Catatonia: A Clinician’s Guide to Diagnosis and Treatment

One evening many years ago, when I was a second-postgraduate-year resident on call for inpatient admissions, I looked up from my chart at the nurses’ station to see a young woman being dragged onto the unit by her boyfriend and his mother. I use the word “dragged” quite literally: the young woman—I’ll call her Laura—was held up on either side by her two companions as they moved her down the hallway. Sometimes her feet made small shuffling movements, but mainly her legs and arms were rigid and her face was in a fixed grimace. Laura was only 20 years old and had given birth to her first baby 2 weeks earlier. Over the past few days she had become mute and akinetic to the point that she was no longer eating or drinking. This was her first hospital admission, although she had seen a psychiatrist in the past for an episode of agitation where she had run into traffic and started disrobing. She carried no specific diagnosis and had been treated briefly with antipsychotic medications.

As a young resident, I was fascinated by Laura. She was close to my own age, an attractive person with shoulder-length dark hair (now unkempt) who had won medals on her high school track team. When I stood near her to examine her—she could not sit down—she did not respond to any of my questions, but kept the same fixed stare, the same odd grimace, although from time to time I thought that I saw a twitch around her mouth when I made an especially kind comment to her.

This was the mid-1980s, an era of not only 4-week hospital stays but psychodynamically oriented nursing staff, who informed me that Laura’s mutism, unresponsiveness, posturing, waxy flexibility, and stereotypic hand movements reflected her murderous ambivalence toward her newborn daughter. Luckily, my senior resident was Allan Reiss (now a prominent behavioral neurogenetic and neuroimaging researcher), and my attending was Irvin Yalom, who always encouraged his trainees to think and work independently. I started to read as much as I could about catatonia, and after a few unsuccessful attempts with other medications, Allan and I decided to try lorazepam. After a single dose of 2 mg, Laura’s limbs began to move, her face relaxed, and she talked! Once she responded to the benzodiazepine, we added lithium carbonate, and within 2 weeks Laura returned home to care for her baby and Allan and I wrote the case up for publication (1).

Flash forward almost two decades: I am holding the 2003 book Catatonia: A Clinician’s Guide to Diagnosis and Treatment. As I start to leaf through it, I ask myself, How germane is this topic to the average practicing psychiatrist? At the same time, memories of Laura’s case come flooding back to me; she is reflected in almost every single chapter. A few minutes later, I am persuaded: Drs. Fink and Taylor have marshaled an impressive amount of both scholarly and clinical evidence in support of the following axioms:

Indeed, the authors’ goal is, through this book, to raise an awareness of catatonic syndromes in psychiatrists and neurologists who work in acute care settings (inpatient units, emergency rooms, consultation services).

Certainly, they have succeeded. Catatonia is a gem of a book. It is written in a clear, accessible, yet authoritative style by two clinician-scientists who have dedicated their careers to improving our recognition, understanding, and treatment of this syndrome. The book is exceptionally well organized, with bold, succinct chapters and sections (“The Signs of Catatonia Are Identifiable,” “Features Demonstrated in Examination,” “Conditions in Which Catatonia Is Expressed”). The authors’ command of the literature—from historically significant citations on clinical features such as Kahlbaum (1874), Leonhard (1942), and Abrams and Taylor (1976), to reviews of dynamic neuroimaging studies and neurotransmitter hypotheses—is truly impressive and sets a new standard for the field.

Despite the high level of the scholarship, this book most definitely is not aimed at academic “talking heads.” There are multiple patient vignettes in each chapter—more than 50 in all. The appendix contains a description of how to examine a patient for catatonic features as well as a catatonia rating scale. A complete differential diagnosis of catatonic syndromes is presented, including conditions that may be mistaken for catatonia (stupor, obsessive-compulsive disorder, stiff-person syndrome). The chapter on treatment contains multiple tables summarizing such clinically important facts as prognostic factors, the management steps for malignant catatonia (neuroleptic malignant syndrome), and factors affecting relapse.

Despite this impressive clinical knowledge base, the neuroscience of catatonia remains nonspecific and somewhat unsatisfying. The authors do a masterful job of synthesizing a large and complex literature and propose that catatonia, a disorder of motor system output, arises from disconnection between frontal circuitry and perceptual-integrating brain systems. Although undoubtedly accurate in its broad terms, this model does not explain why some patients show verbigeration (which must involve Broca’s area), others show ambitendency (supplementary motor area?), and still others show impulsivity or combativeness (orbitofrontal cortex?). Likewise, the authors never fully explain how their model of catatonia contrasts with a distinct clinical disorder of complex motor output such as Tourette’s syndrome.

None of this matters to Laura. She called me this morning to tell me proudly that her daughter (who began working full-time at age 16), bought a condominium last month single-handedly, at the age of 19! Laura herself has been stable for more than two decades on a regimen of lithium, lorazepam, and an antipsychotic, has raised two daughters, and has never needed another hospitalization. With this book in the hands of acute care clinicians, there will be many more outcomes like hers.