First 150 years of catatonia:Looking back at its complicated history and forward to the road ahead

Karl Ludwig Kahlbaum(1828-1899)was the first to conceptualize and describe the main clinical features of a novel psychiatric illness,which he termed catatonia in his groundbreaking monograph published 150 years ago.Although Kahlbaum postulated catatonia as a separate disease entity characterized by psychomotor symptoms and a cyclical course,a close examination of his 26 cases reveals that most of them presented with motor symptom complexes or syndromes associated with various psychiatric and medical conditions.In his classification system,Kraepelin categorized catatonic motor symptoms that occur in combination with psychotic symptoms and typically have a poor prognosis within his dementia praecox(schizophrenia)disease entity.Because of the substantial influence of Kraepelin’s classification,catatonia was predominantly perceived as a component of schizophrenia for most of the 20th century.However,with the advent of the psychopharmacotherapy era starting from the early 1950s,interest in catatonia in both clinical practice and research subsided until the early 2000s.The past two decades have witnessed a resurgence of interest in catatonia.The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition,marked a paradigmatic shift by acknowledging that catatonia can occur secondary to various psychiatric and medical conditions.The introduction of an independent diagnostic category termed“Catatonia Not Otherwise Specified”significantly stimulated research in this field.The authors briefly review the history and findings of recent catatonia research and highlight promising directions for future exploration.

Catatonia:“Fluctuat nec mergitur”

In the beginning of the 1900s,the prevalence of catatonia in inpatient samples was reported to be between 19.5%and 50%.From the mid-1900s,most clinicians thought that catatonia was disappearing.Advances in medical sciences,particularly in the field of neurology,may have reduced the incidence of neurological diseases that present with catatonic features or mitigated their severity.More active pharmacological and psychosocial treatment methods may have either eliminated or moderated catatonic phenomena.Moreover,the relatively narrow descriptive features in modern classifications compared with classical texts and ascribing catatonic signs and symptoms to antipsychotic-induced motor symptoms may have contributed to an apparent decline in the incidence of catatonia.The application of catatonia rating scales introduced in the 1990s revealed significantly more symptoms than routine clinical interviews,and within a few years,the notion of the disappearance of catatonia gave way to its unexpected resurgence.Several systematic investigations have found that,on average,10%of acute psychotic patients present with catatonic features.In this editorial,the changes in the incidence of catatonia and the possible underlying causes are reviewed.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest.One reason for this is that psychiatric patients are generally considered more likely to be aggressive,which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior.Predicting aggression in psychiatric wards is crucial,because aggressive behavior not only endangers the safety of both patients and staff,but it also extends the hospitalization times.Predictions of aggressive behavior also need careful attention to ensure effective treatment planning.This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes(dementia,psychoactive substance use,acute psychotic disorder,schizophrenia,bipolar affective disorder,major depressive disorder,obsessivecompulsive disorder,personality disorders and intellectual disability).The prevalence of aggressive behavior and its underlying risk factors,such as sex,age,comorbid psychiatric disorders,socioeconomic status,and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior.Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed.Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Electroconvulsive therapy:80 years old and still going strong

Electroconvulsive therapy(ECT),which is among the oldest and most controversial treatments in the field of psychiatry,has its 80th birthday this year.In this brief historical overview,the discovery of the therapeutic effects of convulsive therapy by LaszlóMeduna,and the circumstances that motivated Ugo Cerletti and Lucio Bini to use electricity as a means of seizure induction are described.Meduna’s original theory about the antagonism between epilepsy and schizophrenia has been replaced by hypotheses on the mechanism of action of ECT.The position of ECT in modern psychiatry is also discussed with special attention to its most important clinical indications,including catatonia,and preand postpartum affective and psychotic states that are responsive to ECT and in which ECT may even be lifesaving.Adverse effects and comparison of ECT with recently developed brain stimulation methods are also reviewed.The negative media portrayal of ECT and its earlier misuse may have contributed to its negative professional and public perceptions indicated repeatedly in attitude surveys.This negative attitude has played an important role in the decreasing use of ECT in the developed world and a reduction in access to ECT,which constitutes a violation of psychiatric patients’right to an effective treatment.

Catatonia as a putative nosological entity:A historical sketch

Kahlbaum was the first to propose catatonia as a separate disease following the example of general paresis of the insane,which served as a model for establishing a nosological entity.However,Kahlbaum was uncertain about the nosological position of catatonia and considered it a syndrome,or "a temporary stage or a part of a complex picture of various disease forms".Until recently,the issue of catatonia as a separate diagnostic category was not entertained,mainly due to a misinterpretation of Kraepelin's influential views on catatonia as a subtype of schizophrenia.Kraepelin concluded that patients presenting with persistent catatonic symptoms,which he called "genuine catatonic morbid symptoms",particularly including negativism,bizarre mannerisms,and stereotypes,had a poor prognosis similar to those of paranoid and hebephrenic presentations.Accordingly,catatonia was classified as a subtype of dementia praecox/schizophrenia.Despite Kraepelin's influence on psychiatric nosology throughout the 20 th century,there have only been isolated attempts to describe and classify catatonia outside of the Kraepelinian system.For example,the Wernicke-KleistLeonhard school attempted to comprehensively elucidate the complexities of psychomotor disturbances associated with major psychoses.However,the Leonhardian categories have never been subjected to the scrutiny of modern investigations.The first three editions of the DSM included the narrow and simplified version of Kraepelin's catatonia concept.Recent developments in catatonia research are reflected in DSM-5,which includes three diagnostic categories: Catatonic Disorder due to Another Medical Condition,Catatonia Associated with another Mental Disorder(Catatonia Specifier),and Unspecified Catatonia.Additionally,the traditional category of catatonic schizophrenia has been deleted.The Unspecified Catatonia category could encourage research exploring catatonia as an independent diagnostic entity.