What are the changes in diagnosis of unspecified catatonia disorder 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

Catatonia has undergone a fundamental reconceptualization from being exclusively a schizophrenia subtype in early classification systems to an independent syndrome with multiple diagnostic categories in modern DSM-5/5-TR and ICD-11, with the most significant changes being the introduction of "unspecified catatonia" as a distinct diagnostic entity and the recognition that catatonia can occur across diverse psychiatric and medical conditions. 1, 2

Historical Evolution Through DSM Versions

DSM-III and DSM-III-R Era

• In DSM-III and DSM-III-R, catatonia was defined only as a subtype of schizophrenia (code 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 significant underrecognition and misdiagnosis, as clinicians could not formally diagnose catatonia when it occurred outside the context of schizophrenia 3

DSM-IV Changes

• DSM-IV introduced catatonia secondary to a general medical condition as a new diagnostic category 4
• Catatonia was added as an episode specifier for major mood disorders, though it remained a codable subtype for schizophrenia but only a non-codable specifier for mood disorders 4
• A critical limitation emerged: different sets of criteria were used to diagnose catatonia in schizophrenia/mood disorders versus neurological/medical conditions, contributing to continued clinical underrecognition 4

DSM-5 and DSM-5-TR Revolution

• DSM-5 implemented four major structural changes to address diagnostic inconsistencies 4:

  • A single unified set of criteria now applies across all diagnostic contexts, eliminating the previous fragmented approach 4
  • Catatonia became a codable specifier for both schizophrenia and major mood disorders 4
  • Catatonia was extended as a specifier to other psychotic disorders including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder 4
  • "Catatonia not otherwise specified" (unspecified catatonia) was added as a new residual category to allow rapid diagnosis and treatment in severely ill patients when the underlying diagnosis is not immediately available 4

• The core diagnostic features in DSM-5-TR include stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia 1, 5

ICD Classification Evolution

ICD-9 and Earlier

• Similar to early DSM versions, ICD-9 and earlier versions considered catatonia exclusively as a form of schizophrenia, reflecting the Kraepelinian concept of dementia praecox 2

ICD-10 Limitations

• ICD-10 introduced the diagnosis of organic catatonic disorder, representing modest progress 2
• However, ICD-10 maintained 11 disorder groupings with traditional categorical classification and failed to incorporate growing evidence that catatonia occurs in psychiatric conditions such as mood and autism-spectrum disorders 6, 2

ICD-11 Comprehensive Revision

• ICD-11 represents the most significant paradigm shift, conceptualizing catatonia as an independent disorder with a common clinical phenotype regardless of associated condition 1, 2

• The diagnostic criteria require at least 3 clinical features from three categories: decreased psychomotor activity, increased psychomotor activity, or abnormal psychomotor activity, with features from any combination of categories, but only one from the increased activity category should be counted 1

• ICD-11 establishes four distinct catatonia diagnoses 2:

  • Catatonia associated with another mental disorder
  • Catatonia induced by substances or medications
  • Secondary catatonia syndrome
  • Catatonia, unspecified

• The ICD-11 chapter expanded from 11 to 21 disorder groupings and underwent the largest participative revision in classification history, with field studies demonstrating higher reliability and clinical utility compared to ICD-10 1, 6

• ICD-11 provides explicit guidance on distinguishing catatonia from similar behavioral features including psychomotor retardation in depression, delirium, and factitious disorder 1, 2

Convergence of DSM-5-TR and ICD-11

• Both modern classification systems are now broadly aligned in terms of which items are included, item definitions, and number of items required for diagnosis 7
• Both recognize catatonia associated with several psychiatric and general medical conditions, moving away from the schizophrenia-centric model 2
• Both systems now include "unspecified catatonia" as a distinct diagnostic category, addressing cases of idiopathic or recurrent catatonia that do not fit traditional associations 8, 4

Critical Clinical Implications

Diagnostic Recognition

• The evolution toward unified criteria and multiple diagnostic categories should improve consistent recognition of catatonia across the range of psychiatric disorders and facilitate specific treatment 4
• The addition of unspecified catatonia allows for rapid diagnosis and treatment initiation in severely ill patients, which is critical given catatonia's potential for life-threatening complications 8, 4

Remaining Limitations

• Despite improvements, the lack of specific item thresholds in both DSM-5-TR and ICD-11 remains a fundamental limitation that can introduce variance into catatonia caseness 7
• Clear, consistent definitions for catatonia features are essential for reliable detection, and many distinctions across scales and criteria could contribute to diagnostic discordance 7