Catatonia associated with another mental disorder

Essential (Required) Features:

• The general diagnostic requirements for Catatonia are met.
• The catatonic symptoms develop in the context of another mental disorder, such as Schizophrenia or Other Primary Psychotic Disorder, a Mood Disorder, Autism Spectrum Disorder.
• The symptoms are not fully accounted for by Delirium, the effects of a medication or substance, including withdrawal effects, or a primary Movement Disorder classified in the chapter on Diseases of the Nervous System (e.g., Parkinson Disease, Huntington Disease).
• The symptoms are sufficiently severe to be a specific focus of clinical attention.

Note: The associated mental disorder should be diagnosed separately.

Specifiers for autonomic abnormalities in Catatonia:

Catatonia may be accompanied by vital sign abnormalities not fully accounted for by a comorbid medical condition that may signal potentially life-threatening complications and therefore require immediate attention. These include tachycardia or bradycardia; hypertension or hypotension; and hyperthermia or hypothermia. In these cases, as many of the following symptom codes as applicable should be applied.

• MG26 Fever of other or unknown origin
• MG28 Hypothermia, not associated with low environmental temperature
• MC80.0 Elevated blood-pressure reading, without diagnosis of hypertension
• MC80.1 Nonspecific low blood-pressure reading
• MC81.0 Tachycardia, unspecified
• MC81.1 Bradycardia, unspecified

Course Features:

• Acute episodes of Catatonia Associated with Another Mental Disorder typically develop rapidly within hours or days from single symptoms to full presentation.
• In Catatonia Associated with Another Mental Disorder, symptoms most commonly resolve within 4 weeks, although some episodes (e.g., in the context of acute psychosis) may remit spontaneously within hours. However, symptoms may also persist for months or even years with little variation of the clinical presentation and severity.
• The individual may experience recurrent episodes of Catatonia of several weeks duration that remit and recur throughout the course of the associated disorder. Most commonly, these Catatonia episodes occur during some but not all of the episodes of the associated mental disorder (e.g., a Bipolar Disorder). Early signs of recurring episodes may include ambitendency or psychomotor slowing.
• Persistent Catatonia is most commonly associated with Neurodevelopmental Disorders or Schizophrenia or Other Primary Psychotic Disorders. Adolescent onset is more frequent in these cases. Disturbances of volition, such as negativism, mannerisms or stereotypies, are more common in persistent Catatonia, whereas stupor rarely persists over weeks. In some severe cases, persistent Catatonia is characterized by severe, stable symptoms and massive global dysfunction for multiple years.

Developmental Presentations:

• Catatonia may occur throughout the entire life span, but rarely develops before adolescence. However, severe cases in children aged 8 to 11 years have been reported.
• Early onset of Catatonia (before age 20) is associated with underlying medical conditions, particularly Diseases of the Nervous System, or Neurodevelopmental Disorders (e.g., Autism Spectrum Disorder).

Culture-Related Features:

• The incidence of Catatonia appears to vary across cultures, and may occur in some cases in reaction to an overwhelming traumatic experience. Catatonia may be more frequent in some immigrant minority communities (e.g., refugees), including in children, where it may be associated with Post-Traumatic Stress Disorder and Depressive Disorders.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with psychomotor retardation in Depressive or Mixed Episodes: Psychomotor retardation in Depressive Episode and decreased psychomotor activity in Catatonia can manifest in similar ways. In the presence of a Depressive or Mixed Episode, an additional diagnosis of Catatonia Associated with Another Mental Disorder is appropriate if symptoms of increased psychomotor activity or abnormal psychomotor activity are also present. If all Catatonia symptoms are from the decreased psychomotor activity cluster, whether or not an additional diagnosis of Catatonia Associated with Another Mental Disorder is assigned is a clinical judgment based on the severity of the symptoms and whether Catatonia is a specific focus of clinical attention.
• Boundary with psychomotor agitation in Depressive, Manic or Mixed Episode: Psychomotor agitation in a Mood Episode and increased psychomotor activity in Catatonia can manifest in similar ways. In the presence of a Mood Episode, an additional diagnosis of Catatonia Associated with Another Mental Disorder is only appropriate if symptoms of decreased psychomotor activity or abnormal psychomotor activity are also present. If all Catatonia symptoms are aspects of increased psychomotor activity, an additional diagnosis of Catatonia is not warranted.
• Boundary of Catatonia with autonomic abnormality with Neuroleptic Malignant Syndrome: Symptoms of Neuroleptic Malignant Syndrome include high fever, muscle stiffness, altered mental status, and autonomic dysfunction (e.g., wide swings of blood pressure, excessive sweating, excessive secretion of saliva), most of which may also occur in Catatonia with autonomic abnormality. A diagnosis of Neuroleptic Malignant Syndrome is based on the clinical judgment that exposure to an antipsychotic medication or other dopamine receptor blocking agents is the cause of the symptoms. This distinction can be difficult because many individuals who develop Catatonia take antipsychotic medication. It is made based on the timing of the symptoms in relation to medication use, prior history of multiple episodes of Catatonia (in which case Neuroleptic Malignant Syndrome is less likely), and sometimes the presence of certain medical complications that are not characteristic of Catatonia, such as hyperkalemia or liver or kidney failure.
• Boundary with Serotonin Syndrome: Symptoms of Serotonin Syndrome include agitation or restlessness and muscle rigidity as well as autonomic disturbances such as high fever and tachycardia, which may also occur in Catatonia. A diagnosis of Serotonin syndrome involves the clinical judgment that exposure to a serotonergic medication or an interaction between serotonergic medications (e.g., when increasing the dose of a medication or adding a new medication) is the cause of the symptoms, based on the timing of the symptoms in relation to medication use. Serotonin Syndrome is more likely to present with tremor, hyperactive muscle reflexes (including clonus) and nystagmus than Catatonia. However, the presence of these symptoms does not exclude the possibility of co-occurring Catatonia.
• Boundary with Malingering or Factitious Disorder: Malingering and Factitious Disorder are both diagnosed based on evidence of feigning of symptoms, which may include catatonic symptoms. Evidence for feigning often includes the observation that the symptoms occur only when the person is being watched. However, disturbances of volition in Catatonia (e.g., negativism) may only become apparent during social interactions, which should not by itself be interpreted as evidence of feigning.