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To provide a rational basis for reconceptualizing catatonia in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), we briefly review historical sources, the psychopathology of catatonia, and the relevance of catatonic schizophrenia in contemporary practice and research. In contrast to Kahlbaum, Kraepelin and others (Jaspers, Kleist, and Schneider) recognized the prevalence of motor symptoms in diverse psychiatric disorders but concluded that the unique pattern and persistence of certain psychomotor phenomena defined a "catatonic" subtype of schizophrenia, based on intensive long-term studies. The enduring controversy and confusion that ensued underscores the fact that the main problem with catatonia is not just its place in Diagnostic and Statistical Manual of Mental Disorders but rather its lack of conceptual clarity. There still are no accepted principles on what makes a symptom catatonic and no consensus on which signs and symptoms constitute a catatonic syndrome. The resulting heterogeneity is reflected in treatment studies that show that stuporous catatonia in any acute disorder responds to benzodiazepines or electroconvulsive therapy, whereas catatonia in the context of chronic schizophrenia is phenomenologically different and less responsive to either modality. Although psychomotor phenomena are an intrinsic feature of acute and especially chronic schizophrenia, they are insufficiently recognized in practice and research but may have significant implications for treatment outcome and neurobiological studies. While devising a separate category of catatonia as a nonspecific syndrome has heuristic value, it may be equally if not more important to re-examine the psychopathological basis for defining psychomotor symptoms as catatonic and to re-establish psychomotor phenomena as a fundamental symptom dimension or criterion for both psychotic and mood disorders.

Psychiatric diagnoses are currently categorized on a syndromic basis. The syndrome of catatonia, however, remains in a diagnostic limbo, acknowledged predominantly as a subtype of schizophrenia. Yet, catatonia is present in about 10% of acutely ill psychiatry patients, only a minority of whom have schizophrenia. Among those with comorbid affective disorders, who comprise the largest subgroup of catatonic patients, the catatonic signs typically resolve dramatically and completely with benzodiazepine therapy. Those with schizophrenia respond less reliably, suggesting that the underlying processes causing the catatonia may be different in this group. The majority of patients with catatonia have concurrent psychosis. Failure to treat the catatonia before institution of antipsychotic medication may increase the risk of inducing neuroleptic malignant syndrome. At this point of time, the pathobiology of catatonia is unknown; the major reason for considering catatonia as a separate diagnostic entity would be to increase recognition of this eminently treatable neuropsychiatric syndrome.

Age at onset and sex differences in the age at onset were investigated in the schizophrenic subtypes of 200 patients. Significant differences in the age at onset were observed among these subtypes; the disorganized subtype demonstrated the earliest and the paranoid the latest onset. The mean age at onset of all female patients was significantly greater than that of the male. Specifically, in the paranoid subtype the onset for men occurred earlier than for women. Conversely, in the disorganized subtype the disorder appeared earlier in women. There was no significant sex difference in the age at onset in the undifferentiated and the residual subtypes. In the paranoid subtype most men developed the disease before age 30 (72%), whereas women had an even distribution of the onset before and after 30. Ninety-six patients admitted for the first time demonstrated findings similar to those of the total sample. The data provide additional information on the phenotypic expression of the subtypes of schizophrenic disorders and indicate the necessity for further demographic and genetic studies to delineate the underlying defect.

In a recent article, Andreasen and Flaum (Schizophrenia Bulletin, Vol. 17, No. 1, 1991) argued that greater emphasis should be placed on negative symptoms in the diagnosis of schizophrenia, leading to a less important role for positive symptoms. This article presents a counter-argument to this view. Positive symptoms are common and reliable and therefore highly useful diagnostically. First-rank symptoms, although not specific to schizophrenia, show good discriminability. No other type of symptom or investigative method can make such claims to usefulness. Although positive symptoms do not predict outcome, this is not a necessary function of diagnostic criteria. The predictive power of negative symptoms is, in any case, based largely on studies of patients with chronic disorder. Premorbidly impaired social development may interact with schizophrenia, worsening the prognosis. We believe positive symptoms have always been the essence of psychiatric disorder and should remain so. Increasing the diagnostic weight given to negative symptoms risks restricting the definition of schizophrenia excessively.

Data about numerous repeated administrations of the Kent-Rosanoff Association Test to schizophrenic subjects not found elsewhere in the literature are presented. A quantitative scoring system, in the form of a Composite Index, is also provided. And lastly, association results offer further evidence for the theory of segmental set. Data are provided on the responses of 60 schizophrenic patients and 60 normal subjects (college and noncollege) on two repetitions of the test, and five repetition for schizophrenics. Results of the comparison between schizophrenics and normals indicate that schizophrenics give fewer most common, more individual, and more unusual responses; have a higher Composite Index; have a lower percentage of responses given in identical form; and show less learning ability on test repetition. As between paranoids and hebephrenics, paranoids have higher repetition scores, and given more most common, more individual, and fewer unusual responses. These results reflect clinical condition and are viewed as corroborating the segmental set hypothesis.