Schizophrenia Bulletin vol. 36 no. 2 pp.

314–320, 2010
doi:10.1093/schbul/sbp059
Advance Access publication on July 8, 2009

Catatonia Is not Schizophrenia: Kraepelin’s Error and the Need to Recognize

Catatonia as an Independent Syndrome in Medical Nomenclature

Max Fink1,2, Edward Shorter3, and Michael A. Taylor4 In the 19th century, many authors sought to extract

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2
Departments of Psychiatry and Neurology, Stony Brook Uni- identifiable medical conditions from the morass of their
versity, Long Island, NY; 3Faculty of Medicine, University of patients’ behavioral symptoms. The discovery of bacteria
Toronto, Toronto, Ontario, Canada; 4Department of Psychiatry, made possible a medical diagnostic system that identified
University of Michigan School of Medicine, Ann Arbor, MI symptom complexes that were verified by the presence of
specific pathogens. Homogeneous patient populations
and improved antibiotic treatments followed. But no
Catatonia is a motor dysregulation syndrome described by such model existed for disturbances in behavior although
Karl Kahlbaum in 1874. He understood catatonia as a dis- psychopathologists sought common ground in symptoms
ease of its own. Others quickly recognized it among diverse and course of illness. Karl Kahlbaum, director of a pri-
disorders, but Emil Kraepelin made it a linchpin of his con- vate psychiatric clinic in the small town of Görlitz in
cept of dementia praecox. Eugen Bleuler endorsed this sin- Germany, coined the term catatonia in 1874 for symp-
gular association. During the 20th century, catatonia has toms well known to psychiatrists but never coherently de-
been considered a type of schizophrenia. In the 1970s, lineated. Kahlbaum’s catatonia had previously been
American authors identified catatonia in patients with ma- recognized as stupor, and the French called the lack of
nia and depression, as a toxic response, and in general med- communication stupidité. Nonetheless, the symptoms
ical and neurologic illnesses. It was only occasionally found were not unfamiliar and were thought by subsequent gen-
in patients with schizophrenia. When looked for, catatonia erations of clinicians to occur across a wide range of
is found in 10% or more of acute psychiatric admissions. It
different disorders.
is readily diagnosable, verifiable by a lorazepam challenge
Kahlbaum, however, went further in his delineation of
test, and rapidly treatable. Even in its most lethal forms, it
catatonia as a disease comparable to progressive paraly-
responds to high doses of lorazepam or to electroconvulsive
sis or general paralysis of the insane (GPI), later called
therapy. These treatments are not accepted for patients
‘‘neurosyphilis.’’ ‘‘I now want to attempt to portray
with schizophrenia. Prompt recognition and treatment
here a clinical picture in which, just as in progressive
saves lives. It is time to place catatonia into its own
paralysis, certain somatic—indeed muscular—symptoms
home in the psychiatric classification.
are the accompaniment of certain psychiatric phenom-
ena, and in the one disease as in the other [such muscular
Key words: history/classification/DSM
symptoms] take on an essential role for the conceptual-
ization of the entire disease process.’’1(p4) As for the prog-
nosis of catatonia, certainly in contrast to the grim
Introduction outlook for GPI, Kahlbaum wrote: ‘‘Recoveries are, in
general, quite common.’’1(p93)
Catatonia is a syndrome of altered motor behavior ac- Despite the familiarity of the symptoms that Kahlbaum
companying many general medical and neurologic disor- bundled together, his disease concept of catatonia elicited
ders. It is more frequently found among patients an international conflict among psychiatrists. Two
diagnosed with mania, depression, and neurotoxic syn- schools emerged. One view supported Kahlbaum’s pro-
dromes than among those with schizophrenia. Yet, it posal of catatonia as a disease of its own. An opposing
is mainly classified as a form of schizophrenia. This per-
view was that catatonia was a complication of different
sistent failure of proper recognition has unfortunate
pathophysiologies and not a distinctive disease.
consequences, leading to poor treatment choices with
Kahlbaum’s supporters were numerous and articulate,
high morbidity and mortality. How did this come about?
as he had become a hero to a younger generation of psy-
chiatrists for his willingness to discard older diagnoses
1
To whom correspondence should be addressed; PO Box 457, based on humoral concepts and to accept as genuine dis-
St James, Long Island, NY 11780; e-mail: [email protected]. eases only those that could be clinically ascertained as
Ó The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: [email protected].
314
 Kraepelin’s Error: Catatonia Is not Schizophrenia

distinctive in their course. Kahlbaum made the clinical ‘‘Special importance in the establishing of dementia prae-
course a principal feature of nosological classification. cox has, not without justification, been attributed to
His student, Ewald Hecker, used Kahlbaum’s approach the demonstration of the so-called ‘catatonic’ morbid
to delineate hebephrenia as another distinct disease.2 symptoms.’’8(p257)
Clemens Neisser, a young staff psychiatrist in a provin- Kraepelin, professor of psychiatry in Heidelberg and
cial German asylum considered Kahlbaum to be ‘‘one of then after 1903 in Munich, is a founding parent of mod-
those quite unusual investigators in science who come to ern psychiatric nosology. His influence is manifest in the
conclusions on the basis of their thorough clinical expe- popularity of successive editions of his textbooks, the first
rience, and few break with the old Pseudo-system as bril- of which appeared in 1883.10 Catatonia was not men-
liantly as Kahlbaum does in catatonia.’’3 tioned in this first edition, and a friend wrote him to
Within 3 years, catatonia was recognized in 4 patients ask why he had not included it.11

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with mania and depression.4 A decade later, 2 forms of Once Kraepelin became interested in catatonia, he first
catatonia and the cyclic course of illness beginning with agreed with Kahlbaum that it was an independent
an initial stage of melancholia was reported from New illness entity. In the fifth edition of his textbook in
York City’s Ward’s Island.5 In the same year, catatonia 1896, Kraepelin described catatonia as one of the ‘‘met-
was recognized in mania in a German report.3(p84–85) abolic disorders leading to dementia,’’ alongside demen-
Doubters, about as numerous as enthusiasts, consid- tia praecox and dementia paranoides. Even though he did
ered catatonic symptoms complications of different psy- not agree with Kahlbaum in all points, he said, ‘‘I none-
chiatric illnesses without possessing any particular theless see myself obliged, by extensive experience, to
syndromic quality.6 Carl Wernicke, a most influential view the great majority of these cases as examples of a dis-
thinker in German psychiatry before the First World tinctive form of illness [catatonia].’’12
War, wrote: ‘‘One sees the value of Kahlbaum’s work es- Kraepelin’s clinical impressions changed often. By the
sentially therein, that he brought together a number of time of the sixth edition of his textbook in 1899, catatonia
important building blocks for the construction of his had become a category of dementia praecox. There were
[catatonia] edifice, while the edifice itself is not tenable.’’ no data to support this evolution in his thinking; Krae-
For Wernicke, catatonia was configured as an ‘‘akinetic pelin had changed his mind. He now devoted more atten-
motility psychosis.’’7 tion to the catatonic form of dementia praecox than he
did to presenting dementia praecox itself.13 It was in
this 1899 edition that he definitively separated dementia
praecox and manic-depressive illness.
The Kraepelin Position
The catatonia of Kraepelin differed markedly from
Emil Kraepelin’s third image offered catatonia as a Kahlbaum’s. As Eric Arndt, a staff physician in the
complex of symptoms associated with dementia Heidelberg psychiatric clinic, put it in 1902: ‘‘In Kraepelin’s
praecox. Rather than catatonia being an independent view, we are dealing with the occurrence [in catatonia] of
illness entity or a complication of many different illnes- peculiar conditions that end mostly in dementia accompa-
ses, Kraepelin believed that catatonia was, along with nied by stupor or with agitation accompanied by negativ-
hebephrenia and paranoid dementia, a basic presentation ism, stereotypies and suggestibility in expressions and
of dementia praecox. He did not reject Kahlbaum’s actions. The emphasis here is no longer on clinical course
and Hecker’s notions as much as he incorporated them and coarse motor phenomena, but on termination in de-
into the single disease of dementia praecox: ‘‘I got the mentia. It is above all the prognosis that influences the di-
starting point of the line of thought which in 1896 agnosis.’’14 Kraepelin’s catatonia was truly no longer
led to dementia praecox being regarded as a distinct Kahlbaum’s catatonia with its differentiated clinical
disease, on the one hand from the overpowering impres- courses but an effort to bring catatonia into his vision of
sion of the states of dementia quite similar to each other dementia praecox.
which developed from the most varied initial clinical The eighth edition of Kraepelin’s textbook in 1913 was
symptoms, on the other hand from the experience con- the last on which he actively worked. (His death in 1926
nected with the observations of Hecker that these pecu- interrupted completion of a ninth edition after the War.)
liar dementias seemed to stand in near relation to the By 1913, catatonia had become 1 of the 8 subgroups into
period of youth.’’8 which dementia praecox was divided and clearly subor-
Also, ‘‘I kept Kahlbaum’s and Hecker’s ideas in mind dinated to the larger diagnosis. Kraepelin said, ‘‘Later ex-
and tried to collect those cases, which inclined towards perience has shown that catatonic symptoms may in no
dementia as ‘mental degeneration processes.’ Apart way be sharply distinguished from the other forms of De-
from Kahlbaum’s catatonia, I differentiated between de- mentia praecox.’’ He also opined that nothing in the clin-
mentia praecox, which essentially corresponded with he- ical course or the pathological anatomy made one think
bephrenia, and dementia paranoides with hallucinations, these were different diseases: ‘‘At any rate we may
which quickly developed into mental deficiency.’’9 And consider Kahlbaum’s catatonia for the most part as a
315
M. Fink et al.

distinctive clinical course of Dementia praecox.’’ And, with 200 patients meeting Kraepelin’s constructs for
‘‘We must limit the designation [catatonia] to those cases manic-depressive illness and dementia praecox in
alone in which the pathological process of Dementia follow-up studies covering more than 10 years of illness.
praecox is at work.’’15 He found catatonia to be more common among the
In 1920, Kraepelin’s position turned once again, manic-depressive patients than among those with demen-
expressing doubts as to the meaningfulness of separating tia praecox.
dementia praecox and manic-depressive illness because It was Eugen Bleuler, professor of psychiatry in Zurich,
the 2 presentations and clinical courses intermingled.16 who brought Kraepelin’s view that catatonia equaled
This renunciation of much of his life’s work reinforces schizophrenia to North America. In his 1916 textbook,
the view that Kraepelin’s entire system was impression- Bleuler24 assimilated catatonia within schizophrenia. He
istic, including the rather arbitrary shifts about catatonia. had a milder view of schizophrenia, anticipating many

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For him—and for the rest of the world—catatonia recoveries and not the inevitable course to dementia. Ble-
remained firmly part of what Eugen Bleuler had coined uler’s optimistic view was more enthusiastically received in
in 1908 as ‘‘schizophrenia.’’ the United States than was Kraepelin’s pessimism. Bleu-
ler’s acceptance was bolstered by a therapeutic optimism
within psychiatry engendered by psychoanalysis and the
The Ensuing Debates
strong anti-German sentiment that followed World War I.
Kraepelin’s dictum that catatonia equaled schizophrenia Bleuler envisioned the catatonic patient as suppressing
was not immediately accepted among German nosolo- unpleasant memories by silence (mutism), tenseness and
gists. In 1898, Schüle17 acknowledged catatonia a new en- rigidity (holds back acts that are compelled by memories),
tity with 6 subtypes, criticizing Kraepelin’s incorporation refusal to obey commands, and displacing rising emotions
of catatonia within dementia praecox. In the same jour- and tension into motor acts that shut out reality (posturing,
nal, Aschaffenberg18 reported an experience with 227 grimacing, staring, stereotypes). Lethal catatonia was an
psychiatric patients, finding distribution ratios for cata- expression of the death wish. After Bleckwenn’s descrip-
tonia among men and women (men to women, 2:3) dif- tion of the relief of catatonia with amobarbital, Bleuler
ferent from those with dementia paralytica (3:1). considered this effect a ‘‘release’’ of blocking.25
An active academic industry commenting on Kahl- Kraepelin had one more influential disciple abroad.
baum’s concept developed among German, French, and Willi Mayer-Gross, who had been at the Heidelberg clinic
American authors. Eacheffort,in samples of 1–12patients, before fleeing to England in 1933, landed at the Maudsley
confirmed Kahlbaum’s descriptions, often discussing Hospital in London and was soon acknowledged as
‘‘somatic’’ and ‘‘psychologic’’ explanations for the a highly influential figure in British psychiatry. In 1954,
disorder.19 By 1912, a monograph on catatonia by he became the lead author—in collaboration with Eliot
Urstein20 related an experience with 30 patients, faulting Slater and Martin Roth—of that era’s principal English
Kraepelin’s adoption of catatonia within dementia prae- language psychiatry textbook.26 Mayer-Gross’s position
cox, finding catatonia in patients with syphilis and other on catatonia was resolutely Kraepelinian that catatonia
infectious diseases, toxic states, depression, mania, and was a type of schizophrenia. ‘‘Schizophrenia sometimes
delirium. begins with a sudden outburst of wild excitement.. These
In his 1913 textbook, Karl Jaspers, a leading psycho- cases, formerly called ‘delirium acutum’ may begin out of
pathologist at the Heidelberg clinic, portrayed catatonia the blue without any obvious premonitory signs .. The
as an illness sui generis characterized by opposing pairs of restlessness and excitation may exceed everything known
symptoms (negativism vs automatic obedience, eg). in psychiatry, except perhaps some epileptic furors. The
Jaspers’ main interest was in the psychology of catatonia, patient cries, hits, bites, breaks and destroys everything
which he found unknowable: ‘‘Sometimes it seems as he can lay hand on, runs up and down, fights everybody
though the patient is like a dead camera: He sees every- and keeps moving day and night. It is impossible to estab-
thing, hears everything, understands everything and yet is lish any rapport with him, he continues to rage when left
capable of no reaction, of no affective display, and of no alone ..’’26(p250) Kahlbaum and Jaspers would have rec-
action. Even though fully conscious he is mentally para- ognized such patients as catatonic; today we might see
lyzed.’’ Jaspers put the accent on inhibition, not on a clin- them as examples of malignant catatonia (MC) or delirious
ical course trending catastrophically downward; in his mania.19
account of catatonia, he did not mention Kraepelin.21 In contrast, neurologic images by French and other
After Jaspers lost interest in psychiatry and turned to continental authors viewed catatonia as one among many
philosophy, the mantle of authority in psychopathology motor syndromes, similar to dystonia, Parkinsonism, and
fell on Kurt Schneider, first in Cologne and then in dyskinesia.27–31 The neurologic connection was also central
Heidelberg. Schneider thought catatonia a complication to the studies of epidemic encephalitis by von Economo32
of many illnesses and rejected Kraepelin’s formula- who described catatonia in many patients in the acute
tions.22 Another author, Lange23 reported an experience and chronic phases of the illness.
316
 Kraepelin’s Error: Catatonia Is not Schizophrenia

Gjessing33 described a periodic form of catatonia with Catatonia in the Nomenclature

hormonal connections. In the absence of effective treat-
Despite these many descriptions of catatonia in associa-
ment, he observed his patients for long periods, reported
tion with manic depression and general medical and neu-
their spontaneous relapses and remissions, and associ-
rologic conditions, a separate nosologic entity of catatonia
ated the cycles with changes in nitrogen metabolic bal-
was not included in psychiatric classifications.
ance. He described an occasional treatment success
At the beginning of the 20th century, in the absence of
with thyroid extracts and concluded that periodic catato-
an agreed-upon nomenclature, each psychiatrist devel-
nia was a metabolic disorder. Similar reports of a periodic
oped his own descriptive terms for the illnesses of his
form of catatonia with a relationship to thyroid metab-
patients. In an effort to standardize medical diagnoses,
olism dot the literature.34–36
the New York Academy of Medicine held a meeting in
Another form of catatonia, with an acute onset and

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1928 on the nomenclature of disease, from which
a malignant outcome, was described by Stauder37 in 27
emerged the view that catatonia was a subtype of schizo-
patients in 1934. He labeled the disorder Die tödliche
phrenia.48 This document, as well as a parallel effort by
Katatonie, a term that is best translated as lethal or
the American Medico-Psychological Association (as the
malignant catatonia (MC). Young adults between 18
American Psychiatric Association was then known),
and 26 years of age were reported to suddenly become
influenced the first ‘‘DSM’’ disease classification of the
mute, rigid, and either stuporous or severely excited.
American Psychiatric Association, published in 1952.
Fever and autonomic dysfunction were severe, and the
In this version, catatonia is recognized only as schizo-
outcome was quickly fatal. The syndrome has been
phrenic reaction: catatonic type (000-x23).44(p83)
described by many authors and is best known today as
In 1948, the sixth edition of the World Health Associa-
MC.19(ch3),38–41 A subtype of the syndrome associated
tion’s International Classification of Diseases (ICD) recog-
with exposure to antipsychotic drugs is widely recog-
nized a ‘‘catatonic type’’ among the ‘‘schizophrenic
nized as the neuroleptic malignant syndrome (NMS) or
disorders.’’49 The tenth edition in 1992 was essentially un-
neuroleptic induced catatonia.19(ch3) The serotonin syn-
changed, except that clinicians in developed lands were en-
drome is another manifestation of a medication-induced
couraged to ignore the subject: ‘‘For reasons that are poorly
catatonia.42
understood, catatonic schizophrenia is now rarely seen in in-
dustrial countries, though it remains common elsewhere.’’50
Conflicts in America As the ICD was undergoing revision in the 1960s, the
American Psychiatric Association converted the schizo-
Adolf Meyer, Smith Eli Jelliffe, and William Alanson
phrenic reaction to schizophrenia in the second edition
White, leaders in American psychiatry following the
of 1968.51 Catatonia was recognized as a type of schizo-
images set by Bleuler, viewed schizophrenia and espe-
phrenia, with excited and withdrawn subtypes.
cially its catatonic form as evidence of the psychological
Soon after the 1968 DSM edition, successive breaches in
basis for the psychoses.43 Their views became the basis
the wall of catatonia only as a form of schizophrenia called
for the 1952 Diagnostic and Statistical Manual of Mental
for renewed debate. Taylor and Abrams, in 4 publications
Disorders (DSM) classification that described abnormal
between 1973 and 1979, reported catatonia to be more
behaviors as reactions to psychological and physical
common among manic and depressed patients than among
stressors and not as defined syndromes.44
those with schizophrenia, challenging the limited recogni-
Contrasting views in America were expressed by George
tion of catatonia only as schizophrenia.52–55 Follow-up
Kirby who pictured catatonia as typically occurring
studies by Morrison56 found catatonia in more than 10%
among patients with manic-depressive illness.45 He argued
of 500 patients, most commonly among those with mood
that Kraepelin had drawn the boundaries of schizophrenia
disorders. Gelenberg57 described catatonia among patients
much too broadly. In a monograph titled Benign Stupors,
with neurologic and general medical illnesses.
August Hoch described 25 psychiatric patients in stupor.
The Diagnostic and Statistical Manual of Mental Dis-
Thirteen with manic-depressive illness had a favorable
orders (Third Edition) classification of 1980 ignored these
prognosis and 12 with general medical illnesses or schizo-
reports and again catalogued catatonia as a type of
phrenia had a poor prognosis.46
schizophrenia (295.2).58 As a logical consequence catato-
Among psychopathologists, catatonia continued to be
nia, as schizophrenia, called for treatment with neurolep-
recognized within other disorders. In 1969, Pauleikhoff47
tic medications.
described an extensive 35-year experience with 552 hos-
pitalized psychiatric patients with 64% suffering from 1 of
Additional Evidence Against the Catatonia-Schizophrenia
5 forms of catatonia. Deliria were present in his patients,
Link
and he concluded that catatonia was a syndrome of many
forms, most with favorable outcome; catatonia was not Several developments supported the disconnection of cat-
only a phase of a progressive disorder with a dementia atonia from schizophrenia. The first occurred in 1980 with
outcome. descriptions of a toxic response to neuroleptic agents and
317
M. Fink et al.

the identification of the NMS.59 The patients were mute, a type of schizophrenia, and that view is supported by
rigid, posturing, and in stupor, accompanied by fever, the data collected over the 20th century. Nevertheless,
tachycardia, hypertension, and tachypnea. The early some modern clinicians who adhere to Kraepelin’s writ-
authors saw a similarity to malignant hyperthermia and ings and the supporting opinions of Bleuler, Meyer, Kleist,
suggested treatment with dantrolene. They also accepted and Leonhard continue to accept Kraepelin’s image of
dopamine blockade as the central action of these com- catatonia as schizophrenia, however else they differ in
pounds and recommended treatment with dopamine ago- their formulations.
nists. Neither approach was useful. In time, NMS was In 1981, a writer asked where the catatonics had gone,
appreciated as a form of MC with a specific precipi- suggesting that the widespread use of antipsychotic drugs
tant.19,60 Successful treatment trials with benzodiazepines may be responsible.70 A better explanation comes from
and electroconvulsive therapy (ECT), the known effective the early 20th century shift in psychiatric practice from

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treatments for MC, confirmed their identity.61 the asylum, where catatonia was common, to office prac-
Based on these reports and a plea that catatonia de- tice and ambulatory clinic where it is not. The mutism,
served a home of its own in the classification, the 1994 re- negativism, motor abnormalities, and stupors of cata-
vision of Diagnostic and Statistical Manual of Mental tonic patients are not treatable in office settings.71 Sadly,
Disorders (Fourth Edition) additionally recognized catato- even in inpatient psychiatry settings, these patients go
niaasadisorderduetoageneralmedicalconditionwithanu- largely unrecognized. In a Dutch study, clinicians identi-
meric designation of 293.89.62 Catatonia was also hesitantly fied catatonia in 2% of 139 inpatients, but the research
accepted as a features specifier in mood disorders. team identified catatonia in 18%.72
The renewed interest in a catatonia syndrome encour- Failure to recognize catatonia is also a response to de-
aged the development of rating scales and effective exam- terioration in the teaching of psychopathology. A clini-
ination procedures. From 9% to 17% of patients in cian cannot recognize what he has not been taught.
academic psychiatric inpatient units and psychiatric Classification manuals offer limited pictures of catatonia
emergency rooms met criteria for catatonia, more often and list only a handful of more than the 40 recognized
among patients with mood disorders or toxic states than catatonic features. Once the linchpin of training, psycho-
with schizophrenia.19 pathology now focuses on how to recognize the clinical
Catatonia was vouchsafed in many guises.19(ch3),63 It features needed to apply DSM or ICD labels from a lim-
was reported in children and adolescents ill with autism ited number of symptoms listed in symptom check-
and mental retardation; treatment trials for catatonia lists.73,74 The death of phenomenology following
reported quick clinical benefit.64,65 Self-injurious behavior adoption of the DSM nomenclature is ably described
is a repetitive, uncontrollable, damaging stereotypy in chil- by Andreasen.75
dren that is ameliorated by treatment for catatonia.66 Catatonia is singularly identified with schizophrenia in
Catatonia is identified in patients with Gilles de la clinical teaching with the unfortunate consequence that
Tourette syndrome,67 epilepsy, stupors, and fevers of antipsychotic medications are immediately prescribed.
unknown origin19 and in patients with paraneoplastic syn- These medicines offer limited relief and indeed risk con-
dromes.68,69 verting the catatonia syndrome to its malignant form.19
The syndrome of catatonia has 2 attributes that further Authors who adopt the Kraepelin equation that catato-
separate it from schizophrenia. The signs quickly respond nia is schizophrenia defend the use of antipsychotics in
to intravenous amobarbital or benzodiazepines offering adolescents and in chronic psychotic patients. They dis-
clinicians an affirmative test of the syndrome. The same regard the risks of neuroleptic precipitation of MC and
agents are effective treatments, fully resolving catatonia accept delayed resolution of symptoms. Their testimonials
although requiring higher dosages than ordinarily pre- challenge the consideration of lorazepam and ECT.76–78
scribed. About 70% of catatonic patients respond to More critical, however, is the reality that equating catato-
lorazepam alone, while few respond to antipsychotic nia with schizophrenia precludes the use of barbiturates,
agents, another indication that the pathophysiology of benzodiazepines, or ECT.
catatonia is distinct from that of patients with schizo- For more than 125 years after Karl Kahlbaum catego-
phrenia. ECT is another effective treatment for catatonia rized catatonia as a distinct psychopathologic entity, it has
in each of its guises and even in its malignant forms. Nei- been overwhelmingly reported in association with many
ther the sedative anticonvulsants nor ECT is considered conditions. Yet, catatonia is allocated a position of depen-
in treatment algorithms for schizophrenia, further en- dency in the construct of schizophrenia. Catatonia’s di-
dorsing the divorce of the syndrome from schizophrenia. vorce from schizophrenia and its recognition as an
independent syndrome, akin to delirium, are needed in
the next psychiatric classification. The evidence that com-
Resolving the Error
pels this consideration is extensive.79,80 A century of
Many authors, including contemporaries of Kraepelin, well-documented clinical experience cannot be ignored.
recognized the fallacy of regarding catatonia mainly as Catatonia deserves a home of its own in the classification.
318
 Kraepelin’s Error: Catatonia Is not Schizophrenia

Acknowledgments Neurologie und Psychiatrie. Berlin, Germany: Julius Springer;

Vol 31. 1922:169.
This work is supported by our respective academic 24. Bleuler E. Lehrbuch der Psychiatrie. Berlin, Germany:
appointments and not from any industry research Springer; 1916.
grants or lectureship funding. The article is prepared 25. Rogers D. Catatonia: a contemporary approach. J Neuropsy-
as an ‘‘At Issue’’ Commentary for Schizophrenia Bulletin. chiatry Clin Neurosci. 1991;3:334–340.
26. Mayer-Gross W, Slater E, Roth M. Clinical Psychiatry.
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