania but usually deteriorated into ‘Terminalbloedsinn’ – also referred to as ‘terminal idiocy’ and at the time described as ‘dementia stupida’ (Kahlbaum, 1874). Interestingly, Kraeplin later named this eventual state as dementia praecox.
In German psychiatry, Kahlbaum’s conceptualisation has been variously appreciated. While Krafft-Ebing considered catatonia to be a variety of ‘circular madness’ (modern-day bipolar disorder), Kraeplin thought that catatonia had links to dementia praecox (modern-day schizophrenia) (Haustgen, 1997).
In French psychiatry, Séglas and Chaslin (1888a) published a commentary on Kahlbaum’s descriptions of catatonia. The French authors questioned the motoric origin of catatonia imputed by Kahlbaum and instead described catatonia in the context of a number of clinical conditions such as epilepsy, hysteria, delusional disorder, melancholia, stupor, mania and circular madness. Thus, Séglas and Chaslin concluded that catatonia was in fact a syndrome rather than a disorder per se, and therefore, it could occur in the context of a range of disorders (Séglas and Chaslin, 1888b). Remarkably, despite it being commonplace in acute and long-term psychiatric settings, catatonia remains a diagnostic challenge. This is because there is little overall consensus as to how best to define catatonia, and for example, there is no agreement on the number or the duration of symptoms needed to make the diagnosis.
Therefore, it is worthwhile examining the meaning of some of the criteria used to define catatonia in DSM5. This commentary focuses on those criteria that involve different forms of motoric posturing and will examine their overlapping and at times opposing nature.
Waxy flexibility (cerea flexibilitas), for instance, is characterised by a patient having movements induced by an examiner, with a feeling of plasticine resistance. Limbs can be placed in fixed positions as if the person were in fact made from wax. After such induction, catalepsy describes the patient holding these induced positions for a variable amount of time, only slowly returning to their original position, sometimes over hours.
‘Mitgehen’ and ‘mitmachen’ describe the patient’s response to movements induced by an examiner, and the difference between the two is rather subtle. In ‘mitmachen’ (participate), the patient’s body can be put into any posture, despite instructions given to the patient to resist. This differs from catalepsy, as the body returns to its original position once released, and the posture is not held in the induced position for a prolonged period of time.
‘Mitgehen’ (go along with) also called the ‘angle-poise sign’ or ‘anglepoise effect’, is an extreme form of mitmachen in which very slight pressure by the examiner leads to movement in any direction, despite instructions to the patient to resist. The patient often experiences mildly applied pressure as an amplified force. Again the body part returns to its original position upon release.
These signs differ from posturing in which the patient autonomously assumes a posture and holds it for extended periods of time (hours to months), and does not necessarily return to the original position. For example, Kahlbaum described a case in which a young man held his right arm across his chest by grasping the wrist with his other hand so tightly that it eventually left him with permanent cutaneous marks. ‘Schnauzkrampf’ (snout cramp), another form of posturing, involves pursing the lips and pushing them forward, then holding this position for long periods of time. A further extreme example of posturing is the ‘psychological pillow’ where due to contraction of the sternomastoid muscles the patient will hold their head a few centimetres above the bed as if indeed an invisible pillow was present.
Negativism, on the other hand, describes the resistance a patient offers in response to attempts made to move them and instead does the opposite to what is asked (Casey and Kelly, 2007). For instance, a patient might turn away from the examiner when asked to look at them. This is again different from ‘gegenhalten’ (to hold against) in which the patient resists movement with the same degree of force as applied by the examiner but does not perform the opposite movement per se. When used loosely in the literature the two often are interchanged but the distinction is important as it may point to aetiological differences. For example, ‘gegenhalten’ is a predominantly motoric phenomenon, while negativism has a behavioural aspect. Indeed, negativism must be motiveless rather than goal directed and thus motivated hostility or refusal to cooperate do not qualify. It can include social withdrawal, ignoring commands or not engaging at all with the examiner. The patient might do the opposite of what is asked. Séglas (1902) considered negativism to be specific to catatonia with a severity ranging from slight motor slowing to total resistance.
In essence, these motoric phenomena comprise three groups – movements induced by the examiner which are met with compliance by the patient, those the patient assumes autonomously, and those the patient resists with varying levels of force. However, a common feature of these phenomena is the lack of goal-directed activity. DSM5 lists these criteria for catatonia separately despite their overlapping and often opposing nature. We have attempted to create a grouping into compliant, autonomous and opposing movements. This structure might help to recognise these signs in a clinical setting and therefore increase the chance of detecting catatonia.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
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