What are the strengths and weaknesses of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and International Classification of Diseases, Eleventh Revision (ICD-11) in diagnosing catatonia associated with another mental disorder in patients across different age groups?

Diagnostic Systems for Catatonia Associated with Another Mental Disorder

Direct Answer

Both DSM-5-TR and ICD-11 represent significant improvements over prior systems by recognizing catatonia as a cross-diagnostic syndrome with unified criteria, but ICD-11 demonstrates superior clinical utility with its independent diagnostic status and explicit differential guidance, while both systems still lack biological validation and remain fundamentally categorical despite dimensional additions. 1, 2

Strengths of DSM-5-TR

Unified Diagnostic Approach

• DSM-5 introduced a single set of criteria for catatonia across all psychiatric disorders, eliminating the previous inconsistent treatment where different criteria applied to schizophrenia versus mood disorders versus medical conditions 3, 4
• Catatonia became a specifier for schizophrenia, major mood disorders, and other psychotic disorders (schizoaffective, schizophreniform, brief psychotic disorder, substance-induced psychotic disorder), allowing consistent recognition across diagnostic categories 3
• The unified approach facilitates specific treatment initiation regardless of underlying psychiatric condition 3

Clinical Recognition Features

• Core psychomotor disturbances are clearly defined, including stupor, catalepsy, waxy flexibility, mutism, and negativism 1
• Additional features such as posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia are documented 1

Strengths of ICD-11

Independent Diagnostic Status

• ICD-11 conceptualizes catatonia as an independent disorder with a common clinical phenotype regardless of associated condition, representing a fundamental shift from viewing it merely as a subtype of schizophrenia 1, 5
• This independent status emerged from the largest participative revision in classification history, with field studies demonstrating higher reliability and clinical utility compared to ICD-10 1

Superior Diagnostic Precision

• ICD-11 requires at least 3 clinical features from three categories (decreased psychomotor activity, increased psychomotor activity, or abnormal psychomotor activity), with features from any combination but only one from the increased activity category counted 1
• Provides explicit guidance on distinguishing catatonia from similar behavioral features including psychomotor retardation in depression, delirium, and factitious disorder 1

Field-Tested Clinical Utility

• Field studies with 873 clinicians showed measurably higher diagnostic accuracy using ICD-11 compared to ICD-10 2
• 82.5% to 83.9% of clinicians rated ICD-11 as quite or extremely easy to use, accurate, clear, and understandable 2, 6
• High interrater reliability for psychotic disorders in ecological field studies 2, 6

Dimensional Enhancements

• ICD-11 expanded from 11 to 21 disorder groupings in the mental, behavioral, and neurodevelopmental disorders chapter, providing more comprehensive classification 1
• Allows rating symptom severity across multiple domains at each assessment, providing flexibility for treatment planning 2
• Emphasizes documenting episodicity and current status to capture longitudinal patterns beyond categorical diagnosis 2

Shared Weaknesses of Both Systems

Lack of Biological Validation

• Neither DSM-5-TR nor ICD-11 has biological validation, resulting in biologically heterogeneous groups within the same diagnostic category 6
• Both systems classify mental phenomena based on self-reported or clinically observable symptoms rather than underlying pathophysiology 2
• This limitation is particularly problematic for catatonia, which can arise from diverse neurological, psychiatric, and medical etiologies 7, 8

Persistent Categorical Foundation

• Both systems remain categorical at their core despite efforts toward dimensionality, with changes from previous versions being relatively modest 2
• Arbitrary boundaries between diagnostic categories limit reliability and validity 6
• The categorical approach fails to capture the spectrum nature of catatonic presentations across age groups and underlying conditions 7

Limited Field Study Validation

• Advantages of ICD-11 over ICD-10 were largely limited to new diagnostic categories; when excluding new categories, there was no significant difference in diagnostic accuracy, goodness of fit, or clarity 2
• Field study samples could be biased toward practitioners positive about ICD-11, as online participants registered on their own initiative 2
• Vignette studies describe prototypic cases that might not accurately reflect the complexity of real-life situations 2

Specific Weaknesses by Age Group

Pediatric Populations

• Neither system provides age-specific diagnostic thresholds or criteria modifications for children and adolescents 7
• Catatonia recognition rates remain suboptimal in pediatric settings, with the syndrome found in 5-18% of psychiatric inpatients but frequently unrecognized 7

Geriatric Populations

• Both systems lack specific guidance for distinguishing catatonia from delirium in elderly patients, despite this being a critical clinical challenge 9
• The overlap between catatonic features and age-related psychomotor changes is not adequately addressed 9

Critical Improvements Needed

Neurobiological Integration

• Integrate neurobiological subtyping through approaches like the Systems Neuroscience of Psychosis (SyNoPsis) project to identify clinically and neurobiologically homogeneous subgroups 6
• Incorporate findings on aberrant neuronal activity in motor pathways, defective neurotransmitter regulation, and impaired oligodendrocyte function into diagnostic frameworks 8

Enhanced Differential Diagnosis

• Develop more explicit algorithms for distinguishing catatonia from neuroleptic malignant syndrome, anti-NMDA receptor encephalitis, and benzodiazepine/clozapine withdrawal states 8
• Create age-specific differential diagnostic criteria, particularly for pediatric and geriatric populations 7

Hierarchical Dimensional Models

• Develop hierarchical dimensional models that recognize arbitrary boundaries between diagnostic categories and move beyond purely categorical classification 6
• Implement structured diagnostic interviews rather than unstructured clinical assessment to reduce diagnostic bias and improve reliability 2

Longitudinal Assessment Framework

• Create detailed life charts documenting the longitudinal course of symptoms to accurately determine temporal relationships with underlying psychiatric conditions 2
• Plan for longitudinal reassessment, as catatonia diagnosis frequently evolves over time and may require reclassification as more information becomes available 2, 6

Improved Clinical Recognition Tools

• Further ecological field studies are needed to reveal how well ICD-11 works when applied by clinical practitioners under regular conditions 2
• Develop and validate new screening assessments to reduce the high morbidity and mortality associated with unrecognized catatonia in psychiatric and non-psychiatric settings 7

Common Pitfalls to Avoid

• Do not rely solely on categorical diagnosis without dimensional symptom assessment, as this misses critical severity and treatment response information 2
• Gather collateral information from family members and other observers, as patient insight may be limited during acute catatonic episodes 2
• Recognize that catatonia can occur in conditions beyond schizophrenia and mood disorders, including medical conditions like hyponatremia, cerebral venous sinus thrombosis, and following liver transplantation 8
• Early recognition and treatment are crucial, as unrecognized catatonia carries risk of life-threatening complications and early treatment is associated with better outcomes 7, 8