Prototypes of Catatonia: Diagnostic and Therapeutic Challenges in the General Hospital

Abstract

Where psychiatric diagnosis is dominated by subjective report, psychosomatic medicine fosters unique opportunities for clinical assessment that is rooted firmly in the physical examination. Catatonia presents a prime example. By rendering patients unable to describe their internal experiences, catatonia demands from psychiatrists a confident comfort with its variable presentations and diagnostic challenges. This proves especially true in the general hospital. Despite a common tendency to confine the syndrome to psychiatric disease, catatonia is precipitated by general medical conditions in up to 25% of cases and can, itself, trigger serious physical complications. As a result, consultation psychiatrists find themselves routinely at the forefront in providing care for the catatonic patient. Psychiatric evaluation starts with the instinctive appraisal of a patient’s mental status, with a focus on appearance, behavior, and cognition. Often reflexively, the clinician weighs this assessment against a figurative database of characteristic disease states, or prototypes. Mental prototypes can, thereby, guide the formulation of a differential diagnosis. An emphasis on prototype models in psychiatry can be traced to Carl Jung, whose archetypes provided a theoretical framework for human behavior, perception, and cognition. Among more recent literature in psychosomatic medicine, Kahana’s and Bibring’s descriptions of personality types and Groves’ depiction of the “hateful patient” exemplify the design of memorable prototypes to help clinicians identify personality styles and associated experiences of counter-transference in the general medical setting. Prototype models have since been proposed for the diagnosis of several psychiatric conditions, including bipolar disorder and personality disorders, and to predict trends in medication adherence among patients with schizophrenia. Advocates for the use of prototypes in psychiatric nosology argue their effectiveness, pragma-