What are the strengths and weaknesses of 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 disorder due to another medical condition?

Comparative Analysis of DSM-5-TR and ICD-11 for Diagnosing Catatonia Due to Another Medical Condition

ICD-11 demonstrates superior clinical utility for diagnosing catatonia due to another medical condition, with 82.5-83.9% of clinicians rating it as quite or extremely easy to use, accurate, clear, and understandable, primarily due to its independent diagnostic status and explicit differential guidance. 1

Strengths of ICD-11

Conceptual Framework

• ICD-11 conceptualizes catatonia as an independent disorder with a common clinical phenotype regardless of associated condition, representing a fundamental shift from viewing catatonia merely as a subtype of schizophrenia 2, 3
• The system expanded from 11 to 21 disorder groupings in the mental, behavioral, and neurodevelopmental disorders chapter, providing more comprehensive classification 1
• ICD-11 underwent the largest participative revision in classification history, with field studies demonstrating higher reliability and clinical utility compared to ICD-10 2

Diagnostic Criteria Specificity

• ICD-11 requires at least 3 clinical features from three distinct 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 2, 3
• The system provides explicit guidance on distinguishing catatonia from similar behavioral features including psychomotor retardation in depression, delirium, and factitious disorder 2, 3
• ICD-11 allows rating symptom severity across multiple domains at each assessment, enabling longitudinal tracking 1

Strengths of DSM-5-TR

Unified Diagnostic Approach

• DSM-5-TR introduced a single set of criteria for catatonia across all psychiatric disorders, including stupor, catalepsy, waxy flexibility, mutism, and negativism 1
• The system recognizes catatonia associated with several psychiatric and general medical conditions, broadly aligning with ICD-11 in terms of which items are included and item definitions 3, 4

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 1
• Both systems classify mental phenomena based on self-reported or clinically observable symptoms rather than underlying pathophysiology 1

Categorical Limitations

• Both systems remain categorical at their core despite efforts toward dimensionality, with changes from previous versions being relatively modest 1
• Arbitrary boundaries between diagnostic categories limit reliability and validity 1
• The lack of item thresholds is a fundamental limitation in both DSM-5-TR and ICD-11 diagnostic criteria 4

Clinical Detection Challenges

• Many distinctions across scales and criteria contribute to diagnostic discordance, making catatonia widely under-detected 4
• Clear, consistent definitions for catatonia features remain inconsistent across different assessment tools 4

Critical Gaps in Both Systems

Geriatric Population Considerations

• Both systems lack specific guidance for distinguishing catatonia from delirium in elderly patients, despite this being a critical clinical challenge 1
• The overlap between catatonic features and age-related psychomotor changes is not adequately addressed 1

Differential Diagnosis Complexity

• While ICD-11 provides better differential guidance than DSM-5-TR, both systems struggle with the presentation of acute onset psychomotor symptoms in the absence of mental illness history, requiring extensive workup to rule out medical causes 5

Recommended Improvements for Clinical Work and Research

Standardization of Assessment Tools

• Implement the Bush-Francis Catatonia Rating Scale as the standard assessment tool, as it is the most efficient with a screening instrument, videographic resources, and standardized clinical assessment 4
• Alternatively, adopt the Northoff scale for detailed assessment, which uniquely emphasizes emotional and volitional disturbances in catatonia 4

Enhanced Differential Guidance

• Develop specific algorithms for distinguishing catatonia from delirium in elderly patients, addressing the critical gap identified in geriatric populations 1
• Create explicit criteria for differentiating catatonia from psychomotor retardation in depression, particularly in medical settings where 3.3% of inpatients present with catatonia 6

Biological Marker Integration

• Incorporate emerging neurobiological findings into future revisions to move beyond purely phenomenological classification 1
• Develop biomarker-informed subtypes to address the biological heterogeneity within current diagnostic categories 1

Clinical Utility Enhancements

• Mandate severity rating scales at each assessment point, building on ICD-11's framework for longitudinal tracking 1
• Establish clear item thresholds for each catatonic feature to improve diagnostic reliability 4
• Create standardized training modules using videographic resources to improve recognition rates, particularly given that catatonia remains unrecognized in an unknown number of patients at risk of life-threatening complications 6