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Psychiatric Bulletin (2002) 26: 275. doi: 10.1192/pb.26.7.275
© 2002 The Royal College of Psychiatrists
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Psychiatric Bulletin (2002) 26: 275
© 2002 The Royal College of Psychiatrists

correspondence

Catatonia made complex

Tom Clark, Clinical Research Fellow in Psychiatry

University of Birmingham, Reaside Clinic, Birmingham B45 9BE

Sir: Catatonia has been a poorly understood syndrome since psychodynamic theory struggled to explain its symptoms in the first half of the past century. The persistence of the nosologic confusion surrounding catatonia, malignant catatonia and neuroleptic malignant syndrome (NMS) is well illustrated by Carey et al's confused and uncertain case study (Psychiatric Bulletin, February 2002, 26, 68-70).

Did their patient have ‘no history of catatonia’ or did he suffer from ‘persistent stereotypies, mannerisms... dyskinesia and... dystonia’? Both statements cannot be true! It is unsurprising that in such a patient, with a possible history of encephalitis, the administration of high dose, high potency neuroleptics precipitated the malignant syndrome. This is a well-recognised clinical scenario. The association of catatonia with general medical conditions was emphasised by Kahlbaum in 1874 and has been reviewed in detail more recently (Philbrick & Rummans, 1994; Clark & Rickards, 1999).

The important points to remember are:

  1. catatonia may be simple (motor symptoms only) or malignant (motor symptoms together with hyperthermia or autonomic instability)
  2. neuroleptic (and some other) medications may exacerbate simple catatonia and precipitate malignant catatonia, in which case it may be termed the NMS
  3. the most effective treatments for the catatonic syndrome are benzo-diazepines or electroconvulsive therapy.

A fuller, clinically orientated review, including a suggested management plan, has been provided by Clark and Rickards (1999), while other authors have usefully considered the nosologic and dimensional status of the syndrome (for example, Mann et al, 1986; Singerman & Raheja, 1994; Fink, 1996). It is unfortunate that Carey et al's discussion fails to aid understanding of a condition that is often iatrogenic and, as they point out, occasionally fatal.

References

CLARK, T. & RICKARDS, H. (1999) Catatonia 2: diagnosis, management and prognosis. Hospital Medicine, 60(11), 812-814.[Medline]

FINK, M. (1996) Neuroleptic malignant syndrome and catatonia: one syndrome or two? Biological Psychiatry, 39, 1-4.[CrossRef][Medline]

MANN, S. C., CAROFF, S. F., BLEIER, H. R., et al (1986) Lethal catatonia. American Journal of Psychiatry, 143, 1374-1381.[Abstract/Free Full Text]

PHILBRICK, K. L. & RUMMANS, T. A. (1994) Malignant catatonia. Journal of Neuropsychiatry, 6(1), 1-13.[Abstract/Free Full Text]

SINGERMAN, B. & RAHEJA, R. (1994) Malignant catatonia — a continuing reality. Annals of Clinical Psychiatry, 6, 259-266.[Medline]

 

Authors' reply

Stephen Carey, Consultant Psychiatrist

Stratheden Hospital, Cupar KY15 5RR

David Hall, Consultant Psychiatrist

Crichton Royal Hospital, Dumfries DG1 4TG

It is agreed with your correspondent that certainty may often be preferred to confusion. We plead guilty to one nosological omission: the patient described had no history of classical catatonia (akinesis, mutism and waxy flexibility). Your correspondent's own cited review from 1999 (Clark & Rickards) admits there were no randomised controlled trials of treatment in catatonia. It is to be hoped that our article will have refreshed clinicians' awareness of this condition, as it is indeed often iatrogenic.





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