Max Fink on Catatonia in JECT

Out on PubMed is Dr. Fink's latest review of catatonia:

Expanding the Catatonia Tent: Recognizing Electroconvulsive Therapy Responsive Syndromes.

Fink M.J ECT. 2020 Oct 27. doi: 10.1097/YCT.0000000000000729. Online ahead of print.PMID: 33122500

From the text:

Catatonia is an acute onset systemic behavior syndrome with prominent motor and mood features that is increasingly recognized from 3% to 15% of hospital inpatients, usually in emergency, medical, neurology, and psychiatry units. Stupor, mutism, negativism, rigidity, posturing, staring, and 20 other behaviors are the classical signs described for more than a century. When first delineated in 1874 by the German psychiatrist Karl Kahlbaum, he noted “... the obvious association of this illness with other signs of disease, and its constant occurrence with certain somatic (particular muscular) disorders have been more or less ignored.” Soon recognized by others, Emil Kraepelin placed his catatonia cases within his concept of dementia praecox in 1899. A decade later, the Swiss psychiatrist Eugen Bleuler reimaged the illness as schizophrenia, with catatonia as a marker of the illness. It remained so incorporated until it was exhumed in the 1990s with the development of defining rating scales, verification tests, and effective treatments, bringing catatonia within systemic medicine praxis.1,2 Many behaviors are being drawn into the catatonia tent with four described here—neuroleptic malignant syndrome, delirious mania, self-injurious behavior (SIB) in autism, and limbic encephalitis. Recognizing catatonia assures effective, often lifesaving, treatments; first with benzodiazepines, and when these fail, with electroconvulsive therapy (ECT).

...Treatments are effective when proper dosages are administered. In hospitalized patients with stupors, 70% of patients respond fully to high-dose benzodiazepine treatment. Electroconvulsive therapy is the effective treatment for the rest; it is the primary treatment in delirious mania, malignant catatonia, self injurious behaviors in adolescents, and acutely ill limbic encephalitis. Among the variations in technical aspects of ECT, the routine use of bilateral electrode placement, high energy levels determined by age, and daily induced seizures are accepted for these seriously ill.

...Catatonia is a recognizable, verifiable, and treatable behavior syndrome with many guises. The first signs characterized as catatonia were mutism, negativism, posturing, and stupor. Also recognized were periodic excitement. All entities identified so far are responsive to the known interventions; indeed, it is often their responsiveness that assures their recognition. Other conditions with prominent catatonia features successfully treated by ECT are melancholia, Tourette's Syndrome, and obsessive-compulsive disorders, each of which exhibits catatonia features responsive to catatonia treatments, including ECT.28 The motor aspects of melancholia and the prevalence of catatonia signs were detailed by Parker and Hadzi-Pavlovic in 199629 and by Shorter and Fink in 2010.30 The exhumation from its century-long burial in schizophrenia warrants catatonia being brought into the body of clinical medicine, rather than its present place in clinical psychiatry. Its development into an identifiable, verifiable, and treatable systemic syndrome is an unheralded achievement in medical history.

This is an authoritative and scholarly update on catatonia, written by the world's premier expert. It has sections on NMS, delirious mania, limbic encephalitis and self-injurious behavior (SIB) in autism. Dr. Fink's re-discovery of catatonia has had profound implications for medicine, psychiatry and the field of ECT. In 2018 the FDA reclassified ECT devices into Class II for catatonia and severe major depressive episodes, an action that allowed the continuing availability of ECT in the USA.