Making childhood catatonia visible, separate from competing diagnoses.

Abstract

The prevailing belief in the rarity of pediatric catatonia is incorrect. The condition was frequently diagnosed in the past, but under other labels. In the remote past, catalepsy and stupor were diagnostic terms for some symptoms of what Karl Kahlbaum described in 1874 as ‘catatonia’. However, even after Kahlbaum, catatonia in children was often submerged by global competing diagnoses such as ‘schizophrenia’, ‘autism’, and ‘hysteria’. Recently, however, catatonia in children has begun to emerge as an independent diagnosis. Accurate diagnosis is important because catatonia responds readily to well-defined treatments such as benzodiazepines and electroconvulsive therapy, whereas the larger diagnoses that have for many years concealed it are often less responsive to treatment. The concept of catatonia dates back to the Ancients (1, 2). The signs and symptoms of pediatric catatonia do not differ significantly from those of the adult form. However, the history of catatonia in children is of interest because, for many years it was believed that they did not suffer from catatonic symptoms. The purpose of this article is to show that, historically, catatonia in children was not uncommon. As it was described under other terms, however, its existence has been hidden from previous observers. In 1973, two pediatric researchers asserted, ‘Reports of catatonic episodes in childhood are exceedingly rare in the English-language literature’ (3). In light of the earlier historical literature, such skeptical assessments are in need of revision. The problem is that catatonic behavior was not formerly called ‘catatonia’. It was called ‘catalepsy’ (meaning waxy flexibility of the limbs), ‘stupor’, or even ‘coma’, depending on the main presentation. This would of course make sense before Kahlbaum coined the term in 1874 (4). However, even afteward, the pediatric equivalent was not acknowledged, and remained a collection of loose symptoms easily submerged within larger entities such as dementia praecox/schizophrenia, hysteria, and autism (see Table 1 for an overview). Table 1 Diagnostic labels that have historically obscured catatonia as an independent disease In the past, pediatric catatonia manifested itself mainly in the form of ‘hysterical attacks’ of stupor or catalepsy, although catalepsy often entailed stupor as well. Cases are numerous of patients who went into ‘death spells’. Such patients often risked being buried alive. Pierre Pomme, an 18th-century French physician, cites in 1761, the case of a medical colleague, who ‘delayed the funeral services of a girl from the lower classes [une fille du peuple], because her color had not changed at all. And she recovered several hours later. The girl… would already have been buried several times, if we had not been familiar with her attacks of hysterical vapors’ (5). This account is typical of a large body of medical literature from the 18th and early 19th centuries (6).