Drs. Taylor and Fink Reply

To the Editor: We appreciate Drs. Van Den Eede and Sabbe’s support for a separate DSM category for catatonia. Their modification of our suggested catatonia subtyping into malignant and nonmalignant forms, each with the specifier “retarded” and “excited,” is consistent with our view that subtyping should reflect lethality to guide treatment.

Their folding the term “delirious mania” into the malignant excited form, while congruent with our classification, might continue the notion that catatonic excitement differs from severe mania with catatonic features. Bleuler and Kraepelin’s original descriptions of catatonic excitement (1) are consistent with the view that the excitement in catatonia represents breakthrough mania.

Drs. Van Den Eebe and Sabbe minimize the dangers of using atypical antipsychotics in the treatment of catatonic patients. Every atypical agent, however, has been reported to induce the malignant form of catatonia, i.e., the neuroleptic malignant syndrome. But this literature is sparse, and a systematic review of the published cases would serve us well.

Whether catatonia associated with schizophrenia responds less well to benzodiazepines than does catatonia from other sources also requires further study. From their remarks, however, we conclude that Drs. Van Den Eebe and Sabbe agree that benzodiazepine therapy is the initial treatment of choice for catatonia, regardless of etiology.

Finally, Drs. Van Den Eebe and Sabbe consider malignant catatonia induced by antipsychotics (neuroleptic malignant syndrome) to result from striatal D₂ blockade (2), while we and others have suggested that it results from a GABA A/B imbalance because the syndrome can be induced by non-D_2- blocking agents and can be treated by GABA_A agonists. The salient point of this discussion, however, is that the early recognition of catatonia encourages effective treatment that has been developed in clinical experiments that are independent of hypotheses of mechanisms.