Psychomotor Psychoses – The Enigmatic Catatonic Phenotype

Since the second half of the nineteenth century, motor abnormalities have been associated with severe psychotic states. In this respect, the description by Carl Wernicke in 1900 of the so-called motility symptom complex, later termed motility psychosis, should be mentioned.¹ About two decades before, in 1874, Karl Ludwig Kahlbaum had already published his well-known monograph, Die Katatonie oder das Spannungsirresein, in which he delineated catatonia as a separate neuropsychiatric disorder with disturbances in motor functionality and a characteristic alternating course. Previously, such catatonic states were designated as stupor, which in France was termed ‘stupidité’. Kahlbaum identified motor signs in terms of mutism, psychotic negativism, catalepsy, stereotypies, verbigeration and muscular symptoms. In addition, Kahlbaum stressed the combined occurrence of depressive and manic symptoms as part of the different stages of the disease and, based on symptomatology, severity and prognosis, he differentiated three subtypes termed catatonia mitis (melancholia with stupor), catatonia gravis (mixed affective state) and catatonia protracta (chronic course). In the sixth edition of his textbook in 1899, Emil Kraepelin incorporated catatonia in his concept of dementia praecox with its poor prognosis in general, but stressed at the same time that motor symptoms could also be part of his concept of a manic-depressive illness with good prognosis and psychotic features, or may coincide with a great variety of somatic diseases. In 1911, Paul Eugen Bleuler broadened Kraepelin’s concept of schizophrenia and attributed psychological explanations to catatonic symptoms. In his view, posturing and grimacing, for example, were signs of avoiding reality, whereas mutism was regarded as a suppression of undesirable thoughts. In 1917, Karl Bonhoeffer conceptualised the so-called exogenous reaction types associated with medical conditions which could lead to catatonic symptoms.²

Although Kraepelin’s restrictive view that catatonia equals schizophrenia still dominates the psychiatric diagnostic systems, it should be underlined that, since the beginning of the last century, several other disorders have been described in which a motor symptom complex with a phasic course dominates the clinical picture.³ In 1901, Alexander Pilcz wrote Die periodischen Geistesstörungen, in which he made a distinction between the periodic course of, among others, mania, melancholia, amentia, paranoia and circular psychosis.⁴ In 1932, Rolv Gjessing described a catatonic syndrome with a phasic course in which periods with stupor and excitement alternate in strict longitudinal regularity. This periodic catatonic phenotype was hypothesised to originate from nitrogen metabolic imbalances.⁵ As reviewed in 1974 by Leiv Gjessing, this periodic syndrome may last for decades or disappear automatically and the duration of the periods varies individually from days to weeks or months.⁶ Also, in the French psychiatric tradition, catatonia is, apart from schizophrenia, a well-recognised diagnostic entity associated with transient and polymorphic psychotic disorders, such as the ‘bouffées délirantes polymorphes’.⁷ Factor and cluster analytical studies of catatonia have demonstrated that it can be viewed as symptom, syndrome or separate nosological entity.^8,9 Until it is clear which symptoms are most relevant for a diagnosis of catatonia according to the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM), a screening instrument should be used systematically. In this respect, the most appropriate scale seems to be the Bush–Francis Catatonia Rating Scale (BFCRS), although a variety of scales exist.¹⁰ In 1996, Bush et al. defined catatonia by the presence of a spectrum of motor symptoms and described 23 signs (see Table 1).¹¹ They emphasised that symptoms occur in retarded and excited forms.