Commentary: the evolution of treatment in catatonia.

Many residents in psychiatry may go through training never having to make a diagnosis of catatonia, even though they may have to make a diagnosis of catatonic excitement in schizophrenia or a mood disorder with catatonic features. Catatonia due to a general medical condition is less likely to be diagnosed by the psychiatrist. Catatonia was described as far back as 1874 by Karl Kahlbaum, who viewed it as a disorder that went through different phases and ended in dementia. Hence, it was seen as an organic mental disorder. The word is derived from the Greek “to stretch tightly” and the associated catalepsy is also from the Greek, which means “a seizure of body and soul.” The symptoms varied, but mutism, negativism, and waxy flexibility with decreased sensitivity to pain were highlighted. It was Kraepelin and Bleuler who introduced catatonia as a subtype of schizophrenia. They moved away from the organic basis and saw the disorder as psychological blocking. This thinking is represented in DSM-IV. It is now accepted that catatonia could be part of an organic state and other psychiatric disorders. Consequently, neurologists are now aware that they may have to treat this disorder. Many of them see the stupor of catatonia as bordering on coma, whereas psychiatrists tend to view the stupor as a relative preservation of consciousness. A simple definition of catatonia is an abnormal mental state associated with the cataleptic phenomena of akinesia, posturing, and mutism. The psychiatrists who were called on to treat the patient in the case study reported by Bostwick and Chozinski in this issue of the Journal would have acted differently in 1963 and still more differently in 1988, 25 years later. In 1963, electroconvulsive therapy (ECT) would have been in use for 25 years. During that period, acute catatonic schizophrenia seemed more prevalent, and ECT would have been the logical treatment procedure. In that same era, the clinician might have taken a chance and initiated a treatment thought to be appropriate without having the patient’s full consent. In 1988, 25 years later, with the new antipsychotic and anxiolytic drugs available, the clinician might have seen this as an opportunity to avoid ECT. In this case, the psychiatrists used pharmacotherapy to restore mental capacity and then moved on to use ECT. This is indeed a special combination of two treatment modalities, and each modality was predominant at different eras in psychiatry. One notes from the onset that the psychiatrists were on active military duty, as was the patient, who had no relative available. The psychiatrists must be complemented for quickly finding a method to draw this patient out of catatonia. Catatonia is primarily a state of mutism and stupor, and effective communication is impossible. It is viewed more as a feature of the two major psychotic disorders: Schizophrenia and Bipolar Disorders. Classic catatonic schizophrenia with waxy flexibility and posturing is now seen less frequently. In the rural areas of some less-developed countries, this presentation continued longer, presumably because of cultural factors. Demon possession has been used as an explanation for that state, and in these cases, such persons were neglected rather than given active medical care. Dr. Mahy is Deputy Director, School of Clinical Medicine and Research, University of the West Indies, and Head, Department of Psychiatry, Queen Elizabeth Hospital, Bridgetown, Barbados. Address correspondence to: George Mahy, FRCPsych, Head, Department of Psychiatry, Queen Elizabeth Hospital, St. Michael, Barbados, West Indies. E-mail: [email protected]