Edward Shorter and Max Fink: The Madness of Fear: A History of Catatonia

Oxford/New York: Oxford University Press; 2018,  224 pages 

Reviewed by Edward Shorter and Max Fink


Information on Contents

The book contributes in three ways:

(1) It constitutes a reminder that the symptoms of catatonia are as old as time, merely that they were called by other names, such as catalepsy, homesickness, acute delirium and Starrsucht before Karl Kahlbaum coined the term "catatonia" in 1874. Following that, for almost 30 years catatonia was considered an independent syndrome until Emil Kraepelin made it a "subtype" of dementia praecox (schizophrenia) in 1899;

(2) it proposes a new symptom for the list of symptoms that are considered catatonic, namely the alternation of stupor and agitation. Stupor and agitation are found in many psychiatric illnesses, but their alternation is practically pathognomonic for catatonia. In the days of Kraepelin, alternation was considered a key symptom, but this was somehow lost sight of in the symptom lists that followed; and

(3) it widens the range of catatonia to include such diagnoses as delirious mania, Stauder's catatonia, Neuroleptic Malignant Syndrome (NMS), Anti-NMDA-Receptor Encephalitis and Self-Injurious Behavior (SIB) in the context of pediatric autism and intellectual disability. The price we have paid for losing sight of catatonia as a distinct entity is the flourishing of other diagnositc names for familiar clinical phenomena, such as stupor, negativism, and stereotypies.

Effective treatment has been described since the 1930s, first with barbiturates, then by inducing seizures (ECT) and now with benzodiazepines. Recognition as "catatonia" offers quick and effective relief.

The book's contents should help focus discussion in the field on the wide range of catatonic phenomena, on how easily they may be overlooked or misdiagnosed and how readily they respond to treatment.

Authors' Statement

Catatonia is not just a motor phenomenon but a psychological one at well, as seen for example in negativism. Within the field, it has been controversial whether consciousness during a catatonic stupor is extinguished or whether communication with the environment is merely interrupted, with consciousness preserved. Historically, Karl Jaspers and Karl Kleist argued that it was suspended; Henri Baruk and other French authorities argued that it was preserved. On the basis of overwhelming evidence, we argue for the "psychois of fear," that consciousness is indeed preserved and that ideation during a stupor consists of fearful and terrifying images. These may well be some kind of remnant from a pathway of evolution that caused animals to play dead when threatened. In any event, in fearful situations today, such as sexual violence, stupor is not uncommon.

We argue that catatonia is an independent systemic disease, not solely a psychiatric issue, and that it is commonly encountered in emergency medicine, internal medicine and in other non-psychiatric settings. As a systemic disease, catatonia needs to be recognized by physicians from many different specialties, particularly since it may end fatally, and is exquisitely responsive to treatment by benzodiazepines and by ECT.


October 18, 2018