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Max Fink: Reconceptualization of catatonia


Bruno Pfuhlmann’s comment


         Max Fink’s essay reveals a profound misunderstanding of the catatonia concept along the lines of the differentiated psychopathology elaborated in the tradition of the work of Wernicke, Kleist and Leonhard. According to this conception the diagnosis of catatonia is based on a precise ascertainment and differentiation of cardinal catatonic symptoms in characteristic catatonic syndromes. This is diametrically opposed to conceptions defining catatonia cross-sectionally as a more or less arbitrary combination of a minimum number of catatonic symptoms which include various kinds of motor abnormalities. His conception ignores the interrelationship of the motor symptoms within each other and the significance of motor abnormalities within distinct symptom constellations as well as the importance of a differentiation between qualitative and quantitative psychomotor disturbances. This is a major impediment since only psychomotor abnormalities in the strict sense occurring independently from disorders of affect or thought can provide a basis for a differentiated diagnostic classification of catatonic psychoses beyond diagnostically unspecific catatonic syndromes.

         The differentiation between periodic catatonia and the group of system catatonias was shown to be highly reliable with a quite considerable stability of the diagnoses (Franzek and Beckmann 1992; Pfuhlmann, Franzek, Stöber et al. 1997). Various published catamnestic case records and video documentations in regular psychopathology workshops of the International Wernicke-Kleist-Leonhard-Society demonstrate that the catatonic phenotypes identified by Leonhard are still observable in everyday clinical practice. Empirico-genetic and molecular studies confirm the scientific value of this differentiation (Stöber and Reis 2009). Systematic catatonias appeared in most cases to be sporadic, and among potential environmental risk factors, the excess of mid-gestational maternal infections indicates early neurodevelopmental disturbances. In contrast, periodic catatonia is strongly transmitted within pedigrees with evidence for genetic heterogeneity in linkage studies and genome-wide association studies. Therefore, a more complex classification of catatonia seems to provide a useful tool for further neurobiological and therapeutic research.

         The categorical approach of differentiated psychopathology has major implications for treatment and prognosis, too. In this top-down concept research is focused on putative pathophysiological mechanisms.

         As for example also by Ungvari and coworkers was noted, there is up to now no consensus on which signs and symptoms constitute the catatonic syndrome (Ungvari, Caroff and Gerevich 2010). If Shorter therefore suggests that the problem of a valid psychopathological characterization of catatonia is already solved, this denotes nothing more than an oversimplification of clinical reality. This is also the case if he propagates BZD or ECT as a magic bullet in every case of “catatonia,” whereas especially patients with system catatonias have much more benefit from psychosocial treatment than from any kind of psychopharmacotherapy or ECT.



Franzek E, Beckmann H. Reliability and validity of the Leonhard classification tested in a five year follow-up study of 50 chronic schizophrenics. In: Ferrero FP, Haynal AE, Sartorius N (eds); Schizophrenia and affective psychoses. Nosology in contemporary psychiatry. New York: John Libbey.1992, pp. 67-72. 

Pfuhlmann B, Franzek E, Stöber G, Cetkovich-Bakmas M, Beckmann H. On interrater reliability for Leonhard´s classification of endogenous psychoses. Psychopathology. 1997; 30:100-105.

Stöber G, Reis A. Periodic catatonia. In: Lang F. (Ed.) Encyclopedia of Molecular Mechanisms of Disease. Heidelberg: Springer. 2009, pp. 1615-16. 

Ungvari GS, Caroff SN, Gerevich J. The catatonic conundrum: evidence of psychomotor phenomena as a symptom dimension in psychotic disorders, Schizophr Bull. 2010; 36:231-8.


April 8, 2021