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Catatonia Schizophrenia Spectrum and Other Psychotic Disorders

Table of Contents for Summit Review 9-24-2012

1. Proposed DSM-5 and DSM-IV Criteria – Current proposed criteria as edited by APA staff, Dr. Michael First, and

the DSM-5 Task Force

2. CPHC Review Summary – Contains CPHC score and review comments

3. CPHC Proposal – Cover letter from WG for CPHC Review

4. 1st SRC Review Summary – Contains SRC review comments on the initial SRC proposal for Insomnia Disorder

5. 2nd Review Summary – Contains SRC scores and review comments on the 1st SRC resubmission.

6. 3rd SRC Review Summary – Contains SRC scores and review comments on the 2nd SRC resubmission.

7. 4th SRC Review Summary – Contains SRC scores and review comments on the 3rd SRC resubmission.

8. SRC Proposal – Proposal submitted for SRC review

9. SRC Resubmission 1 – The Work Group’s response to the SRC comments on the initial SRC proposal

10. SRC Resubmission 2 – The Work Group’s response to the SRC comments on the SRC Resubmission 1

11. SRC Resubmission 3 – The Work Group’s response to the SRC comments on the SRC Resubmission 2

12. Appendix 1: Dhossche and Wachtel, 2010 – Key article

13. Appendix 2: Peralta et al., 1997 – Key Article

14. Appendix 3: Peralta and Cuesta, 2001 – Key Article

15. Appendix 4: Ghaziuddin, Dhossche, and Marcotte, 2011 – Key Article

16. Appendix 5: Appendix 5. Consoli et al., 2012 – Key Article

17. Appendix 6. Peralta et al., 2010 – Key Article

18. Appendix 7. Daniels, 2009 – Key Article

19. Appendix 8. Wing and Shah – Key Article

20. Appendix 9. Dhossche et al., 2010 – Key Article

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The Task Force is in agreement with the Catatonia proposal and fully endorses the points in the proposal concerning the public health implications of the proposed changes.

Catatonia

Schizophrenia Spectrum and Other Psychotic Disorders

Proposed Criteria for DSM-5 DSM-IV Criteria Catatonia

The clinical picture is dominated by 3 or more of the following symptoms:

1. Catalepsy

2. Waxy flexibility

3. Stupor

4. Agitation

5. Mutism

6. Negativism

7. Posturing

8. Mannerisms

9. Stereotypies

10. Grimacing

11. Echolalia

12. Echopraxia

Catatonia can be used as a specifier for schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, manic and depressive episodes in bipolar I disorder, major depressive episodes in major

Catatonia

This disorder is not listed in DSM-IV; therefore, DSM-IV criteria for this disorder do not exist. This disorder was previously subsumed under Schizophrenia - Catatonic Type, Bipolar I Disorder - Single Manic Episode, Bipolar I Disorder - Most Recent Episode Manic, Bipolar I Disorder - Most Recent Episode Depressed, Bipolar I Disorder - Most Recent Episode Mixed, Bipolar II Disorder, Major Depressive Disorder, Single Episode, Major Depressive Disorder, Recurrent, and Catatonic Due to a General Medical Condition Schizophrenia – Catatonic Type

A type of Schizophrenia in which the clinical picture is dominated by at least two of the following:

(1) motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

(2) excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

(3) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411























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depressive disorder and bipolar II disorder, and catatonia attributed to another medical condition. Catatonia not elsewhere classified would be coded if criteria for catatonia are met in the absence of schizophrenia, a major bipolar or depressive disorder, or a relevant medical condition.

rigid posture against attempts to be moved) or mutism

(4) peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

(5) echolalia or echopraxia

Catatonia Due to a General Medical Condition

A. The clinical picture is dominated by at least three of the following:

1. Catalepsy

2. Waxy flexibility

3. Stupor

4. Agitation

5. Mutism

6. Negativism

7. Posturing

8. Mannerisms

9. Stereotypies

10. Grimacing




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11. Echolalia

12. Echopraxia

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition

C. The disturbance is not better accountedfor by another mental disorder (e.g., a Manic episode)

Coding Note: Include the name of the general medical condition on Axis 1, eg. 293.89 Cataonic disorder due to hepatice encephalopathy; also code the general medical condition on Axis III

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CPHC Memo: Catatonia

From: Drs. McIntyre and Yager on behalf of the DSM-5 Clinical and Public Health

Review Committee (CPHC)

To: Dilip Jeste, M.D. President APA

DATE: August 29, 2012

Enclosed please find the CPHC report on Catatonia reviewed at our meeting of August 28, 2012. For this proposal the CPHC was asked to consider the diagnostic category of Catatonic NEC. Although traditional validators as rated by the SRC are lacking, for this new diagnostic category the CPHC saw little in the way of downside and thought that the category could be clinically useful as a residual or working diagnosis. The SRC score was 5. The average score of 5 CPHC reviewers was 3.2.

Based on our external reviews and discussions in the CPHC, we rate this proposal as:

1.93 = GOOD

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Memo to CPHC on Catatonia

We submit a request to the CPHC to add a residual category of Catatonia NEC in DSM-5. There is a critical need to identify the presence of catatonia across different clinical conditions because of relatively specific response to certain treatments (eg., benzodiazepines and electroconvulsive therapy for refractory or severe cases) and its potentially fatal outcome without adequate treatment. In recognition of this fact, a category “Catatonic disorder secondary to a general medical condition” was added and catatonia was added as a specifier for major mood disorders in DSM-IV. Limitations in the DSM-IV treatment of catatonia have since been recognized and several additional changes have been proposed by the Psychotic Disorders Workgroup and reviewed and supported by the SRC (please see attached summary). These include the addition of catatonia as a specifier for other psychotic disorders, including brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance-induced psychotic disorder, and psychosis not otherwise specified. This is consistent with the need to recognize catatonic syndromes across different clinical conditions and be able to diagnose and treat them. There are, however, other clinical settings in which catatonic syndromes occur without a current ability to record their presence. In particular, there are two important clinical situations outside the ones above where it would be important to be able to diagnose the presence of catatonia:

a. The general medical condition that is likely contributing to catatonia may not be identified initially. Either the information may be insufficient or the work-up may be ongoing. If a catatonia NEC is identified, however, specific treatment for catatonia can ensue and general medical conditions more likely associated with catatonia can be more specifically considered.

b. Presence of catatonia in psychiatric conditions other than various psychotic disorders

and major mood disorders, specifically in the context of autism and other neurodevelopmental disorders Catatonia frequently occurs in these disorders in the absence of major mood or other diagnosable psychotic disorders. The occurrence of catatonia in autism and other developmental disorders has important prognostic and treatment implications.

Consequently, addition of a residual category of Catatonia NEC (Not Elsewhere Classified) is a clinical imperative. Without such a residual category, the presence of a catatonic disorder in the above conditions cannot be recognized and catalogued and this can result in a failure to provide specific appropriate treatment, with potentially serious adverse consequences.

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In that this represents the addition of a new residual diagnostic category, this represents a substantial change. Several experts from across the world have strongly emphasized the need and urgency to add this residual diagnostic category, including a group of 33 catatonia scholars from across the world. There are over 100 publications that have commented on the adverse impact of DSM-IV criteria on the recognition and appropriate treatment of catatonia and this was concern was also reflected in comments on the dsm5.org website. A more detailed rationale for this change is provided in the attached document. This change will likely lead to a more appropriate recognition of catatonia across different clinical conditions and be utilized either in lieu of another NOS or NEC diagnosis or as a comorbid diagnosis in conjunction with another condition such as an autism spectrum disorder. The consistent treatment of catatonia in DSM-5 (identical criteria across manual and utilization as a specifier for different disorders) should significantly improve diagnostic precision and clinical utility by simplifying and clarifying. Of particular importance to this specific change, addition of a residual category Catatonia NEC will allow recognition of a condition for which there is specific treatment, without which there could be significant adverse consequences. This particular change was not evaluated in DSM-5 field trials. The same criteria that are utilized for the diagnosis of catatonia in other sections of DSM-5 will be used to diagnose catatonia in Catatonia NEC. In terms of caseness, this change will ostensibly result in a recognition of catatonia in clinical conditions where it exists but is not recognized, but there is no category of NEC in DSM-IV. In terms of its public health impact, addition of the residual category of Catatonia NEC will allow the recognition of a clinical syndrome with specific treatment implications across different clinical conditions and settings and thereby provide the basis for appropriate and effective treatment. Members of other workgroups support this change as will enable a consistent treatment of catatonic syndromes across the DSM-5 manual and will address an important clinical need. Below, we attach a summary of our submissions to the SRC and their reviews.

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Catatonia in the DSM–5.

The catatonia diagnosis in DSM-IV-TR1,2

1. Catatonic Disorder due to a GMC (293.89) 2. Schizophrenia, catatonic subtype (295.20) 3. Specifier “with Catatonic Features” without specific code for current or most recent

Major Depressive Episode, Manic Episode, or Mixed Episode in: a. Major depressive disorder, b. Bipolar I disorder, or c. Bipolar II disorder

Specific criteria are provided for its identification in each of these contexts in DSM-IV, although they are different across the above settings. Catatonia is diagnosed by the presence of any of the following: motoric immobility, excessive motor activity, extreme negativism, peculiarities of voluntary movement or echopraxia/echolalia in the context of 1 (catatonic disorder due to a general medical condition), In contrast, in 2 and 3 (schizophrenia subtype and specifier for major mood disorders, respectively), catatonia is diagnosed only if the clinical picture is dominated by at least two of the above five.

Major Challenges in DSM-IV Treatment of Catatonia3-25

1. Different sets of criteria used to diagnose catatonia in different sections of the manual.

2. Different treatment of catatonia in different sections of the manual (distinct disorder, subtype, or specifier).

3. Inability to diagnose catatonia in a range of psychotic and nonpsychotic disorders where it is prevalent.

4. Inconsistent criteria and discrepant treatment across the manual have led to diagnostic confusion and low rates of recognition of catatonia across different clinical settings and patient populations and consequent inappropriate treatment and resultant poor outcomes.

Current Workgroup Proposal: The catatonia diagnosis in DSM 5 (dated May 19, 2012)3

1. Catatonic Disorder due to a GMC (293.89) 2. Specifier “with Catatonia" for:

a. Schizophrenia

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b. Schizoaffective Disorder c. Schizophreniform Disorder d. Brief psychotic disorder e. Substance-Induced Psychotic Disorder f. Psychosis Not otherwise Specified

3. Specifier “with Catatonia” for current or most recent Major Depressive Episode or Manic Episode in: a. Major depressive disorder, b. Bipolar I disorder, or c. Bipolar II disorder

4. Catatonic Disorder, Not Elsewhere Classified

Use of the same set of criteria to diagnose catatonia across the DSM manual.

History of Submissions by Psychotic Disorders Workgroup to SRC and SRC Reviews

Proposed Changes in Psychotic Disorders Workgroup (WG) Original Submission April 2011

1. a) Use of an identical set of criteria to diagnose catatonia across the manual b) Change in criteria to diagnose catatatonia

2. Catatonia should be a specifier for various disorders across the manual.

Therefore it should be a specifier and not a subtype of schizophrenia in DSM-5

3. Catatonia should be added as a specifier for five other psychotic disorders (Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, Substance-induced Psychotic Disorder, and Psychosis Not Otherwise specified)

4. A residual category of Catatonia Not Otherwise Specified should be added in

the Psychotic Disorders section.

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SRC Review of Original Proposal (July 29, 2011)

In its initial review of the original proposal, the SRC explicitly supported changes# 2 and 3 (rating both a 2), and #1a. They provisionally supported change# 1b (rating it a 3), but did not support change# 4. They asked for additional information on # 1b and 4.

The Psychotic Disorders WG specifically responded to questions and comments regarding changes# 1b and 4, providing a rationale for both a modest change in criteria to diagnose catatonia and for the addition of a residual category of Catatonia NEC.

SRC Review of Revised Proposal (September 16, 2011)

In its review of the revised proposal submitted by the WG, the SRC only commented on change# 1b , asking some additional questions and raising some concerns. They did not comment on the additional information provided with regard to change #4.

The Psychotic Disorders WG provided additional data supporting a modest change in criteria (Proposed change 1b) and supplemented the justification for the addition of a residual category of Catatonia NEC (Proposed change # 4)

SRC Review of 2nd Revised Proposal (January 23, 2012)

In its review of the revised proposal submitted by the WG, the SRC disapproved both changes 1b and 4, rating both a 5 (poor support- do not include).

The Psychotic Disorders Workgroup carefully considered the reviews of the SRC and has decided to withdraw its proposal for a change in the specific criteria to diagnose catatonia (change 1b) because validating data are limited and there is no clinical imperative for the change. As proposed by the workgroup and strongly endorsed by the SRC, the same set of criteria will be utilized to diagnose catatonia across the DSM manual and this will be the criterion set used to diagnose catatonia in 2 of the 3 places in the DSM-IV manual.; i.e., catatonia is defined on the basis of the presence of 2 of the following five sets of symptoms: (a) Motoric immobility, as evidenced by catalepsy or stupor; (b) excessive motor activity; (c) extreme negativism or mutism; (d) peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing; (v) echolalia or echopraxia

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In contrast, there is a strong clinical need for the addition of a residual category of Catatonia NEC (change 4). After a brief summary of the status of our proposed changes, we provide a succinct rationale.

Overall SRC Review Summary of Proposed Changes 1-4

1 a) Use of an identical set of criteria to diagnose catatonia across the manual Approve. In fact, the SRC “strongly recommended” that criteria for catatonia be consistent across the manual. b) Change in criteria to diagnose catatatonia Disapprove. Score of 5 (Poor support, do not include). [The Psychotic Disorders workgroup withdraws this change from further consideration]

2 Catatonia should be a specifier for various disorders across the manual. It should be a

specifier and not a subtype of schizophrenia in DSM-5 Approve

3. Catatonia should be added as a specifier for five other psychotic disorders

(Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, Substance-induced Psychotic Disorder, and Psychosis Not Otherwise specified). Approve

4. A residual category of Catatonia Not Elsewhere Classified (NEC) should be added in the Psychotic Disorders section.

Disapprove. Score of 5 (Poor support, do not include)

We would like to urge the SRC to reconsider its recommendation to disapprove the addition of a residual category of Catatonia NEC and would like to urge the CPHC to favorably consider the addition of this diagnostic category because of a strong clinical imperative and in the interests of harmonization with the proposed ICD-11 criteria.

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Why the Workgroup Believes that a residual category of Catatonia Not Elsewhere Classified should be added in the Psychotic Disorders section.

The fundamental justification for creating this residual category of Catatonia NEC is the existence of catatonia outside the diagnoses in which it can be utilized as a specifier in DSM-5 and the clinical (and research) importance of identifying the presence of catatonia because of its prognostic and therapeutic implications. B. Existence of Catatonia in Conditions Other Than DSM-5 Diagnoses Where it is a Specifier

Based on the prior SRC review, catatonia will be utilized as a specifier for schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with a diagnosed general medical condition, psychotic disorder not elsewhere classified, and the major mood disorders. There are two important clinical situations outside the ones above where it would be important to be able to diagnose the presence of catatonia:

a. The general medical condition which is likely contributing to catatonia may not be identified initially. Either the information may be insufficient or the work-up may be ongoing. If a catatonia NEC is identified, however, specific treatment for catatonia can ensue and general medical conditions more likely associated with catatonia can be more specifically considered.4-8

b. Presence of catatonia in psychiatric conditions other than various psychotic disorders and major mood disorders, specifically in the context of autism and other neurodevelopmental disorders9-22 Catatonia frequently occurs in these disorders in the absence of major mood or other diagnosable psychotic disorders. The occurrence of catatonia in autism and other developmental disorders has important prognostic and treatment implications.

Several experts from across the world, including a group of 33 “catatonia scholars”,9 and a multitude of clinical research publications from across the world, including five published in 2012,18-22 emphasize the clinical imperative of being able to diagnose catatonia in these conditions in order to ensure appropriate treatment.

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Unfortunately, the exact prevalence of catatonia in these other conditions is unknown as there has been no ability thus far to diagnose its presence in this context. Hopefully, there will be better data about this co-occurrence and make an informed decision in the future about whether to diagnose catatonia NEC as a comorbid condition or instead as a specifier for a certain limited set of additional DSM conditions. Until such time, Catatonia NEC would be a residual category which would allow the diagnosis of catatonia.

B. Importance of Recognizing Catatonia

Catatonia in such settings (similar to conditions where it can be diagnosed as a specifier in DSM-5) does respond to treatment with benzodiazepines and electroconvulsive therapy, as also identification and treatment of the primary psychiatric disorder or general medical condition. This had led to the use of a category of idiopathic catatonia (unrecognized in ICD-10 and DSM-IV).7,8 The predictive validity of the condition of catatonia(specific response of catatonia to treatment with benzodiazepines and electroconvulsive therapy23-25 is fairly established.

This would also be important from a research perspective, as genetic factors for “catatonia” are being identified. At the present time, there is also no ability to diagnose/document catatonia except in a limited number of conditions.

The principal need to identify catatonia whenever it occurs (as a specifier in a range of DSM-5 conditions as also in other clinical circumstances as Catatonia NEC) is clinical- a predictable response to specific treatments such as benzodiazepines and electroconvulsive therapy.

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References

1. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders- 4th edition (DSM-IV). American Psychiatric Association, Washington D.C.

2. Fink M. Catatonia. In Widiger TA, Frances AJ, Pincus HA, First MB, Ross R, Davis WW (Eds). DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association; 1996; 181-192.

3. American Psychiatric Association, 2011. DSM-5 Progress. www.DSM5.org 4. Rizos DV, Peritogiannis V, Gkogkos C. Catatonia in the intensive care unit. General Hospital

Psychiatry 2011;33:e1-e2. 5. Tuerlings JHAM, van Waarde JA, Verwey B. A retrospective study of 34 catatonic patients:

analysis of clinical care and treatment. General Hospital Psychiatry 2010;32:631-635. 6. Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: A review. Ann Clin Psychiatry

2008;20:97-107. 7. Benegal V, Hingorani S, Khanna S. Idiopathic catatonia: validity of the concept. Psychopathology

1993;26:41-46. 8. Krishna KR, Maniar RC, Harbishettar VS. A comparative study of “Idiopathic catatonia” with

catatonia in schizophrenia. As. J. Psychiatry 2011;4:129-133. 9. Francis A, Fink M, Appiani F, Bertelsen A, Bolwig TG, Braunig P, Caroff SN, Carroll BT, Cavanna

AE, Cohen D, Cottencin O, Cuesta MJ, Daniels J, Dhossche D, Fricchione GL, Gazdag G, Ghaziuddin N, Healy D, Klein D, Kruger S, Lee JWY, Mann SC, Mazurek M, McCall WV, McDaniel WW, Northoff G, Peralta V, Petrides G, Rosebush P, Rummans TA, Shorter E, Suzuki K, Thomas P, Vaiva G, Wachtel L. Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of ECT; 26:246-247.

10. Dhossche DM, Wachtel LE. Catatonia is hidden in plain sight among different pediatric disorders: A review article. Pediatr Neurol 2010;43:307-315.

11. DhosscheD, Cohen D, Ghaziuddin N, Wilson C, Wachtel LE. The study of pediatric catatonia supports a home of its own for catatonia in DSM-5. Medical Hypotheses 2010;75:558-560.

12. Wing L, Shah A. Catatonia in autism spectrum disorders. Br J Psychiatry 2000;176:357-362. 13. Hare DJ, Malone C. Catatonia and autism spectrum disorders. Autism 2004;8:183-195. 14. Thakur A, Jagadheesan K, Dutta S, Sinha VK. Incidence of catatonia in children and adolescents in

a pediatric psychiatric clinic. Aust N Z J Psychiatry 2003;37:200-203. 15. Cornic F, Consoli A, Cohen D. Catatonic syndrome in children and adolescents. Psychiatr Annals

2007;37:19-26. 16. Takaoka K, Takata T. Catatonia in childhood and adolescence. Psychiatry Clin Neurosci

2003;57:129-137. 17. van der Heijden FM, Tuinier S, Arts NJ, Hoogendoorn ML, Kahn RS, Verhoeven WM. Catatonia:

disappeared or under-diagnosed? Psychopathology. 2005;38:3-8. 18. Dhossche DM, Ross CA, Stoppelbein L. The role of deprivation, abuse and trauma in pediatric

catatonia without a clear medical cause. Acta Psychiatrica Scanidinavica 2012; 125:25-32. 19. Fink M. Hidden in plain sight: catatonia in pediatrics. Acta Psychiatrica Scandinavica 125: 11-12. 20. Shorter E. Making childhood catatonia visible. Acta Psychiatrica Scandinavica 2012; 125: 3-10. 21. Ghaziuddin N, Dhossche D, Marcotte K. Retrospective chart review of catatonia in child and

adolescent psychiatric patients. Acta Psychiatrica Scandinavica 2012; 125:33-38.

http://www.dsm5.org/

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22. Consoli A, Raffin M, Laurent C, Bodeau N, Campion D, Amoura Z, Sedel F, An-Gourfinkel I, Bonnot O, Cohen D. Medical and developmental risk factors in catatonia in children and adolescents: A prospective case-control study. Schizophr. Res., In Press. Doi:10.1016/j.schres.2012.02.012.

23. Caroff SN, Ungvari GS, Bhati MT, Datto CJ, O'Reardon JP. Catatonia and prediction of response to electroconvulsive therapy. Psychiatr Ann 2007;37:57-64.

24. Hawkins JM, Archer KJ, Strakowski SM, et al. Somatic treatment of catatonia. Int J. Psychiatry Med 1995;25:345-369.

25. Rohland BM, Carroll BT, Jacoby RG. ECT in the treatment of the catatonic syndrome. J Affective Disorders 1993;29:255-261.

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Summary

The most compelling reason to add a residual category of Catatonia NEC is the

following rationale:

(i) catatonia is often manifest in acute illness episodes;

(ii) in an emergency room or initial clinical diagnostic contact, the

underlying disease may be unknown (eg., consider a mute, catatonic

presentation without other information to clarify basic disease process);

(iii) catatonia is a distinctive syndrome with unique therapeutic and

prognostic significance;

(iv) Catatonia NEC is therefore essential as a diagnosis and for initiation of

treatment;

(v) Catatonia NEC is, in a sense, generally a holding place until full

evaluation is possible and the basic disorder is identified.

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SRC Memo on Catatonia

From: Drs. Kendler and Freedman on behalf of the DSM-5 Scientific Review Committee

To: Dr. John Oldham (APA President), Dr. David Kupfer (DSM-5 Task Force Chair), and Dr. Darrel Regier (DSM-5 Task Force Vice-Chair)

DATE: July 29, 2011

Catatonia – This proposal raised a great deal of discussion. Given its complexity, we charged one member of the SRC to develop a consensus document that we all have reviewed and approved. Thus, we did not blindly vote as we do typically. In summary, the committee supports change #1, although the empirical support was limited and we had some additional suggestions. We support changes 2 and 3, but not change 4. We also raise an issue about the possible application of these criteria to cases of autism about which we would appreciate clarification.

Here is this summary consensus report:

Change #1: In the SRC’s opinion, the most relevant data here are in Peralta et al. Schizophrenia Research 2010. That study used the proposed criteria and found that it agreed well with DSM-IV. However, since there was only one, moderately-sized study using these criteria, the SRC rated the proposal as a “3”.

The SRC also notes that the factor analysis in Peralta et al. 2010 found a three-factor solution (see Section 3.6), indicating that the Work Group should consider re-grouping the original 5-group criteria into three groups instead of adopting a system of symptom counting.

The SRC also noted that the criteria for Catatonic Disorder due to a General Medical Condition in DSM-IV differ markedly from the catatonia specifier criteria, in that the former are much more loosely operationalized. The SRC strongly recommends that the Work Group make the criteria consistent across the DSM, or alternatively provide justification for not doing so.

Changes #2 and 3: There are no validating data available, but this is a minor change that makes the use of the catatonia specifier more consistent across the DSM. Therefore, the SRC rated this proposal as a “2”.

Change #4: The SRC rated this proposal a “4” because neither the criteria for catatonia NEC are nor provide the rationale for it was provided. This is a major change that involves the addition of a new diagnosis.

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During the SRC’s discussion of this change, the subject of diagnosing catatonia in the context of autism was raised. Although this was not specified in the materials from the Work Group, we wondered whether, consistent with the argument in Dhossche et al, Med Hypotheses 2010, one of the Work Group’s motivations in proposing this change was to allow individuals with autism and other neurodevelopmental disorders to receive the diagnosis of catatonia, even if the catatonic symptoms occur outside the context of a psychotic or mood disorder. If this is the case, the Work Group should provide strong justification, since it represents a major change. Also, to the extent that the argument for a new diagnosis of catatonia NEC rests on the contention that the disorder should be treated with lorazepam and/or ECT rather than antipsychotic medication, it is essential to provide strong justification for that view. The original proposal included limited data (i.e., case series) to support it.

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SRC Memo

From: Drs. Kendler and Freedman on behalf of the DSM-5 Scientific Review

Committee

To: John Oldham President APA

DATE: September 16, 2011

Enclosed please find one report on the Genito-Pelvic Pain Disorder proposal from the SRC that was reviewed at our meeting on September 12, 2011. Our input on the Catatonia Resubmitted Proposal is contained herein.

We would like to add the following contextual comments:

Genito-Pelvic Pain Disorder- As you will see, our committee felt that this proposal was

insufficiently informed by validating data to be able to meet our criteria for adequate

scientific support. We therefore cannot recommend adoption of this proposal on the

basis of validating scientific information.

Catatonia Resubmitted Proposal- We need further information to make a final decision on this proposal. In particulate, proposal 14R presents the following diagnostic scheme:

Catatonia is defined as the presence of three or more of the following: Catalepsy Waxy flexibility Stupor Agitation Mutism Negativism Posturing Mannerisms Stereotypies Grimacing Echolalia Echopraxia However, the Peralta study, which examined criteria separately as proposed for DSM5 by the Workgroup, found that three of the 12 proposed (mannerisms, stereotypies, and agitation) did not reliably distinguish catatonia from other illnesses:

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Table 2. Discriminant loadings, their associated ANOVAs and ROC analysis for the catatonic symptomsa Discriminant loading Univariate ANOVA

ROC analysis

Fdf=185 P AUC (95% CI) Mutism 0.466 260.8 0.000 0.896 (0.820–0.972) Rigidity 0.419 210.9 0.000 0.856 (0.764–0.947) Negativism 0.388 179.8 0.000 0.828 (0.728–0.927) Immobility/stupor 0.317 20.4 0.000 0.876 (0.808–0.943) Oppositionism 0.315 119.2 0.000 0.719 (0.602–0836) Echophenomena 0.275 90.1 0.000 0.725 (0.609–0.840) Withdrawal/food refusal 0.260 81.1 0.000 0.721 (0.606–0.837) Catalepsy 0.241 69.7 0.000 0.656 (0.536–0.776) Posturing 0.132 21.1 0.000 0.575 (0.457–0.693) Automatic obedience 0.128 19.5 0.000 0.596 (0.478–0.715) Verbigeration 0.122 17.7 0.000 0.584 (0.466–0.702) Staring 0.045 2.4 0.118 0.543 (0.428–0.657) Mannerism/stereotypy 0.018 0.3 0.542 0.483 (0.375–0.591) Agitation 0.017 0.3 0.547 0.512 (0.400–0.624) a ROC, receiver operating characteristic; AUC, area under the curve.

Under the revised proposed criteria, these three criteria alone would be sufficient to make a diagnosis of catatonia. Please describe the evidence that supports making the diagnosis of catatonia on these three criteria alone.

http://www.sciencedirect.com/science/article/pii/S0920996400000359#ref_TBLFN2

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3rd SRC Review Summary


Committee (SRC)

To: John Oldham President APA, Dr. David Kupfer (DSM-5 Task Force Chair),

and Dr. Darrel Regier (DSM-5 Task Force Vice-Chair)

DATE: January 24, 2012

14R2 Catatonia: The SRC felt that there was little change in this revision and it continues to lack evidence in support of this change (poor support).

The average score for this proposal was 5.

Scoring Summary: 1=strong support 2=moderate support (acceptable) 3=modest support (questionable) 4= limited support (probably not justified) 5= poor support (do not include) 6= insufficient data

ADDITIONAL COMMENT:

1) There is no evidence adduced for the new diagnosis. The sensitivity and specificity of the revised diagnostic scheme or evidence that it specifically responds to benzodiazepines selectively were not presented.

ADDITIONAL COMMENT(s):

1) This is the second revision. In response to the first revision, we sent a memo on 9.16.11 that noted that a patient could meet criteria for catatonia based on three of 12 symptoms, but that in the cited publication (Peralta 2001), three of the 12 symptoms (stereotypy, mannerisms, agitation) did not differentiate catatonia from other illnesses. In response, the authors now cite Peralta 2010, in which 24 catatonic patients are compared to 176 non-catatonic patients (all patients had nonaffective psychotic diagnoses). The later study includes first-episode antipsychotic naïve patients, whereas the older study included chronically ill patients. In Peralta 2010, each of the 12 symptoms is more prevalent in catatonic than non-catatonic patients. Furthermore, the work group interprets the data as indicating that stereotypy and mannerisms

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discriminate well between catatonic and non-catatonic patients; the measure of discrimination is degree of correlation with alternative measures of catatonia severity. While agitation has the weakest correlations with the measures of catatonia severity, the work group argues that eliminating agitation from the list of criteria would diminish continuity with DSM-IV and change the psychometrics of the criterion set. Of course, the change that the work group is proposing would diminish continuity with DSM-IV and change the psychometrics of the criterion set.

2) The work group proposes no further justification for the addition of this new diagnosis. In particular, they continue to justify its inclusion based on the therapeutic implications of making the diagnosis of catatonia, but they have not produced any more literature beyond the originally submitted case reports to suggest that the diagnosis has specific treatment implications.

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1

4th SRC Review Summary


Committee (SRC)

To: Dilp V. Jeste, President APA, Dr. David Kupfer (DSM-5 Task Force Chair),

and Dr. Darrel Regier (DSM-5 Task Force Vice-Chair)

DATE: July 5, 2012

14R3=Catatonia: This is the third SRC review of this proposal. The committee did not feel that the work group provided any new information to consider and gave it poor support. The SRC felt this proposal should be reviewed by the CPHC.

The group voted with a final score of 5 (poor support).

Scoring Summary: 1=strong support 2=moderate support (acceptable) 3=modest support (questionable) 4= limited support (probably not justified) 5= poor support (do not include) 6= insufficient data

ADDITIONAL COMMENT: The Work Group proposes this category despite a lack of evidence because of an unexplained clinical need. Presumably they are referring to benzodiazepine treatment. Since this is a clinical need that is not justified by data, it is not the purview of the SRC. ADDITIONAL COMMENT: Clinical need based on judgment of experienced clinicians should be referred to the Clinical and Health committee. ADDITIONAL COMMENT: The Work Group states that catatonia predicts response to ECT and benzodiazepines, but on previous reviews the SRC did not find the evidence to be persuasive. No new evidence is presented in this proposal. ADDITIONAL COMMENT: No new data are presented that would cause the SRC to change its previous rating.

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Catatonia in DSM-5 Introduction In the first section of this review, we discuss the treatment of catatonia in DSM-IV and summarize recent literature dealing with catatonia. We next outline recommended changes in its treatment in DSM-5 based on this work and related limitations in its current conceptualization. We then specifically discuss each of the suggested changes, utilizing the format recommended by Kendler et al., (2009).1 Catatonia in DSM-IV History The current status of catatonia in DSM-IV is best understood from a historic perspective. It was first introduced as a distinct psychiatric syndrome by Karl Kahlbaum in the 1860s.2 Subsequently in the early 1900s, it was combined with hebephrenia and dementia paranoides into a single entity (dementia praecox) by Emil Kraepelin3 and the presence of catatonia became synonymous with dementia praecox or schizophrenia.4 The Kraepelin-Bleuler view of catatonia as a subtype of schizophrenia3,4 became prevalent and was reflected in the first three editions of DSM5-7 where the only mention of catatonia was as a subtype of schizophrenia. Findings in the 1970’s and 1980s, however, revealed the presence of catatonia in a number of neurological and other medical disorders,8,9 and “organic catatonia” or “catatonia secondary to a general medical condition” was added as a new category in DSM-IV.10 Additional findings in the 1970s and 1980s revealed that a significant proportion of catatonia occurred in the context of major mood disorders (particularly manic disorders)11-13 and catatonia was added as an episode specifier of major mood disorders in DSM-IV.10

Catatonia in DSM-IV Currently, the presence of catatonia is recognized in three contexts in DSM-IV:

1. Catatonic Disorder due to a General Medical Condition (293.89) 2. Schizophrenia- Catatonic Subtype (295.20) 3. Episode specifier for Major Mood Disorders (296.xx) without specific numerical code:

a. Bipolar 1 Disorder- single manic episode; (296.00) b. Bipolar 1 Disorder- Most recent episode manic (296.40) c. Bipolar 1 Disorder- Most recent episode depressed (296.50) d. Bipolar 1 Disorder- Most recent episode mixed (296.60) e. Major Depressive Disorder, Single episode (296.20) f. Major Depressive Disorder, Recurrent (296.30)

Specific criteria are provided for the identification of catatonia in each of these contexts, with the requirement that the clinical picture be dominated by:

a. Motoric immobility, as evidenced by catalepsy or stupor b. Excessive motor activity c. Extreme negativism or mutism d. Peculiarities of voluntary movement as evidenced by posturing, stereotyped movements,

prominent mannerisms, or prominent grimacing e. Echolalia or echopraxia

Whereas the definition of catatonia as a subtype of schizophrenia or episode specifier for major mood disorders explicitly requires the presence of at least two of these five sets of symptoms, there is no such requirement for its definition in the context of “Catatonic disorder due to a general medical condition”. [ICD-1014 recognizes catatonia only in two contexts- 1 and 2 above; i.e., Organic Catatonic Disorder (F06.1) and catatonic schizophrenia (F20.2)]

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Summary of New Data and Limitations in DSM-IV Treatment of Catatonia

Studies over the past two decades confirm the occurrence of catatonia in the context of schizophrenia, major mood disorders, and due to a range of general medical conditions.15-17 The continued importance of identifying the presence of catatonia in these different contexts is supported by a range of antecedent (familial aggregation and co-aggregation with schizophrenia and major mood disorders,18,19), concurrent (clear etiological attribution to a range of specific general medical conditions as evidenced by its abatement in temporal conjunction with effective treatment of the general medical condition17 and defined neural substrates20) and predictive (specific response of catatonia to treatment with benzodiazepines and electroconvulsive therapy21,22 and improvement of catatonia in conjunction with treatment of the primary condition) validators.

Whereas recent data provide clear support for the changes in the approach to catatonia made in

DSM-IV, they also point to several limitations in its current definition and treatment. These are summarized below:

1. Under-recognition. The presence of catatonia is frequently not recognized by clinicians.23 The

under-recognition of catatonia has been noted in the context of schizophrenia,15,24 major mood disorders,25,26 and general medical conditions. Additionally, catatonia has been found to be significantly under-recognized in a range of clinical populations and settings.27-29 One significant factor contributing to the under-recognition of catatonia is its inadequate definition.30,31

2. Prevalence in several psychotic disorders other than schizophrenia and psychotic mood disorders. Currently, catatonia can be diagnosed only in the context of schizophrenia (subtype) and major mood disorders (episode specifier). It is, however, frequently observed in other psychotic disorders such as schizoaffective disorder, brief psychotic disorder, schizophreniform disorder, and substance-induced psychotic disorder.16,32-34

3. Low frequency of use as schizophrenia subtype. Although catatonic symptoms are prominent in a significant proportion of schizophrenia patients, their presence is frequently not noted or diagnosed. This is significantly attributable to the fact that the only method to document the presence of catatonic symptoms in schizophrenia is as a diagnostic subtype. Despite the fact that catatonic schizophrenia is at the top of the diagnostic hierarchy of schizophrenia subtypes (in DSM-IV, prominent catatonic symptoms have to be absent before any other subtype can be diagnosed), catatonic schizophrenia is rarely (0.2-3%.) diagnosed 35,36 In addition to rarity of use, catatonic schizophrenia as a subtype has low diagnostic stability and poor reliability.37-39

4. Presence of catatonia in other psychiatric conditions and undiagnosed general medical conditions. There have been several hundred reports of catatonia in a range of other psychiatric conditions such as autism,40,41 and other disorders in the pediatric setting.27,42-44 Additionally, the link between catatonia and the causal general medical condition may not be clear at earlier stages of clinical assessment/treatment and/or the general medical condition putatively causing catatonia may not be initially evident . There is a broad consensus among catatonia experts45 that there should be an ability to diagnose catatonia in these circumstances because of its clinical importance. Catatonia in such settings does respond to treatment with benzodiazepines and electroconvulsive therapy, as also identification and treatment of the primary psychiatric disorder or general medical condition. This had led to the use of a category of idiopathic catatonia (unrecognized in ICD-10 and DSM-IV). 46,47

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Recommended Changes for DSM-548

Following an extensive review of the literature and consultation with several experts, the Work-Group considered several options to address the identified gaps in the DSM-IV treatment of catatonia. The workgroup placed emphasis on clinical utility and applicability, retaining maximal continuity with DSM-IV, and utilizing the research evidence to build on the strengths of the DSM-IV approach to improve diagnostic practice.

Based on these considerations, the workgroup proposes retaining the DSM-IV entities of catatonia

secondary to a general condition and catatonia as an episode specifier for major mood disorders without change.

The workgroup proposes four specific changes to the DSM-IV approach to catatonia. First, the

workgroup proposes replacing the catatonic subtype of schizophrenia with catatonia as a specifier (analogous to its treatment in conjunction with the major mood disorders). Second, the workgroup proposes the addition of four additional psychotic disorders (brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, and substance-induced psychotic disorder), for which catatonia could be a specifier. Third, the workgroup proposes a modest refinement in the existing criteria for the diagnosis of catatonia and additionally proposes that the same definition of catatonia should be utilized across the diagnostic manual. Fourth, the workgroup proposes the addition of a new diagnostic category of Catatonia not otherwise classified or not elsewhere classified (Catatonia NEC).

The proposed approach for the treatment of catatonia in DSM-5 is now described in greater detail.

NO CHANGES FROM DSM-IV

1. Catatonia as an episode specifier for major mood disorders. No changes were recommended.

2. Catatonia secondary to a general medical condition. No changes were recommended.

RECOMMENDED CHANGES FROM DSM-IV

To improve simplicity and clinical utility, it was recommended that catatonia be treated in a similar manner across DSM-5 and that similar criteria should be utilized for its definition across the diagnostic manual. The following specific changes were recommended:

1. Change in criteria for diagnosing catatonia.

The workgroup recommends modest changes in the specific diagnostic criteria for diagnosing catatonia.

In DSM-IV, catatonia was defined on the basis of the presence of 2 of the following five sets of symptoms: (a) Motoric immobility, as evidenced by catalepsy or stupor; (b) excessive motor activity; (c) extreme negativism or mutism; (d) peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing; (v) echolalia or echopraxia Based on data which suggested that limitations in this definition contributed to under-identification of catatonia,30,31 and a comprehensive review of alternative definitions,32,49,50 the workgroup recommends the following definition of catatonia which should be utilized across the DSM-5 manual:

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Catatonia is defined as the presence of three or more of the following: 1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Negativism 7. Posturing 8. Mannerisms 9. Stereotypies 10. Grimacing 11. Echolalia 12. Echopraxia

IMPACT OF CHANGE This change is primarily designed to address Limitation 1 above (under-recognition and inconsistent definition). It retains maximal continuity with DSM-IV (It lists all the 12 elements in DSM-IV with more valid operationalization), is supported by recent comparative data about diagnostic criteria for schizophrenia, and will be similarly applied across the manual. Its major clinical impact will be enhanced simplicity and consistency, with increased reliability and clinical utility.

2. Catatonia should be a specifier and not a subtype of schizophrenia in DSM-5 The workgroup recommends that catatonia be an episode specifier for schizophrenia, as it for the major mood disorders. IMPACT OF CHANGE This change is primarily designed to address Limitation 1 (under-recognition and inconsistent definition) and Limitation 3 above (low frequency of use and low utility and low diagnostic stability of catatonic subtype of schizophrenia). This change is also necessary in order to allow the use of catatonia as a specifier for other psychotic disorders as below and address Limitation 2. Additionally, this change is in keeping with the workgroup recommendation to delete all schizophrenia subtypes. Its major clinical impact will be improved concurrent and predictive validity, enhanced clinical utility, and easier clinical applicability.

3. Catatonia should be added as a specifier for four other psychotic disorders (Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, and Substance-induced Psychotic Disorder) The workgroup recommends that catatonia be added as a specifier to four additional psychotic disorders:

(i) Brief Psychotic Disorder (ii) Schizophreniform Disorder (iii) Schizoaffective Disorder (iv) Substance-induced Psychotic Disorder

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IMPACT OF CHANGE This change specifically addresses Limitation 2 above (inability to document prevalence of catatonia in psychotic disorders other than schizophrenia and psychotic mood disorders). This change will permit the necessary identification of catatonia in these psychotic disorders, thereby enhancing concurrent (patterns of comorbidity and biological markers) and predictive (response to treatment) validity. This change will additionally improve clinical utility. Its major clinical impact will be enhanced clinical utility and improved concurrent and predictive validity.

4. A new category of Catatonia Not Otherwise Specified should be added in the Psychotic Disorders section. The workgroup proposes the addition of a new diagnostic category of Catatonia NOS or NEC (not elsewhere classified). The terminology to be used (NOS or NEC) will be determined by the terminology which will be utilized across the diagnostic manual. IMPACT OF CHANGE This change specifically addresses Limitation 4 above (presence of catatonia in other psychiatric conditions and undiagnosed general medical conditions). This addition of a new diagnosis represents a major change which is clinically necessary and is supported by concurrent (patterns of comorbidity and biological markers) and predictive (treatment response and illness course) validators. This change is strongly supported by a broad consensus of catatonia experts. Its major clinical impact will be enhanced clinical utility and improved concurrent and predictive validity.

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References

1. Kendler K, Kupfer D, Narrow W, Phillips K, Fawcett J. Guidelines for making changes to DSM-V. Revised 10/21/09

2. Kahlbaum, KL, 1973. Catatonia, (originally published in 1974), John Hopkins University Press, Baltimore.

3. Kraepelin, E., 1971. Dementia Praecox and Paraphrenia, 1919, edited by Robertson GM), Krieger, New York.

4. Bleuler, E., 1950. Dementia Praecox, or the group of Schizophrenias,1911. Translated by J Zinkin, International University Press, New York.

5. American Psychiatric Association, 1952. Diagnostic and Statistical Manual of Mental Disorders- 1st edition (DSM-I). American Psychiatric Association, Washington D.C..

6. American Psychiatric Association, 1968. Diagnostic and Statistical Manual of Mental Disorders- 2nd edition (DSM-II). American Psychiatric Association, Washington D.C.

7. American Psychiatric Association, 1980. Diagnostic and Statistical Manual of Mental Disorders- 3rd edition (DSM-III). American Psychiatric Association, Washington D.C..

8. Gelenberg AJ. The catatonic syndrome. Lancet 1976;1:1339-1341. 9. Ahuja N. Organic catatonia: A review. Indian J Psychiatry 2000;42:327-346. 10. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders- 4th

edition (DSM-IV). American Psychiatric Association, Washington D.C. 11. Abrams R, Taylor MA. Catatonia. A prospective clinical study. Arch Gen Psychiatry. 1976;33:579-

81. 12. Taylor MA, Abrams R. Catatonia, prevalence and importance in the manic phase of manic-

depressive illness. Arch Gen Psychiatry 1977; 34:1223-1225. 13. Fink M. Catatonia. In Widiger TA, Frances AJ, Pincus HA, First MB, Ross R, Davis WW (Eds). DSM-IV

Sourcebook, Volume 2. Washington DC: American Psychiatric Association; 1996; 181-192. 14. World Health Organization, 1992. The ICD-10 classification of mental and behavioral disorders:

clinical descriptions and diagnostic guidelines (CDDG). World Health Organization, Geneva. 15. Ungvari GS, Leung SK, Ng FS, Cheung HK, Leung T. Schizophrenia with prominent catatonic

features ('catatonic schizophrenia'): I. Demographic and clinical correlates in the chronic phase. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29:27-38.

16. Peralta V, Cuesta MJ, Serrano JF, Mata I. The Kahlbaum’s syndrome: a study of its clinical validity, nosological status and relationship with schizophrenia and mood disorder. Compr. Psychiatry 1997;38:61-67.

17. Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: A review. Ann Clin Psychiatry 2008;20:97-107.

18. Peralta V, Cuesta MJ. The relationship between syndromes of the psychotic illness and familial liability to schizophrenia and major mood disorders. Schizophr Res. 2007;91:200-9.

19. Kendler KS, Hays P. Schizophrenia subdivided by the family history of affective disorder: a comparison of symptomatology and course of illness, Arch Gen Psychiatry 1983;40:951–955

20. Northoff G. Neuroimaging and neurophysiology. In Caroff S, Mann S, Francis A et al. (Eds). Catatonia: From Psychopathology to Neurobiology. Washington D.C., American Psychiatric Press; 2004.



23. van der Heijden FM, Tuinier S, Arts NJ, Hoogendoorn ML, Kahn RS, Verhoeven WM. Catatonia: disappeared or under-diagnosed? Psychopathology. 2005;38:3-8.

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24. Kleinhaus K, Harlap S, Perrin M, et al. Catatonic Schizophrenia: A Cohort Prospective Study, Schizophrenia Bulletin, Advance Access published August 6, 2010

25. Brauning P, Kruger S, Shugar G. Prevalence and clinical significance of catatonic symptoms in mania. Compr Psychiatry 1998;39:35-46.

26. Starkstein SE, Petracca G, Teson A, et al. Catatonia in depression: prevalence, clinical correlates, and validation of a scale. J Neurol Neurosurg Psychiat 1996;60:326-332.


28. Rizos DV, Peritogiannis V, Gkogkos C. Catatonia in the intensive care unit. General Hospital Psychiatry 2011;33:e1-e2.

29. Caroff SN, Mann SC, Campbell EC, et al. Epidemiology. In Caroff S, Mann S, Francis A et al. (Eds). Catatonia: From Psychopathology to Neurobiology. Washington D.C., American Psychiatric Press; 2004.

30. Fink M, Taylor MA. Catatonia: A clinician’s guide to diagnosis and treatment. Cambridge University Press, Cambridge, 2003.

31. Carroll BT, Kirkhart R, Ahuja N, et al. Katatonia: a new conceptual understanding of catatonia and a new rating scale. Psychiatry 2008;5:42-50.

32. Peralta V, Campos MS, Garcia de Jalon E, Cuesta M. DSM-IV catatonia signs and criteria in first-episode, drug-naïve, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophr Res. 2010;118:168-175.

33. Tuerlings JHAM, van Waarde JA, Verwey B. A retrospective study of 34 catatonic patients: analysis of clinical care and treatment. General Hospital Psychiatry 2010;32:631-635.


35. Xu TY. The subtypes of schizophrenia. Shanghai Archives of Psychiatry 2011;23:106-108. 36. Stompe T, Ortwein-Swoboda G, Ritter K, et al. Are we witnessing the disappearance of catatonic

schizophrenia? Compr Psychiatry 2002;43:167-174. 37. Helmes E, Landmark J. Subtypes of schizophrenia: a cluster analytic approach. Can J Psychiatry

2003;48, 702-708. 38. McGlashanTH, Fenton WS. Classical subtypes of schizophrenia. In Widiger TA, Frances AJ, Pincus

HA, et al. (Eds). DSM-IV Sourcebook, Volume 1. Washington DC: American Psychiatric Association; 1994; pp 381-392.

39. Carpenter WT, Bartko, JJ, Carpenter CL, Strauss JS, 1976. Another view of schizophrenia subtypes: A report from the International Pilot Study of schizophrenia. Arch. Gen. Psychiatry 1976;33:508-516.

40. Wing L, Shah A. Catatonia in autism spectrum disorders. Br J Psychiatry 2000;176:357-362. 41. Hare DJ, Malone C. Catatonia and autism spectrum disorders. Autism 2004;8:183-195. 42. Thakur A, Jagadheesan K, Dutta S, Sinha VK. Incidence of catatonia in children and adolescents in a

pediatric psychiatric clinic. Aust N Z J Psychiatry 2003;37:200-203. 43. Cornic F, Consoli A, Cohen D. Catatonic syndrome in children and adolescents. Psychiatr Annals


2003;57:129-137. 45. Francis A, Fink M, Appiani F, Bertelsen A, Bolwig TG, Braunig P, Caroff SN, Carroll BT, Cavanna AE,

Cohen D, Cottencin O, Cuesta MJ, Daniels J, Dhossche D, Fricchione GL, Gazdag G, Ghaziuddin N, Healy D, Klein D, Kruger S, Lee JWY, Mann SC, Mazurek M, McCall WV, McDaniel WW, Northoff G, Peralta V, Petrides G, Rosebush P, Rummans TA, Shorter E, Suzuki K, Thomas P, Vaiva G, Wachtel L. Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of ECT; 26:246-247.

46. Benegal V, Hingorani S, Khanna S. Idiopathic catatonia: validity of the concept. Psychopathology 1993;26:41-46.

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47. Krishna KR, Maniar RC, Harbishettar VS. A comparative study of “Idiopathic catatonia” with catatonia in schizophrenia. As. J. Psychiatry 2011;doi:10.1016/j.ajp.2011.04.007.

48. American Psychiatric Association, 2011. DSM-5 Progress. www.DSM5.org 49. Peralta V, Cuesta M. Motor features in psychotic disorders. II Development of diagnostic criteria

for catatonia. Schizophr Res. 2001;47:117-126. 50. Pascal S, Jonas R, Jurgen DF. Measuring catatonia: A systematic review of rating scales. J Affect

Disord 2011;doi:10.1016/j.jad.2011.02.012.

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Response to the SRC Memo on Catatonia We thank the SRC for their thorough review of our proposal regarding the treatment of catatonia in DSM-5 and the opportunity to clarify some of their observations and comments. In an effort to address some of the limitations in the DSM-IV construct/definition of catatonia and following an extensive review of the literature and consultation with experts, we had proposed the following four changes:

1. Change in criteria for diagnosing catatonia.

2. Catatonia should be a specifier and not a subtype of schizophrenia in DSM-5

3. Catatonia should be added as a specifier for four other psychotic disorders (Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, and Substance-induced Psychotic Disorder)

4. A residual category of Catatonia Not Otherwise Specified should be added in the Psychotic Disorders section.

The SRC explicitly supported changes# 2 and 3, provisionally supported change# 1, but did not support change# 4. We therefore specifically respond to questions and comments regarding changes# 1 and 4.

1. Change #1: Change in criteria for diagnosing catatonia.

In an effort to simplify the definition of catatonia and thereby improve its recognition, we proposed a modest revision of the DSM-IV criteria. The revised criterion is closely aligned with and strongly correlated with the DSM-IV definition, but represents a substantial simplification which should improve clinical utility. Furthermore, we had proposed that this definition be utilized across DSM-5 (a position also strongly endorsed by the SRC). As noted by the SRC, however, there are a limited number of studies which have utilized this new definition thus far. In view of the fact that this revision from DSM-IV is modest, the two definitions strongly correlate (no effect on caseness),1,2 is supported by the Catatonia Scholars Group,3 and its elements are all reflected in all current catatonia rating scales,1,4 we hope the SRC will be more positive in its appraisal of this recommended change in its definition (Attachment 1). As the SRC correctly notes, the Peralta et al. 2010 study2 identified three factors but specifically noted that defining catatonia on the basis of the presence of any 3 of 12 signs was recommended (this statement is now specifically highlighted in a pdf of the paper- Attachment 2). Consequently, we propose the definition as below which should be utilized across the DSM-5 manual:

Catatonia is defined as the presence of three or more of the following: 1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Negativism 7. Posturing 8. Mannerisms 9. Stereotypies 10. Grimacing 11. Echolalia 12. Echopraxia

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IMPACT OF CHANGE # 1 This change is primarily designed to address issues of under-recognition and inconsistent definition of catatonia. It retains maximal continuity with DSM-IV (It lists all the 12 elements in DSM-IV with more valid operationalization), is supported by recent comparative data about diagnostic criteria for schizophrenia, does not affect caseness, and will be similarly applied across the manual. Its major clinical impact will be enhanced simplicity and consistency, with increased clinical utility.

2. A residual category of Catatonia Not Elsewhere Classified should be added in the Psychotic Disorders section.

The workgroup proposed the addition of a residual diagnostic category of Catatonia NEC (not elsewhere classified). The SRC did not support this recommendation because “neither the criteria for catatonia NEC nor the rationale for it were provided”. We regret not adequately providing this information and do so here and address related questions posed by the SRC. The fundamental justification for creating this residual category of Catatonia NEC is the existence of catatonia outside the diagnoses in which it can be utilized as a specifier in DSM-5 and the clinical (and research) importance of identifying the presence of catatonia because of its prognostic and therapeutic implications. A. Existence of Catatonia in Conditions Other Than DSM-5 Diagnoses Where it is a Specifier

Based on the prior SRC review, catatonia will be utilized as a specifier for schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, substance-

Criteria for Catatonia Not Elsewhere Classified A. The presence of catatonia as manifested by three or more of the following:

Catalepsy Waxy flexibility Stupor Agitation Mutism Negativism Posturing Mannerisms Stereotypies Grimacing Echolalia Echopraxia

B. The disturbance is not due to schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, bipolar disorder, or major depressive disorder.

C. The disorder is not due to the direct physiological effects of a substance (eg., a drug of abuse, a medication) or a diagnosed general medical condition

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induced psychotic disorder, psychotic disorder secondary to a diagnosed general medical condition, and the major mood disorders. There are two important clinical situations outside the ones above where it would be important to be able to diagnose the presence of catatonia:

a. The general medical condition which is likely contributing to catatonia may not be identified initially. Either the information may be insufficient or the work-up may be ongoing. If a catatonia NEC is identified, however, specific treatment for catatonia can ensue and general medical conditions more likely associated with catatonia can be more specifically considered5-7 (Attachment 3).

b. Presence of catatonia in psychiatric conditions other schizophrenia and major mood disorders, specifically in the context of autism and other neurodevelopmental disorders8-16 (Attachments 4 and 5). Catatonia frequently occurs in these disorders in the absence of major mood or other diagnosable psychotic disorders. The occurrence of catatonia in autism and other developmental disorders has important prognostic and treatment implications.

Unfortunately, the exact prevalence of catatonia in these other conditions is unknown as there has been no ability thus far to diagnose its presence in that context. Hopefully, we will generate better data about this co-occurrence and make an informed decision in the future about whether to diagnose catatonia as a comorbid condition or as a specifier for a certain set of additional DSM conditions. Until such time, Catatonia NEC would be a residual category which would allow the diagnosis of catatonia. This would also be important from a research perspective, as genetic factors for “periodic catatonia” are being identified.17,18 At the present time, there is also no ability to diagnose/document periodic catatonia.

IMPACT OF CHANGE

This change specifically addresses the limitation of our inability to diagnose the presence of catatonia in other psychiatric conditions and undiagnosed general medical conditions. This is a residual category and is strongly supported by a broad consensus of catatonia experts.3

Its major clinical impact will be enhanced clinical utility and improved concurrent and predictive validity.

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References

1. Peralta V, Cuesta M. Motor features in psychotic disorders. II Development of diagnostic criteria for catatonia. Schizophr Res. 2001;47:117-126. ATTACHMENT 1

2. Peralta V, Campos MS, Garcia de Jalon E, Cuesta M. DSM-IV catatonia signs and criteria in first-episode, drug-naïve, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophr Res. 2010;118:168-175. ATTACHMENT 2

3. Francis A, Fink M, Appiani F, Bertelsen A, Bolwig TG, Braunig P, Caroff SN, Carroll BT, Cavanna AE, Cohen D, Cottencin O, Cuesta MJ, Daniels J, Dhossche D, Fricchione GL, Gazdag G, Ghaziuddin N, Healy D, Klein D, Kruger S, Lee JWY, Mann SC, Mazurek M, McCall WV, McDaniel WW, Northoff G, Peralta V, Petrides G, Rosebush P, Rummans TA, Shorter E, Suzuki K, Thomas P, Vaiva G, Wachtel L. Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of ECT; 26:246-247.

4. Pascal S, Jonas R, Jurgen DF. Measuring catatonia: A systematic review of rating scales. J Affect Disord 2011;doi:10.1016/j.jad.2011.02.012.

5. Daniels J. Catatonia: clinical aspects and neurological correlates. J Neuropsychiatry Clin Neurosci 2009;21:371-380. ATTACHMENT 3

6. Rizos DV, Peritogiannis V, Gkogkos C. Catatonia in the intensive care unit. General Hospital Psychiatry 2011;33:e1-e2.

7. Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: A review. Ann Clin Psychiatry 2008;20:97-107.


9. DhosscheD, Cohen D, Ghaziuddin N, Wilson C, Wachtel LE. The study of pediatric catatonia supports a home of its own for catatonia in DSM-5. Medical Hypotheses 2010;75:558-560. ATTACHMENT 4

10. Wing L, Shah A. Catatonia in autism spectrum disorders. Br J Psychiatry 2000;176:357-362. ATTACHMENT 5

11. Hare DJ, Malone C. Catatonia and autism spectrum disorders. Autism 2004;8:183-195. 12. Thakur A, Jagadheesan K, Dutta S, Sinha VK. Incidence of catatonia in children and adolescents in a

pediatric psychiatric clinic. Aust N Z J Psychiatry 2003;37:200-203. 13. Cornic F, Consoli A, Cohen D. Catatonic syndrome in children and adolescents. Psychiatr Annals


2003;57:129-137. 15. Benegal V, Hingorani S, Khanna S. Idiopathic catatonia: validity of the concept. Psychopathology

1993;26:41-46. 16. Krishna KR, Maniar RC, Harbishettar VS. A comparative study of “Idiopathic catatonia” with

catatonia in schizophrenia. As. J. Psychiatry 2011;doi:10.1016/j.ajp.2011.04.007. 17. Stober G, Saar K, Ruschendorf F, et al. Splitting schizophrenia: periodic catatonia susceptibility

locus on chromosome 15q15. Am J Hum Genet 2000;67:1201-1207. 18. Chagnon Y. Shared susceptibility region on chromosome 15 between autism and catatonia. Int Rev

Neurobiol 2006;72:165-178.

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Response to SRC Memo on Catatonia dated Sept. 16, 2011 We thank the SRC for their comprehensive review of our response to their assessment of our original proposal regarding the treatment of catatonia in DSM-5. The SRC had questions about one aspect of our submission related to the diagnostic criteria proposed for catatonia in DSM-5. Specifically, the SRC noted that three of the 12 items (namely, agitation, stereotypy, and mannerisms) were found not to reliably distinguish catatonia from other syndromes in the original 2001 analysis by Peralta and co-workers,1 and further noted that the presence of just these three features would lead to a diagnosis of catatonia in DSM-5 as per the proposed criteria (any 3 of listed 12 items). Based on these observations, the SRC asked us to provide evidence that supports making the diagnosis of catatonia on these three criteria alone. We agree with the SRC’s understanding of the Peralta et al., 2001 findings and its implications for the proposed DSM-5 definition of catatonia. There are two reasons why we proposed these criteria for DSM-5 catatonia in the face of this anomaly.

1. More Recent Data on the Discriminating Value of the 12 DSM-IV Signs It should be noted that while the DSM-5 definition of catatonia differs from that of DSM-IV, the 12 features included in the DSM-5 definition are the same 12 items included in the DSM-IV definition of catatonia. In a 2010 comprehensive evaluation of these 12 signs for the diagnosis of catatonia, Peralta and co-workers2 (Attached) found each one of the 12 signs to discriminate between catatonia and other syndromes. Furthermore, they observed that stereotypy and mannerisms had particularly high discriminating value (Please see Table 2 of the paper)- they were 4th and 5th of 12 after posturing, catalepsy, and mannerisms. Agitation continued to exhibit the weakest correlation with other catatonia constructs even though it was found to discriminate between catatonia and non-catatonia (chi square=23.0; df=1; p<0.001). One major difference between the more recent 2010 sample and the previous 2001 sample is noteworthy: the 2010 sample was comprised of drug-naive, first episode patients in contrast to the 2001 sample which included chronic and medicated patients.

Catatonia is defined as the presence of three or more of the following: 1. Catalepsy 2. Waxy flexibility 3. Stupor 4. Agitation 5. Mutism 6. Negativism 7. Posturing 8. Mannerisms 9. Stereotypies 10.Grimacing 11.Echolalia 12.Echopraxia

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2. Inadequate Evaluation of Alternative Definition and Continuity with DSM-IV As noted above, the twelve items proposed for the DSM-5 definition of catatonia are exactly the same 12 items included in the DSM-IV definition of catatonia but are reorganized differently to provide a more valid definition of catatonia. It can be argued that since agitation is the weakest of the 12 items, its exclusion should be considered. It should be noted, however, that excluding agitation from the list of 12 items creates a new scale whose psychometric properties are unknown. It is possible that a more valid definition might emerge but it is equally plausible that it might not be as good as the proposed definition- the effect of deleting agitation from the 12 items proposed for a definition of catatonia (of which, at least three need to be present) is not known at present. Additionally, deletion of agitation would represent a greater discontinuity with DSM-IV and at present it appears unnecessary.

Summary and Specific Question Raised by SRC The SRC raised a specific question as to the evidence that supports making a diagnosis of catatonia based on the presence of agitation, mannerisms, and posturing alone. More recent data indicate that both mannerisms and stereotypy are very highly discriminating items between catatonia and other syndromes. While agitation is found to be the least discriminating among the 12 items proposed for the definition of catatonia, it does discriminate between catatonia and other syndromes. It should also be noted that according to DSM-IV, catatonia would be diagnosed based on this profile (items from two of several groups of signs- agitation is in one group and mannerisms and stereotypy in another group). Based on this evidence, we believe that our proposed definition of catatonia is the best one currently possible- (i) it is supported by recent comparative data about different definitions of catatonia; (ii) it retains maximal continuity with DSM-IV (listing all 12 items listed in DSM-IV with

more valid operationalization); (iii) it will be similarly applied across the manual; and (iv) it provides simplicity and easy clinical applicability.

Additional Issue Residual category of Catatonia Not Elsewhere Classified should be added in the Psychotic Disorders section.

The workgroup had proposed (in July) the addition of a residual diagnostic category of Catatonia NEC (not elsewhere classified). The SRC requested detailed proposed criteria for catatonia NEC and a better explanation of our rationale for this recommendation. We subsequently provided this information in our response dated August 24, 2011 in which we also submitted additional justification and materials in support of this recommendation. In summary, the fundamental justification for creating this residual category of Catatonia NEC is the existence of catatonia outside the diagnoses in which it can be utilized as a specifier in DSM-5 and the clinical (and research) importance of identifying the presence of catatonia because of its prognostic and therapeutic implications. A. Existence of Catatonia in Conditions Other Than DSM-5 Diagnoses Where it is a Specifier In

DSM-5, catatonia will be utilized as a specifier for schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, substance-induced psychotic disorder,

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psychotic disorder secondary to a diagnosed general medical condition, and the major mood disorders. There are two important clinical situations outside the ones above where it would be important to be able to diagnose the presence of catatonia:

a. The general medical condition which is likely contributing to catatonia may not be identified initially. Either the information may be insufficient or the work-up may be ongoing. If a catatonia NEC is identified, however, specific treatment for catatonia can ensue and general medical conditions more likely associated with catatonia can be more specifically considered.

b. Presence of catatonia in psychiatric conditions other schizophrenia and major mood disorders, specifically in the context of autism and other neurodevelopmental disorders. Catatonia frequently occurs in these disorders in the absence of major mood or other diagnosable psychotic disorders. The occurrence of catatonia in autism and other developmental disorders has important prognostic and treatment implications.

c. Additionally, as genetic factors for “periodic catatonia” are being identified, and

there is also no ability to diagnose/document periodic catatonia, it could be coded as Catatonia NEC.

As per international convention, Catatonia NEC would be placed in the section of Psychotic Disorders. Should there be a change in its placement in ICD-11, this would be reconsidered.

References

1. Peralta V, Cuesta M. Motor features in psychotic disorders. II Development of diagnostic criteria for catatonia. Schizophr Res. 2001;47:117-126..

2. Peralta V, Campos MS, Garcia de Jalon E, Cuesta M. DSM-IV catatonia signs and criteria in first-episode, drug-naïve, psychotic patients: psychometric validity and response to antipsychotic medication. Schizophr Res. 2010;118:168-175.

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Response to SRC Memo on Catatonia We thank the SRC for their comprehensive review of our response to their assessment of our revised proposal regarding the treatment of catatonia in DSM-5. In view of the SRC’s unfavorable assessment with regard to our proposal for a modest change in the criteria to diagnose catatonia, we withdraw that proposal in view of the limited validation data as also the absence of an urgent clinical need for the change. We, however, request the SRC to reconsider their unfavorable assessment of our recommendation to add a residual category of Catatonia NEC because of the clinical imperative even though data with reference to the range of validators is incomplete.

We provide a brief summary below of the three SRC reviews of our original proposal and two subsequent revisions. We then resubmit a more succinct rationale for our request to the SRC to reconsider its disapproval of our recommendation to add a residual category of Catatonia NEC.

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Catatonia in the DSM–5. The catatonia diagnosis in DSM-IV-TR1,2

1. Catatonic Disorder due to a GMC (293.89) 2. Schizophrenia, catatonic subtype (295.20) 3. Specifier “with Catatonic Features” without specific code for current or most recent

Major Depressive Episode, Manic Episode, or Mixed Episode in: a. Major depressive disorder, b. Bipolar I disorder, or c. Bipolar II disorder

Specific criteria are provided for its identification in each of these contexts in DSM-IV, although they are different across the above settings. Catatonia is diagnosed by the presence of any of the following: motoric immobility, excessive motor activity, extreme negativism, peculiarities of voluntary movement or echopraxia/echolalia in the context of 1 (catatonic disorder due to a general medical condition), In contrast, in 2 and 3 (schizophrenia subtype and specifier for major mood disorders, respectively), catatonia is diagnosed only if the clinical picture is dominated by at least two of the above five.

Major Challenges in DSM-IV Treatment of Catatonia3

1. Different sets of criteria used to diagnose catatonia in different sections of the manual. 2. Different treatment of catatonia in different sections of the manual (distinct disorder,

subtype, or specifier). 3. Inability to diagnose catatonia in a range of psychotic and nonpsychotic disorders

where it is prevalent. Current Workgroup Proposal: The catatonia diagnosis in DSM 5 (dated May 19, 2012)3

1. Catatonic Disorder due to a GMC (293.89) 2. Specifier “with Catatonia" for:

a. Schizophrenia b. Schizoaffective Disorder c. Schizophreniform Disorder d. Brief psychotic disorder e. Substance-Induced Psychotic Disorder f. Psychosis Not otherwise Specified

3. Specifier “with Catatonia” for current or most recent Major Depressive Episode or Manic Episode in: a. Major depressive disorder, b. Bipolar I disorder, or c. Bipolar II disorder

4. Catatonic Disorder, Not Elsewhere Classified Use of the same set of criteria to diagnose catatonia across the DSM manual

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History of Submissions by Psychotic Disorders Workgroup to SRC and SRC Reviews Proposed Changes in Psychotic Disorders Workgroup (WG) Original Submission April 2011

1. a) Use of an identical set of criteria to diagnose catatonia across the manual b) Change in criteria to diagnose catatatonia

2. Catatonia should be a specifier for various disorders across the manual.

Therefore it should be a specifier and not a subtype of schizophrenia in DSM-5

3. Catatonia should be added as a specifier for five other psychotic

disorders (Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, Substance-induced Psychotic Disorder, and Psychosis Not Otherwise specified)

4. A residual category of Catatonia Not Otherwise Specified should be

added in the Psychotic Disorders section.

SRC Review of Original Proposal (July 29, 2011) In its initial review of the original proposal, the SRC explicitly supported changes# 2 and 3 (rating both a 2), and #1a. They provisionally supported change# 1b (rating it a 3), but did not support change# 4. They asked for additional information on # 1b and 4. The Psychotic Disorders WG specifically responded to questions and comments regarding changes# 1b and 4, providing a rationale for both a modest change in criteria to diagnose catatonia and for the addition of a residual category of Catatonia NEC. SRC Review of Revised Proposal (September 16, 2011) In its review of the revised proposal submitted by the WG, the SRC only commented on change# 1b , asking some additional questions and raising some concerns. They did not comment on the additional information provided with regard to change #4. The Psychotic Disorders WG provided additional data supporting a modest change in criteria (Proposed change 1b) and supplemented the justification for the addition of a residual category of Catatonia NEC (Proposed change # 4) SRC Review of 2nd Revised Proposal (January 23, 2012) In its review of the revised proposal submitted by the WG, the SRC disapproved both changes 1b and 4, rating both a 5 (poor support- do not include).

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The Psychotic Disorders Workgroup carefully considered the reviews of the SRC and has decided to withdraw its proposal for a change in the specific criteria to diagnose catatonia (change 1b) because validating data are limited and there is no clinical imperative for the change. As proposed by the workgroup and strongly endorsed by the SRC, the same set of criteria will be utilized to diagnose catatonia across the DSM manual and this will be the criterion set used to diagnose catatonia in 2 of the 3 places in the DSM-IV manual.; i.e., catatonia is defined on the basis of the presence of 2 of the following five sets of symptoms: (a) Motoric immobility, as evidenced by catalepsy or stupor; (b) excessive motor activity; (c) extreme negativism or mutism; (d) peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms, or prominent grimacing; (v) echolalia or echopraxia In contrast, there is a strong clinical need for the addition of a residual category of Catatonia NEC (change 4). After a brief summary of the status of our proposed changes, we provide a succinct rationale. Overall SRC Review Summary of Proposed Changes 1-4

1 a) Use of an identical set of criteria to diagnose catatonia across the manual Approve. In fact, the SRC “strongly recommended” that criteria for catatonia be consistent across the manual. b) Change in criteria to diagnose catatatonia Disapprove. Score of 5 (Poor support, do not include). [The Psychotic Disorders workgroup withdraws this change from further consideration]

2 Catatonia should be a specifier for various disorders across the manual. It should be

a specifier and not a subtype of schizophrenia in DSM-5 Approve. Score of 2.

3. Catatonia should be added as a specifier for five other psychotic disorders (Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, Substance-induced Psychotic Disorder, and Psychosis Not Otherwise specified). Approve. Score of 2.

4. A residual category of Catatonia Not Elsewhere Classified (NEC) should be added in the Psychotic Disorders section.

Disapprove. Score of 5 (Poor support, do not include)

We would like to urge the SRC to reconsider its recommendation to disapprove the addition of a residual category of Catatonia NEC and would like to urge the CPHC to favorably consider the addition of this diagnostic category because of a strong clinical imperative and in the interests of harmonization with the proposed ICD-11 criteria.

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Why the Workgroup Believes that a residual category of Catatonia Not Elsewhere Classified should be added in the Psychotic Disorders section.

The fundamental justification for creating this residual category of Catatonia NEC is the existence of catatonia outside the diagnoses in which it can be utilized as a specifier in DSM-5 and the clinical (and research) importance of identifying the presence of catatonia because of its prognostic and therapeutic implications. A. Existence of Catatonia in Conditions Other Than DSM-5 Diagnoses Where it is a

Specifier Based on the prior SRC review, catatonia will be utilized as a specifier for schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with a diagnosed general medical condition, psychotic disorder not elsewhere classified, and the major mood disorders. There are two important clinical situations outside the ones above where it would be important to be able to diagnose the presence of catatonia:

a. The general medical condition which is likely contributing to catatonia may not be identified initially. Either the information may be insufficient or the work-up may be ongoing. If a catatonia NEC is identified, however, specific treatment for catatonia can ensue and general medical conditions more likely associated with catatonia can be more specifically considered.4-8

b. Presence of catatonia in psychiatric conditions other than various psychotic disorders and major mood disorders, specifically in the context of autism and other neurodevelopmental disorders9-21 Catatonia frequently occurs in these disorders in the absence of major mood or other diagnosable psychotic disorders. The occurrence of catatonia in autism and other developmental disorders has important prognostic and treatment implications.

Several experts from across the world, including a group of 33 “catatonia scholars”,9 and a multitude of clinical research publications from across the world, including four published in 2012,18-22 emphasize the clinical imperative of being able to diagnose catatonia in these conditions in order to ensure appropriate treatment.

Unfortunately, the exact prevalence of catatonia in these other conditions is unknown as there has been no ability thus far to diagnose its presence in this context. Hopefully, there will be better data about this co-occurrence and make an informed decision in the future about whether to diagnose catatonia NEC as a comorbid condition or instead as a specifier for a certain limited set of additional DSM conditions. Until such time, Catatonia NEC would be a residual category that would allow the diagnosis of catatonia.

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B. Importance of Recognizing Catatonia Catatonia in such settings (similar to conditions where it can be diagnosed as a specifier in DSM-5) does respond to treatment with benzodiazepines and electroconvulsive therapy, as also identification and treatment of the primary psychiatric disorder or general medical condition. This had led to the use of a category of idiopathic catatonia (unrecognized in ICD-10 and DSM-IV).7,8 The predictive validity of the condition of catatonia(specific response of catatonia to treatment with benzodiazepines and electroconvulsive therapy23-25 is fairly established. This would also be important from a research perspective, as genetic factors for “catatonia” are being identified. At the present time, there is also no ability to diagnose/document catatonia except in a limited number of conditions. The principal need to identify catatonia whenever it occurs (as a specifier in a range of DSM-5 conditions as also in other clinical circumstances as Catatonia NEC) is clinical- a predictable response to specific treatments such as benzodiazepines and electroconvulsive therapy.

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References

1. American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders- 4th edition (DSM-IV). American Psychiatric Association, Washington D.C.

2. Fink M. Catatonia. In Widiger TA, Frances AJ, Pincus HA, First MB, Ross R, Davis WW (Eds). DSM-IV Sourcebook, Volume 2. Washington DC: American Psychiatric Association; 1996; 181-192.

3. American Psychiatric Association, 2011. DSM-5 Progress. www.DSM5.org 4. Rizos DV, Peritogiannis V, Gkogkos C. Catatonia in the intensive care unit. General Hospital

Psychiatry 2011;33:e1-e2. 5. Tuerlings JHAM, van Waarde JA, Verwey B. A retrospective study of 34 catatonic patients:

analysis of clinical care and treatment. General Hospital Psychiatry 2010;32:631-635. 6. Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: A review. Ann Clin Psychiatry

2008;20:97-107. 7. Benegal V, Hingorani S, Khanna S. Idiopathic catatonia: validity of the

concept. Psychopathology 1993;26:41-46. 8. Krishna KR, Maniar RC, Harbishettar VS. A comparative study of “Idiopathic catatonia” with

catatonia in schizophrenia. As. J. Psychiatry 2011;4:129-133. 9. Francis A, Fink M, Appiani F, Bertelsen A, Bolwig TG, Braunig P, Caroff SN, Carroll BT,

Cavanna AE, Cohen D, Cottencin O, Cuesta MJ, Daniels J, Dhossche D, Fricchione GL, Gazdag G, Ghaziuddin N, Healy D, Klein D, Kruger S, Lee JWY, Mann SC, Mazurek M, McCall WV, McDaniel WW, Northoff G, Peralta V, Petrides G, Rosebush P, Rummans TA, Shorter E, Suzuki K, Thomas P, Vaiva G, Wachtel L. Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of ECT; 26:246-247.


11. DhosscheD, Cohen D, Ghaziuddin N, Wilson C, Wachtel LE. The study of pediatric catatonia supports a home of its own for catatonia in DSM-5. Medical Hypotheses 2010;75:558-560.

12. Wing L, Shah A. Catatonia in autism spectrum disorders. Br J Psychiatry 2000;176:357-362. 13. Hare DJ, Malone C. Catatonia and autism spectrum disorders. Autism 2004;8:183-195. 14. Thakur A, Jagadheesan K, Dutta S, Sinha VK. Incidence of catatonia in children and

adolescents in a pediatric psychiatric clinic. Aust N Z J Psychiatry 2003;37:200-203. 15. Cornic F, Consoli A, Cohen D. Catatonic syndrome in children and adolescents. Psychiatr

Annals 2007;37:19-26. 16. Takaoka K, Takata T. Catatonia in childhood and adolescence. Psychiatry Clin Neurosci

2003;57:129-137. 17. van der Heijden FM, Tuinier S, Arts NJ, Hoogendoorn ML, Kahn RS, Verhoeven WM.

Catatonia: disappeared or under-diagnosed? Psychopathology. 2005;38:3-8. 18. Dhossche DM, Ross CA, Stoppelbein L. The role of deprivation, abuse and trauma in

pediatric catatonia without a clear medical cause. Acta Psychiatrica Scanidinavica 2012; 125:25-32.

19. Fink M. Hidden in plain sight: catatonia in pediatrics. Acta Psychiatrica Scandinavica 125: 11-12.

20. Shorter E. Making childhood catatonia visible. Acta Psychiatrica Scandinavica 2012; 125: 3-10.

21. Ghaziuddin N, Dhossche D, Marcotte K. Retrospective chart review of catatonia in child and adolescent psychiatric patients. Acta Psychiatrica Scandinavica 2012; 125:33-38.

http://www.dsm5.org/

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22. Consoli A, Raffin M, Laurent C, Bodeau N, Campion D, Amoura Z, Sedel F, An-Gourfinkel I, Bonnot O, Cohen D. Medical and developmental risk factors in catatonia in children and adolescents: A prospective case-control study. Schizophr. Res., In Press. Doi:10.1016/j.schres.2012.02.012.




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