What are the changes in diagnosis and management of catatonia associated with another medical disorder across Diagnostic and Statistical Manual of Mental Disorders (DSM) (Diagnostic and Statistical Manual of Mental Disorders) versions 3, 4, 5, and 5-Text Revision (TR), and International Classification of Diseases (ICD) (International Classification of Diseases) versions 10 and 11?

Evolution of Catatonia Diagnosis Across DSM and ICD Classifications

Direct Answer

Catatonia has evolved from being exclusively conceptualized as a subtype of schizophrenia in DSM-III and ICD-9 to being recognized as an independent syndrome with its own diagnostic criteria that can be applied across multiple psychiatric and medical conditions in DSM-5-TR and ICD-11. 1, 2

Historical Evolution Through DSM Versions

DSM-III Era (1980s-Early 1990s)

• Catatonia was defined only as a subtype of schizophrenia (295.2), despite clinical evidence showing catatonic symptoms occurred prominently in patients with psychoses, affective disorders, systemic illnesses, and neurotoxic states 3
• This narrow classification led to misdiagnosis and undertreatment of a highly treatable condition 3

DSM-IV (1994)

• Introduced "catatonia secondary to a general medical condition" as a new codable diagnosis 2
• Added catatonia as an episode specifier for major mood disorders, but without coding capability 2
• Critical limitation: Different sets of criteria were used to diagnose catatonia in schizophrenia/mood disorders versus neurological/medical conditions, creating diagnostic inconsistency 2
• Catatonia remained a codable subtype of schizophrenia but only a non-codable specifier for mood disorders 2

DSM-5 and DSM-5-TR (2013-Present)

• Unified approach: A single set of criteria now applies across all diagnostic categories 2
• Catatonia became a specifier for schizophrenia, major mood disorders, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder 2
• Added "catatonia not otherwise specified" as a residual category for rapid diagnosis in severely ill patients when the underlying diagnosis is not immediately available 2
• Requires at least 3 symptoms from a list of 12 clinical features 4

Historical Evolution Through ICD Versions

ICD-9 and Earlier

• Catatonia was considered exclusively as a form of schizophrenia, reflecting the Kraepelinian concept of dementia praecox 1

ICD-10

• Introduced "organic catatonic disorder" as a new diagnosis 1
• Major limitation: Did not incorporate growing evidence that catatonia occurs in psychiatric conditions such as mood disorders and autism-spectrum disorders 1
• Maintained 11 disorder groupings with traditional categorical classification 5

ICD-11 (2022-Present)

• Paradigm shift: Conceptualizes catatonia as an independent disorder with a common clinical phenotype regardless of associated condition 1
• Expanded from 11 to 21 disorder groupings in the mental, behavioral, and neurodevelopmental disorders chapter 5
• Catatonia is no longer regarded as a subtype of schizophrenia but as a syndrome of primarily psychomotor disturbances 5, 6

Current Diagnostic Criteria Comparison

ICD-11 Diagnostic Framework

• Requires at least 3 clinical features from three categories: decreased psychomotor activity, increased psychomotor activity, or abnormal psychomotor activity 1
• Important restriction: Only one feature from the increased psychomotor activity category should be counted 1
• Features may come from any combination of categories 1

Four ICD-11 Catatonia Diagnoses

1. Catatonia associated with another mental disorder 1
2. Catatonia induced by substances or medications 1
3. Secondary catatonia syndrome 1
4. Catatonia, unspecified 1

DSM-5-TR vs ICD-11 Alignment

• Both systems are broadly aligned in terms of which items are included, item definitions, and number of items required for diagnosis 4
• DSM-5-TR requires at least 3 symptoms from 12 clinical features 4
• Fundamental limitation in both systems: Lack of item thresholds for individual symptoms 4

Clinical Features Recognized

Core Psychomotor Disturbances (ICD-11 and DSM-5-TR)

• Stupor, catalepsy, waxy flexibility, mutism, negativism 5, 6
• Posturing, mannerisms, stereotypies 5, 6, 7
• Psychomotor agitation, grimacing 5, 6
• Echolalia and echopraxia 5, 6

Differential Diagnosis Guidance

ICD-11 Distinguishing Features

• Provides guidance on distinguishing catatonia from psychomotor retardation in depression 1
• Differentiates from delirium 1
• Distinguishes from factitious disorder 1

Common Pitfalls and Clinical Implications

Recognition Challenges

• The discrepant treatment of catatonia across DSM-IV led to frequent non-recognition by clinicians 2
• Many distinctions across scales and diagnostic criteria contribute to diagnostic discordance 4
• Clear, consistent definitions for catatonia features are essential for reliable detection 4

Assessment Tools

• Bush-Francis scale is the most efficient, with a screening instrument, videographic resources, and standardized clinical assessment 4
• Northoff scale offers the most detailed assessment and uniquely emphasizes emotional and volitional disturbances 4
• Both Bush-Francis and Northoff scales can be converted to diagnostic criteria with limited modification 4

Treatment Implications

• The expanded recognition in ICD-11 and DSM-5-TR should improve identification of this highly treatable condition 1
• Historical data shows excellent response to ECT (8 of 11 patients) compared to psychotropic medications (2 of 34 trials successful) 3
• Benzodiazepines and ECT provide quick treatment to remission 8

Key Advantages of Current Systems

ICD-11 Improvements

• Underwent the largest participative revision in classification history 9
• Field studies demonstrated higher reliability and clinical utility compared to ICD-10 9
• The expanded view more closely resembles DSM-5-TR in recognizing catatonia across psychiatric and general medical conditions 1

Remaining Limitations

• Despite advances, important limitations remain in both ICD-11 and DSM-5-TR regarding item thresholds and standardization 4
• Differences across scales and criteria continue to impede reliable catatonia detection 4