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

Evolution of Catatonia Diagnosis Across DSM and ICD Versions

The diagnosis of catatonic disorder due to another medical condition has undergone fundamental reconceptualization from being exclusively a schizophrenia subtype in early DSM/ICD versions to an independent syndrome with unified diagnostic criteria across all associated conditions in DSM-5/5-TR and ICD-11.

DSM-3 and DSM-3-R (1980s-1990s)

• Catatonia was defined exclusively as a subtype of schizophrenia (295.2 - Catatonic Schizophrenia), with no recognition of catatonia occurring in other psychiatric or medical conditions 1
• This narrow conceptualization led to systematic underdiagnosis of catatonia when it occurred in affective disorders, systemic illnesses, and neurotoxic states 1
• No separate diagnostic category existed for catatonia secondary to general medical conditions during this era 2

DSM-4 (1994)

• DSM-IV introduced catatonic disorder due to a general medical condition as a new, separate diagnostic category, representing the first major shift away from viewing catatonia solely as a schizophrenia subtype 2
• Catatonia was added as an episode specifier for major mood disorders, though without separate coding capability 2
• A critical limitation emerged: different sets of diagnostic criteria were used for catatonia in schizophrenia/mood disorders versus neurological/medical conditions, creating diagnostic inconsistency 2
• Catatonia remained a codable subtype for schizophrenia but only a non-codable specifier for mood disorders, contributing to continued clinical underrecognition 2

DSM-5 and DSM-5-TR (2013-2022)

• A single, unified set of diagnostic criteria was established for catatonia across all conditions, eliminating the previous diagnostic discrepancies 2
• Catatonia became a specifier (with coding) for both schizophrenia and major mood disorders, as well as for other psychotic disorders including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder 2
• A new residual category of "catatonia not otherwise specified" was added to allow rapid diagnosis and treatment in severely ill patients when the underlying diagnosis is not immediately available 2
• Core diagnostic features include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia 3, 4

ICD-9 and Earlier

• Like early DSM versions, ICD-9 and earlier versions considered catatonia exclusively as a form of schizophrenia, reflecting the Kraepelinian concept of dementia praecox 5

ICD-10 (1990s)

• ICD-10 introduced the diagnosis of "organic catatonic disorder", representing initial recognition that catatonia could occur in medical conditions 5
• However, ICD-10 failed to incorporate growing evidence that catatonia occurs in psychiatric conditions such as mood disorders and autism-spectrum disorders 5
• The classification maintained 11 disorder groupings with traditional categorical structure 6

ICD-11 (2022)

• ICD-11 represents the most comprehensive reconceptualization, defining catatonia as an independent disorder with a common clinical phenotype regardless of associated condition 3, 5
• The diagnostic criteria require at least 3 clinical features from three categories: decreased psychomotor activity, increased psychomotor activity, or abnormal psychomotor activity 3
• Features may come from any combination of categories, but only one from the increased psychomotor activity category should be counted 3
• ICD-11 establishes four distinct catatonia diagnoses: (1) catatonia associated with another mental disorder, (2) catatonia induced by substances or medications, (3) secondary catatonia syndrome (due to medical conditions), and (4) catatonia, unspecified 5
• The classification expanded from 11 to 21 disorder groupings, with field studies demonstrating higher reliability and clinical utility compared to ICD-10 3, 6
• ICD-11 provides explicit guidance on distinguishing catatonia from similar behavioral features in psychomotor retardation in depression, delirium, and factitious disorder 3, 5

Key Convergence Between DSM-5-TR and ICD-11

• Both current systems are broadly aligned in terms of which items are included, item definitions, and conceptualization of catatonia as occurring across multiple conditions 7
• Both recognize catatonia associated with psychiatric disorders, general medical conditions, and substance-induced states 5, 2
• A fundamental limitation remains in both systems: the lack of specific item thresholds for individual features, which can introduce diagnostic variance 7

Clinical Implications of These Changes

• The evolution from schizophrenia-exclusive to syndrome-based diagnosis has improved recognition of catatonia across psychiatric and medical settings, where it occurs in 5-18% of psychiatric inpatients and 3.3% of medical inpatients 8
• Early recognition is crucial because unrecognized catatonia carries risk of life-threatening complications and high morbidity and mortality 8
• The unified diagnostic approach facilitates consistent treatment with benzodiazepines, electroconvulsive therapy, and NMDA antagonists across all catatonia presentations 8