Catatonia: From Psychopathology to Neurobiology

Catatonia: From Psychopathology to Neurobiology sets out to familiarize the practitioner with the clinically important and recently neglected syndrome of catatonia. As noted in the book, catatonia is present among 7 to 17 percent of acute psychiatric patients, is associated with a high morbidity and mortality risk if not treated promptly, and responds dramatically to specific treatments (electroconvulsive therapy and benzodiazepines), yet it is underrecognized. In part, this underrecognition is due to a lack of clear consensus about the definition of catatonia and to the fact that the training of clinicians to recognize catatonic symptoms is often inadequate. Although catatonia was described extensively for centuries, with much written about it in the 19th century, interest has dropped off over the past 50 to 100 years.

The authors of this book conceptualize catatonia as a motor-behavioral syndrome that can occur across many different illnesses, including mood disorders, schizophrenia, a variety of medical and neurologic conditions, substance-induced states, and idiopathic states. They also discuss the possible relationships between catatonia and neuroleptic malignant syndrome (NMS) and parkinsonian syndromes. Antipsychotics used to treat psychosis or agitation can actually cause catatonia to progress to NMS.

The book differentiates between several types of catatonia, which have different features, clinical courses, prognoses, genetic patterns, and responses to treatment. I found the classification schemes confusing. Some differentiate between "excited" and "retarded" forms of catatonia. "Periodic catatonia," often not recognized by clinicians, has a cyclical pattern and has strong genetic transmission. "Systematic" catatonias can be more chronic. "Malignant catatonia," possibly related to NMS, can have a high mortality rate, especially if treated with neuroleptic medications.

Because catatonia is underrecognized and underemphasized in residency training programs, it would have been useful for the authors to focus more on the clinical presentation of the syndrome, maybe including more case descriptions. The book does include a chapter on clinical examination, listing some of the classic signs of catatonia, but I would have liked to see more extensive discussion of this area, especially given that the diagnosis is not always easy.

Some forms of catatonia, specifically malignant catatonia, are associated with high mortality rates, especially without the rapid institution of appropriate treatment. The authors review literature showing a striking reduction in mortality when catatonia is recognized early and immediately treated with benzodiazepines or electroconvulsive therapy.

Also contributing to the morbidity and mortality of catatonia are medical complications related to immobility (such as venous thrombosis and pulmonary embolism, decubitus ulcers, and rhabdomyolysis), those related to dehydration and malnutrition (such as pneumonia, skin breakdown, and feeding tube complications), and others. If the catatonic syndrome is precipitated by a medical or neurologic illness, it is crucial that the underlying condition be recognized and treated. The morbidity of catatonia could also manifest if the syndrome is left untreated (or inadequately treated) and it evolves into more of a chronic state.

The book's authors are clearly experts in neuropsychiatry. They cover topics such as the current understanding of the neurophysiology and genetics of catatonia, as well as epidemiology and standardized assessment tools. This volume is a comprehensive, up-to-date summary of this clinically relevant and complex syndrome. I highly recommend it to all psychiatrists, so we can to remind ourselves not to miss this critical diagnosis.