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

Jose de Leon’s comments



                I am extremely grateful to have been asked to comment on the book The Madness of Fear:  A History of Catatonia written by Edward Shorter and Max Fink.  First, I have to acknowledge that I would be naïve to pretend that my critique can be objective since I am a great admirer of both authors.  Shorter is a very productive historian who has published several important books on the history of psychiatry.  When psychiatry residents ask me for an introductory book on the history of psychiatry, I recommend A History of Psychiatry (Shorter 1997).  To make things worse, I met Shorter in Madrid on September 16, 2014.  Since then we have kept in touch by email and he has provided nice comments on my clumsy attempts to write articles on the history of psychiatry.  More importantly, he was very critical of one of my conceptual articles for its lack of clarity, so after rewriting it several times I was able to publish a very clear version two years later. 

                I have never met Max Fink, but I have read several of his interviews with historians of psychopharmacology.  More significantly, in 1991 I read a very important article by Fink and Taylor which took a very critical approach to the classification of catatonia in the DSM-III (Fink and Taylor 1991)   The issue stopped being merely academic for me when, in 1996, I moved to my current job in Kentucky, directing a unit for treatment-refractory patients at a state hospital.  In 1998, an extremely complex case of a familial form of catatonia, which I diagnosed as periodic catatonia, became my baptism by fire regarding catatonia.  (I wrote Fink’s collaborator, Dr. Frances, requesting their catatonia scale and to ask about their experience with electro convulsive therapy [ECT] as a means of treatment for patients recovering from a benzodiazepine response to catatonic symptoms.)  I followed that catatonia patient for more than four years and that patient taught me a lot of what I know about the relevance of fear, as well as biological abnormalities in catatonia, including hypercortisolemia and creatine kinase elevations, resulting in a paper 20 years later (Zwiebel, Villasante, Tejanos and de Leon 2018). 

                After my 1998 experience, in an attempt to save lives among patients with severe mental illness, I started a crusade to teach doctors in the Kentucky state public health system how to diagnose and treat catatonia.  One article describing six deaths (all secondary to pulmonary embolism) illustrates my limited success in preventing deaths (Puentes, Brenzel and de Leon  2017).  So it is not surprising that over the years since 1991 I have cheered any time Fink and Taylor published a new review article trying to convince the DSM Task Force to provide a better approach to catatonia in various updates of the DSM editions.  I am extremely critical of DSM-5, but one of the few things I welcome is that finally DSM-5 has paid attention to the recommendations of Fink and Taylor.  It only took 22 years, from 1991 to 2013, but it finally happened.


Critical Review

                This long introduction serves the purpose of forcing me to restrain my bias so that I can downplay my laudatory tone and make a major effort to be critical concerning a book that is a major contribution to the field of catatonia. 

                I am a compulsive reader of psychiatric articles and books, so it is very difficult to impress me by trying to teach me new things.  I rarely value books written by U.S. authors since they tend to be outdated when they are published.  They are not subject to a detailed peer review and rarely provide any original ideas beyond the review articles written by the book’s authors.  For example, I have the book on catatonia by Fink and Taylor in my office (Fink and Taylor 2006).  Although I have read it and highlighted several chapters, I rarely use it with residents because only very specific areas of the book are not presented in more recent review articles by Fink.  I have all of his review articles since 1991. 

                This new book is different and I think it will become a classic.  Some of its chapters, the historical ones, will never become outdated.  As a consumer of catatonia literature, I am extremely grateful for the very wise decision of Shorter and Fink to collaborate.  I have hundreds of articles on Kraepelin, Bleuler, Kahlbaum and Leonhard, but I thought that the historical chapters before Chapter 11, “Catatonia in DSM-III and after,” were excellent for their clarity and detail. It feels to me as though they are a true version of a very complex historical process.  I know and have heard many versions of the history of agreement and disagreement in the area of neuroleptic malignant syndrome (Chapter 9), so it was very helpful to see Fink’s view in writing; now I can quote it when teaching psychiatry residents. 

                I had also heard of the major contribution of Stephan Heckers in convincing the Steering Committee for DSM-5 to finally pay attention to the views of Fink and Taylor on catatonia.   While Chapter 11 explains how Heckers’ prior catatonia articles were the basis for his receptivity to catatonia as a separate entity,  Shorter and Fink do not appear to know that Heckers’ receptivity to catatonia probably goes back to his medical training when  he studied at the University of Würzburg.  At that time the department, under the leadership of Helmut Beckman, initiated an effort to make English-speaking psychiatrists aware of Leonhard’s work  and finally translate his textbook into English (Beckmann, Bartsch, Neumärker et al. 2000),

                I would like to take advantage of this opportunity to publicly acknowledge Heckers for helping give birth to DSM-5’s advancement in catatonia.  One suspects that 60-70% of the credit should go to Drs. Fink and Taylor, 20-30% to other authors, but Heckers probably deserves at least 10% for his final efforts that made the advancement possible. 

                After stating that this book is likely to be relevant 50 or 100 years from now, I have to force myself to find three weaknesses:  one is the chapter order; another, the absence of a chapter on catatonia not secondary to other illnesses; and the third concerns the possibility of overzealousness in extending the limits of catatonia into some unusual areas.

                It was very easy for me to understand the first 12 chapters when they referred to catatonia treatments.  I knew most of what Chapter 13, “Treatments of Catatonia,” was going to say.  Those who are not familiar with the history of catatonia treatments may want to read Chapter 13 after Chapter 6 (“Kidnapped!”);  it may then be easier to understand Chapters 7 through 12.

                Fink’s clinical setting at Stony Brook University Hospital does not appear to have been a good setting for conducting long-term longitudinal studies.  Thus, Fink has written little about what DSM-5 calls “unspecified catatonia”;  these patients do not have other mental or medical conditions that explain the catatonia.  In articles from English-speaking authors, these patients are usually diagnosed as having idiopathic catatonia, but for those following Leonhard many of these patients are said to have familial forms of periodic catatonia.  As Chapter 7 (“Psychology”) explains, Leonhard’s classification of psychosis is complex and not practical, but his hypothesis about the existence of a familial periodic catatonia is very likely to stand the destructive effect of time in our practice of psychiatric nosology.  So one would have liked to have seen a chapter on this form of catatonia as a “separate disease sui generis” (Chapter 7).  Unfortunately, recently published information on periodic catatonia is very limited.  A few groups, including the Würzburg group in Germany and Peralta and Cuesta in Spain, may have relevant clinical experience in this neglected area.

                Any psychiatric researcher specializing in a psychiatric diagnosis tends to over diagnose and extend the diagnosis beyond its real limits.  This book is not, surprisingly, free of that overzealousness.  A prior article by Fink describes in detail an alleged overlap between catatonia and obsessive-compulsive disorder (OCD) (Fink 2013).  While Chapter 14 (“L’Envoi”) stresses that overlap, it does so without getting into details.  It is possible that patients with OCD may occasionally have catatonic symptoms, but I personally doubt this is the norm.  Similarly, Chapter 12 (“New Faces of Catatonia?”), on self-injurious behavior (SIB) in mental retardation and autism, appears contaminated to me by overzealousness. I am very aware of the literature on catatonia in children with intellectual disability (ID).  As a matter of fact, I published the first cases of patients with ID diagnosed with catatonia in their 50s or older (White, Maxwell, Milteer and de Leon 2015).  So I have seen a few adult patients with ID in which SIB was explained by catatonia and showed symptom improvement by treating their catatonia.  However, SIB is extremely frequent in adults and children with ID.  A recent SIB review suggests a 30% prevalence in non-residential care settings and a 41% prevalence in residential care settings (Huisman, Mulder, Kuijk et al. 2018).  Although I agree that occasionally SIB in adult patients with ID can be explained by catatonia, the majority of adult patients with SIB who I have seen in Kentucky long-term facilities do not appear to have catatonia and are not expected to benefit from ECT.  I make this statement despite having fought opponents of ECT in Kentucky on behalf of patients for whom ECT was life saving for catatonia or psychotic depression.  Unfortunately, ECT is banned in Kentucky state public hospitals and occasionally we need to send patients to private facilities for outpatient ECT.

                In summary, I am convinced Shorter and Fink’s book will become a classic.  I want to at least ask Shorter the next time I see him to sign my highlighted copy to increase its historical value.  I hope to still be alive 10 to 15 years from now, although by that time books may no longer be relevant.  I have a library with hundreds of psychiatric books.  Most of them will likely become irrelevant once I am dead.  However, for my oldest daughter who is studying to be a psychiatrist, I expect to recommend that she keep no more than 10 of my psychiatry books.  I am convinced that my highlighted copy of this book will probably be one of them. 



Beckman H, Bartsch AJ, Neumärker KJ, Pfuhlmann B, Verdaguer MF, Franzek E. Schizophrenias in the Wernicke-Kleist-Leonhard school. Am J Psychiatry 2000; 157:1024-5.

Fink M. Rediscovering catatonia: the biography of a treatable syndrome. Acta Psychiatrica Scandinavica Supplement 2013;(441):1-47.

Fink M, Taylor MA.  Catatonia: a separate category in DSM-IV? Integrative Psychiatry 1991; 7:  2-7.

Fink M, Taylor MA. Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge, UK: Cambridge University Press; 2006.

Huisman S, Mulder P, Kuijk J, Kerstholt M, van Eeghen A, Leenders A, van Balkom I, Oliver C, Piening S, Hennekam R. Self-injurious behavior. Neurosciences and Biobehavioral Reviews 2018; 84:483-91.

Puentes R, Brenzel A, de Leon J. Pulmonary embolism during stuporous episodes of catatonia was found to be the most frequent cause of preventable death according to a state mortality review: 6 deaths in 15 years. Clinical Schizophrenia & Related Psychoses. 2017 Aug 4. doi: 10.3371/CSRP.RPAB.071317.

Shorter E. A History of Psychiatry. From the Era of the Asylum to the Age of Prozac.  New York:  John Wiley & Sons, Inc;1997.

White M, Maxwell E, Milteer WE, de Leon J. Catatonia in older adult individuals with intellectual disabilities. Case Rep Psychiatry. 2015; 2015:120617.

Zwiebel S, Villasante-Tejanos AG, de Leon J. Periodic catatonia marked by hypercortisolemia and exacerbated by the menses: a case report and literature review. Case Rep Psychiatry. 2018 Jul 4; 2018:4264763.


March 14, 2019