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The Madness of Fear: A History of Catatonia
What are the real disease entities in psychiatry? This is a question that has bedeviled the study of the mind for more than a century yet it is low on the research agenda of psychiatry. Basic science issues such as neuroimaging, neurochemistry, and genetics carry the day instead. There is nothing wrong with basic science research, but before studying the role of brain circuits or cerebral chemistry, shouldn't we be able to specify how the various diseases present clinically?
Catatonia is a human behavioral syndrome that for almost a century was buried in the poorly designated psychiatric concept of schizophrenia. Its symptoms are well-know, and some of them are serious. Catatonic patients may die as their temperatures accelerate; they become dehydrated because they refuse to drink; they risk inanition because they refuse to eat or move. Autistic children with catatonia may hit themselves repeatedly in the head. We don't really know what catatonia is, in the sense that we know what pneumonia is. But we can identify it, and it is eminently treatable. Clinicians can make these patients better on a reliable basis. There are few other disease entities in psychiatry of which this is true.
So why has there been so little psychiatric interest in catatonia? Why is it simply not on the radar of most clinicians? Catatonia actually occurs in a number of other medical illnesses as well, but it is certainly not on the radar of most internists or emergency physicians.
In The Madness of Fear , Drs. Shorter and Fink seek to understand why this "vast field of ignorance" exists. In the history of catatonia, they see a remarkable story about how medicine flounders, and then seems to find its way. And it may help doctors, and the public, to recognize catatonia as one of the core illnesses in psychiatry.
Catatonia is a human behavioral syndrome that for almost a century was buried in the poorly designated psychiatric concept of schizophrenia. Its symptoms are well-know, and some of them are serious. Catatonic patients may die as their temperatures accelerate; they become dehydrated because they refuse to drink; they risk inanition because they refuse to eat or move. Autistic children with catatonia may hit themselves repeatedly in the head. We don't really know what catatonia is, in the sense that we know what pneumonia is. But we can identify it, and it is eminently treatable. Clinicians can make these patients better on a reliable basis. There are few other disease entities in psychiatry of which this is true.
So why has there been so little psychiatric interest in catatonia? Why is it simply not on the radar of most clinicians? Catatonia actually occurs in a number of other medical illnesses as well, but it is certainly not on the radar of most internists or emergency physicians.
In The Madness of Fear , Drs. Shorter and Fink seek to understand why this "vast field of ignorance" exists. In the history of catatonia, they see a remarkable story about how medicine flounders, and then seems to find its way. And it may help doctors, and the public, to recognize catatonia as one of the core illnesses in psychiatry.
224 pages, Paperback
Published July 27, 2018
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Displaying 1 - 6 of 6 reviews
October 16, 2018
What is catatonia? Is it a symptom of schizophrenia? Can it be treatable and reversible?
These are the questions I asked myself when I picked up Dr. Edward Shorter and Dr. Max Fink's tome, The Madness of Fear: A History of Catatonia that explores the critical factors that have affected its recognition and treatment.
Before reading the book, I did a little research and found Batya Swift Yasgur's brief article in the August 08, 2018 edition of Psychiatry Advisor where he points out that catatonia affects 9.8% of patients admitted to psychiatric hospitals.
Unfortunately, it frequently goes unrecognized and thus leads to the erroneous belief that it is rare. Yasgur goes onto state that according to a Dutch study clinicians identified catatonia in only 2% of 139 patients, whereas a research team identified catatonia in 18%.
Dr. Shorter and Dr. Fink explain that in the same sense that we know what pneumonia is, we do not know what exactly is catatonia nor do we know its causes. Moreover, catatonia has been variously described as a distinct disease entity, as a part of schizophrenia, and as a nonspecific manifestation of many disorders. According to the authors, we can identify it and recognize its many forms, and yes, it is treatable, and there is a good prognosis for recovery. Consequently, they have written their book to help and educate doctors, their patients, and the general public to recognize and understand catatonia as a core illness in psychiatry and medicine in general.
Catatonia is a psychomotor or abnormal behavioural syndrome that is a feature of many psychiatric disorders which historically has been associated with schizophrenia. As the authors point out, “it is an identifiable and verifiable syndrome of abnormal motor and psychic changes, acute in onset, disruptive of living, often malignant, with fatal outcome, and yet eminently recognizable and fully treatable today.” In most cases, prompt treatment can produce immense improvement. It is not exclusively associated with schizophrenia and is very common in clinical practice.
Relying on their vast amount of research and experience, Drs. Shorter and Fink provide their readers with a comprehensive survey and commentary on catatonia as well as the evolution of the science of descriptive psychopathology giving us a clearer picture in its understanding.
Generally, most clinical historians agree that it was the German psychiatrist, Dr. Karl Kahlbaum who had been the first to describe catatonia in 1874 and his work was published a few years later. However, according to the authors, this is technically correct but historically wrong. Physicians for centuries had been describing the symptoms of catatonia, although it was Kahlbaum who eventually assembled them into a neat package bearing the label “catatonia.” Before Kahlbaum, it was called a different thing wherein the most common one was catalepsy.
Since Kahlbaum's description, catatonia has undergone numerous descriptions over the years reflecting several changes in psychiatric disease classification. For example, in 1893, Dr. Emil Kraepelin believed that catatonia was a subtype of dementia praecox which was later termed by Dr. Eugene Bleuler, schizophrenia. Shorter and Fink disagree with Kraepelin stating that the syndrome was co-opted and misidentified by him “as a feature of his poorly defined and poorly treatable syndrome of dementia praecox. Alas, his writings were so authoritative that for more than a century catatonia remained buried within his disorder,” and as the authors further state, “it was kidnapped by dementia praecox and schizophrenia, the Bonnie and Clyde of the diagnosis world.”In the ensuing decades the association of catatonia with schizophrenia was repeatedly endorsed, first by Eugen Bleuler, and then in the iterations of the American Psychiatric Association DSM including those in 1980 and 1994.
Insofar the treatment of catatonia, the authors indicate that two effective therapies were discovered one in 1929-30, sodium Amytal and the induction of grand mal seizures in 1934, that developed into the modern electroconvulsive therapy, the definitive treatment of catatonia. And as they further state, by the 1990s catatonia has been increasingly acknowledged as an independent and treatable syndrome and as a different disorder in the psychiatric glossary, a recognition that was finalized in the 2013 publication of the American Psychiatric Association's DSM-5.
The Madness of Fear: A History of Catatonia is an excellent well-documented book skilfully exploring critical factors that have affected the recognition, treatment, and study of catatonia. And for those who wish to pursue more extensive study and investigation, the notes at the end of the book provide readers with excellent valuable resources. Without a doubt this is a book that should find a place in doctors' and health care providers' libraries.
FOLLOW HERE https://waa.ai/apXp TO READ NORM'S INTERVIEW WITH THE AUTHORS OF THE MADNESS OF FEAR
These are the questions I asked myself when I picked up Dr. Edward Shorter and Dr. Max Fink's tome, The Madness of Fear: A History of Catatonia that explores the critical factors that have affected its recognition and treatment.
Before reading the book, I did a little research and found Batya Swift Yasgur's brief article in the August 08, 2018 edition of Psychiatry Advisor where he points out that catatonia affects 9.8% of patients admitted to psychiatric hospitals.
Unfortunately, it frequently goes unrecognized and thus leads to the erroneous belief that it is rare. Yasgur goes onto state that according to a Dutch study clinicians identified catatonia in only 2% of 139 patients, whereas a research team identified catatonia in 18%.
Dr. Shorter and Dr. Fink explain that in the same sense that we know what pneumonia is, we do not know what exactly is catatonia nor do we know its causes. Moreover, catatonia has been variously described as a distinct disease entity, as a part of schizophrenia, and as a nonspecific manifestation of many disorders. According to the authors, we can identify it and recognize its many forms, and yes, it is treatable, and there is a good prognosis for recovery. Consequently, they have written their book to help and educate doctors, their patients, and the general public to recognize and understand catatonia as a core illness in psychiatry and medicine in general.
Catatonia is a psychomotor or abnormal behavioural syndrome that is a feature of many psychiatric disorders which historically has been associated with schizophrenia. As the authors point out, “it is an identifiable and verifiable syndrome of abnormal motor and psychic changes, acute in onset, disruptive of living, often malignant, with fatal outcome, and yet eminently recognizable and fully treatable today.” In most cases, prompt treatment can produce immense improvement. It is not exclusively associated with schizophrenia and is very common in clinical practice.
Relying on their vast amount of research and experience, Drs. Shorter and Fink provide their readers with a comprehensive survey and commentary on catatonia as well as the evolution of the science of descriptive psychopathology giving us a clearer picture in its understanding.
Generally, most clinical historians agree that it was the German psychiatrist, Dr. Karl Kahlbaum who had been the first to describe catatonia in 1874 and his work was published a few years later. However, according to the authors, this is technically correct but historically wrong. Physicians for centuries had been describing the symptoms of catatonia, although it was Kahlbaum who eventually assembled them into a neat package bearing the label “catatonia.” Before Kahlbaum, it was called a different thing wherein the most common one was catalepsy.
Since Kahlbaum's description, catatonia has undergone numerous descriptions over the years reflecting several changes in psychiatric disease classification. For example, in 1893, Dr. Emil Kraepelin believed that catatonia was a subtype of dementia praecox which was later termed by Dr. Eugene Bleuler, schizophrenia. Shorter and Fink disagree with Kraepelin stating that the syndrome was co-opted and misidentified by him “as a feature of his poorly defined and poorly treatable syndrome of dementia praecox. Alas, his writings were so authoritative that for more than a century catatonia remained buried within his disorder,” and as the authors further state, “it was kidnapped by dementia praecox and schizophrenia, the Bonnie and Clyde of the diagnosis world.”In the ensuing decades the association of catatonia with schizophrenia was repeatedly endorsed, first by Eugen Bleuler, and then in the iterations of the American Psychiatric Association DSM including those in 1980 and 1994.
Insofar the treatment of catatonia, the authors indicate that two effective therapies were discovered one in 1929-30, sodium Amytal and the induction of grand mal seizures in 1934, that developed into the modern electroconvulsive therapy, the definitive treatment of catatonia. And as they further state, by the 1990s catatonia has been increasingly acknowledged as an independent and treatable syndrome and as a different disorder in the psychiatric glossary, a recognition that was finalized in the 2013 publication of the American Psychiatric Association's DSM-5.
The Madness of Fear: A History of Catatonia is an excellent well-documented book skilfully exploring critical factors that have affected the recognition, treatment, and study of catatonia. And for those who wish to pursue more extensive study and investigation, the notes at the end of the book provide readers with excellent valuable resources. Without a doubt this is a book that should find a place in doctors' and health care providers' libraries.
FOLLOW HERE https://waa.ai/apXp TO READ NORM'S INTERVIEW WITH THE AUTHORS OF THE MADNESS OF FEAR
May 23, 2019
Summary: Excellent history, fascinating patient stories, a focus on scientific process and credit that left me a bit bored, and overall just a little bit too dogmatic for my taste.
I didn't read the entire thing (skimmed many of the middle chapters), so please take this review with a healthy helping of salt. However, as I've said previously, I don't believe that someone needs to read the entirety of a book before they review it as long as they are honest and are specific. Otherwise, we will needlessly incentivize the ratings of long and complex books.
*Stuff I enjoyed*:
- The patient stories, especially ones from before catatonia was well-defined, are well-chosen and extremely illustrative (e.g., the college athlete who wouldn't speak or move but would start playing baseball when he was given a ball and told what to do).
- The idea that Kahlbaum's catatonia:catatonic syndrome::Parkinson's disease:parkinsonism.
- The chapter on the history of treatments for catatonia, including failed treatments using cocaine.
- The section on people who likely had catatonia and were so nonreactive to the environment that they were thought to be dead (and were sometimes even buried).
- The criticisms of schizophrenia as a diagnosis were good: it is an important reminder that schizophrenia is an enormously heterogeneous diagnosis. It also deserves to be shouted from the rooftops that catatonia is not particularly associated with schizophrenia.
*Stuff I didn't like*:
- The casual dismissal of PTSD as "a strong-arm political play" by the Vietnam veterans and of major depression as included in the DSM3 only to "get approval by the psychoanalysts" (p. 5). Maybe these points are true, but they needed to be referenced and backed up with more evidence; otherwise, they were just pot shots.
- Slightly dogmatic in that it seemed to be a little bit biased towards the prevalence and importance of catatonia. E.g., in claiming that historical cases were catatonia when the evidence was not always all that strong (example: John Bucknill's case report in 1858 of disordered movements in mania, p. 13).
- The book is a bit obsessed with who should receive credit for coming up with a particular diagnosis. Not only was this not particularly interesting to me, but it actually seems to contribute to the problems that the book described regarding psychiatric nosology. If there were less of an incentive to be "the first" to come up with a diagnosis, perhaps people would be more likely to come up with accurate and more importantly helpful diagnoses. Or even better: attempt to disrupt our current conceptions of diagnosis altogether?
Quotes I liked:
- "The voyage of discovery lies not in seeking new horizons, but in seeing with new eyes." - Marcel Proust
- "Catatonia is not a disorder in thought or emotion, although such accompaniments are common. Some authors consider catatonia an "end-state" whole-body response to imminent doom, a behavior inherited from ancestral encounters with carnivores, an adaptation that remains an inherent feature of living. This image makes catatonia an atavism. Catatonia is associated with fear and has been likened to the animal defense of tonic immobility, the relic of the flight-and-fight defenses of living in a predatory environment. Mutism, negativism, posturing, and rigidity are adaptations that disappear when the stress is relieved." p. 157
I didn't read the entire thing (skimmed many of the middle chapters), so please take this review with a healthy helping of salt. However, as I've said previously, I don't believe that someone needs to read the entirety of a book before they review it as long as they are honest and are specific. Otherwise, we will needlessly incentivize the ratings of long and complex books.
*Stuff I enjoyed*:
- The patient stories, especially ones from before catatonia was well-defined, are well-chosen and extremely illustrative (e.g., the college athlete who wouldn't speak or move but would start playing baseball when he was given a ball and told what to do).
- The idea that Kahlbaum's catatonia:catatonic syndrome::Parkinson's disease:parkinsonism.
- The chapter on the history of treatments for catatonia, including failed treatments using cocaine.
- The section on people who likely had catatonia and were so nonreactive to the environment that they were thought to be dead (and were sometimes even buried).
- The criticisms of schizophrenia as a diagnosis were good: it is an important reminder that schizophrenia is an enormously heterogeneous diagnosis. It also deserves to be shouted from the rooftops that catatonia is not particularly associated with schizophrenia.
*Stuff I didn't like*:
- The casual dismissal of PTSD as "a strong-arm political play" by the Vietnam veterans and of major depression as included in the DSM3 only to "get approval by the psychoanalysts" (p. 5). Maybe these points are true, but they needed to be referenced and backed up with more evidence; otherwise, they were just pot shots.
- Slightly dogmatic in that it seemed to be a little bit biased towards the prevalence and importance of catatonia. E.g., in claiming that historical cases were catatonia when the evidence was not always all that strong (example: John Bucknill's case report in 1858 of disordered movements in mania, p. 13).
- The book is a bit obsessed with who should receive credit for coming up with a particular diagnosis. Not only was this not particularly interesting to me, but it actually seems to contribute to the problems that the book described regarding psychiatric nosology. If there were less of an incentive to be "the first" to come up with a diagnosis, perhaps people would be more likely to come up with accurate and more importantly helpful diagnoses. Or even better: attempt to disrupt our current conceptions of diagnosis altogether?
Quotes I liked:
- "The voyage of discovery lies not in seeking new horizons, but in seeing with new eyes." - Marcel Proust
- "Catatonia is not a disorder in thought or emotion, although such accompaniments are common. Some authors consider catatonia an "end-state" whole-body response to imminent doom, a behavior inherited from ancestral encounters with carnivores, an adaptation that remains an inherent feature of living. This image makes catatonia an atavism. Catatonia is associated with fear and has been likened to the animal defense of tonic immobility, the relic of the flight-and-fight defenses of living in a predatory environment. Mutism, negativism, posturing, and rigidity are adaptations that disappear when the stress is relieved." p. 157
February 10, 2023
Catatonia alone almost makes me, an MS3, want to go into psychiatry because it is so interesting - great read!
Read
May 26, 2025amazing amazing amazing!
November 26, 2023
ILB via CPL. Alot of history. NMS is considered one manifestation. Very treatable according to the authors with ativan or ECT. Wrongly included in schizophrenia for a century, is separate in DSM5.
This entire review has been hidden because of spoilers.
May 14, 2023
Spellbinding academic work by Edward Shorter and Max Fink. The historical context that shaped the debate around catatonia was really remarkable to read about-I had little idea that the history of psychiatry was so fraught with strong personalities and ‘popularity contests’ which determined which diagnoses persisted and which did not. It was also illuminating seeing how catatonia came into its own as a diagnosis that was easily treated, even if it is still relatively unknown and difficult to identify.
I became interested in this topic as I’m an RN in an acute inpatient psychiatric unit, and I would estimate we encounter 1-2 catatonic patients per month, and they seem surprisingly difficult to identify and treat. This book has really helped me to wrap my head around this admittedly befuddling phenomenon. Great work, rather pricey for what is probably a niche academic topic, but great work nonetheless!
I became interested in this topic as I’m an RN in an acute inpatient psychiatric unit, and I would estimate we encounter 1-2 catatonic patients per month, and they seem surprisingly difficult to identify and treat. This book has really helped me to wrap my head around this admittedly befuddling phenomenon. Great work, rather pricey for what is probably a niche academic topic, but great work nonetheless!
Displaying 1 - 6 of 6 reviews