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Starting from a case of marked pain insensitivity in a patient suffering from catatonic schizophrenia we state in this paper that analgesia seems to be an ubiquitous phenomenon which is not only caused by physical disorders of the central nervous system. Different models of interpretation as to be found in scientific literature are reviewed. On the basis of today's physiological knowledge, five hypotheses on causal explanation of pain insensitivity in schizophrenics are discussed: Hypalgesia and analgesia are an expression of motorial inability to react; a consequence of a disorder of consciousness; an analgetic effect of neuroleptic drugs; a basic deficit in schizophrenia and; a result of a disturbed psycho-physiological development.

Probably due to the rarity of the disorder and the general inability of catatonic patients to cooperate with standardized assessment, no data exist documenting the psychological features associated with catatonic schizophrenia that may appear on psychological tests. This study utilized standard assessment techniques to examine clinical hypotheses regarding the psychogenic correlates of catatonic conditions from the performance of one man on psychological tests. In accordance with previous theory, test findings indicated frequent constriction, rigidity, and negativism in conjunction with compulsive traits. Experiences of cognitive and self-fragmentation were juxtaposed with a formal, mechanistic body ego; disorganization and discontinuity were countered with attempts at self-cohesion. Depressed feelings and human interest were apparent, although interpersonal relatedness was frequently characterized by an avoidant, distancing style.

A bipolar patient presenting with catatonia may be misdiagnosed as having noncatatonic schizophrenia or unipolar depression because these conditions share the same signs. Of 12 patients with episodes of catatonia who were admitted to the authors' inpatient units, 8 were initially diagnosed as schizophrenic. Within 2 years, 8 of the 12 were ultimately diagnosed as suffering from bipolar affective disorder. Catatonia--a syndrome, not a diagnosis--seems more closely linked with bipolar disorder than with schizophrenia or unipolar depression.

The validity of the current systems of classification of endogenous psychoses has not yet been unambiguously demonstrated using the criterion of prognosis. An alternative to these systems may be seen in the Leonhard classification of endogenous psychoses. In a catamnestic study, 93% of the initial diagnoses and prognoses made between 1969 and 1973 could be confirmed in 1986.

We present a case description of a 15-year-old youth admitted in a psychotic state to the Adolescent Department of Shalvata Mental Health Center and diagnosed as having Idiopathic Hypoparathyroidism. A review of the neurological and psychiatric manifestations accompanying Hypoparathyroid Syndrome is presented, together with several aspects we feel are relevant in reaching this particular diagnosis.

Schizophrenics with high or low levels of frontalis muscle tensions while at rest (base-line) were instructed to respond (button-press) at different rates, allowed to respond at any rate they preferred, and reinforced for responding under different schedules of reinforcement. Information about response-reinforcement relationships was provided for each reinforcement schedule. High and low levels of base-line muscle tensions were associated with high and low rates of preferred and reinforced responding, respectively. Response rates also varied with different contingencies of reinforcement. Further, the data permit the following tentative conclusions: (a) under certain contingencies, responding may vary more with base-line muscle tensions than with the contingency of reinforcement, and (b) instructed rates of responding may not be correlated consistently with base-line muscle tensions.

In discussing some clinical cases the paper suggests an interpretation of catatonic syndrome based on the original and main characteristics of this psychopathological condition. Kahlbaum described this disease underlining the "affective" symptoms, but since then, catatonia has been considered a schizophrenic syndrome. The paper proposes a definition of catatonia based on Kahlbaum's earlier view in which the complex of psychomotor disturbances can be seen as the expression of schizophrenia, bipolar psychoses or of a specific cyclic disease.

Although catatonia has traditionally been thought of as a type of schizophrenia, the author presents studies indicating that catatonia may be at least as common in bipolar disorder as it is in schizophrenia. He points out that changing definitions of schizophrenia and affective disorder require a reassessment of catatonia and its incorporation in modern diagnostic systems. The discussion represents material presented at the Affective Disorders Advisory Committee of the American Psychiatric Association Work Group to Revise DSM-III.

A case history of a man with atypical psychosis who exhibited catatonic stupor is reported. Amytal interview procedures used and the differential diagnosis for catatonia are discussed. Response to Loxitane was excellent, though this was clouded by the patient's belief in root medicine, a source of cultural incongruity between him and his therapist. Distinguishing between psychosis and cultural belief systems is shown to be essential in therapy.

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.

A psychopathometric study on the course of schizophrenic patients was carried out in order to analyse the long-term prognostic value of the psychopathological state on clinical admission and discharge. Eighty-one patients with schizophrenic or similar psychoses were rate three times using well-validated psychopathological scales ("Inpatient Multidimensional Psychiatric Scale", "Clinical Selfrating Scales"): in the beginning, at the end of clinical treatment and 5-6 years after discharge. As for differentiated or global outcome-criteria, the psychopathological state on discharge was of more prognostic importance than the psychopathological state on admission. There existed syndrome-specific relationships between discharge and follow-up, i.e., in general each syndrome correlated most closely with itself between the two times of measurement. As for global outcome criteria, depressive-apathetic symptoms were of more special importance than productive schizophrenic symptoms indicating a poor outcome. The stepwise multiple regression analysis gave prognostically optimal combinations of IMPS-syndromes at admission and discharge which were different for each outcome criterium. Nevertheless, some syndromes were repeatedly among the best predictors. The combination of best predictors explained a greater part of outcome-variance than one predictor alone. The prognostic value of the combination could be optimated by including the factors of the self-rating scales.

Catatonic stupor is a cluster of symptoms and not necessarily a disease entity. It may be seen not only in schizophrenia, but in major affective disorders, conversion disorders, organic brain syndromes, and atypical psychoses. The dexamethasone suppression test is a valuable tool in the diagnosis of major affective disorders, differentiating them from other types of psychopathology. In a twelve month retrospective study, five patients admitted to Psychiatric Institute of Atlanta were identified as meeting the criteria for catatonic schizophrenia. A dexamethasone suppression test was performed shortly after admission. Four of the five had patterns of inadequate suppression, indicative of a major affective disorder rather than a schizophrenic disorder. The dexamethasone suppression test is simple to administer, relatively painless, free from hazards, easy to interpret, readily available, and reliable. Not only can the dexamethasone suppression test be used in diagnosis, but also as a valuable aid in following the therapeutic progress in resolution of a major affective disorder.

Initial presentations of encephalitis are sometimes misdiagnosed as psychoses due to the predominance of psychiatric symptoms and frequently negative neurological work-ups. It is likely that many of these errors are never discovered. The patient described herein is an exception. Her symptoms, diagnosis, and treatment have now been followed for nearly two years and suggest not only that the initial diagnosis was in error but also that both psychiatric and organic symptoms can endure as sequelae of encephalitis. Questions regarding optimal treatment and reasons for clinical improvement are addressed.

gamma-Vinyl GABA, an irreversible inhibitor of GABA transaminase, was administered orally to five patients with catatonic or hebephreno-catatonic schizophrenia. Improvement of psychiatric symptoms was observed in four cases. The results are discussed in relation to previously reported attempts to increase the CNS gabaergic function of patients with schizophrenia.

In an attempt to detect electroencephalographic (EEG) changes associated with characteristic clinical signs and symptoms of schizophrenia, power spectra were derived from scalp EEGs of schizophrenic patients recorded by telemetry during free behaviour on their psychiatric wards. Power spectra from EEG epochs coincident with psychomotor blocking, stereotyped automatism or hallucinations were compared with spectra derived during periods of relatively normal behaviour, during performance of specific tasks and spectra from control subjects. Ramp spectra, characterised by a smooth decline in power from lowest to highest frequencies, previously found in conjunction with subcortical spike activity of epilepsy were not found in any control subject, but appeared in spectra from schizophrenic patients during catatonic episodes, hallucinatory periods and visual checking. Schizophrenic patients also had more slow activity and less alpha activity in their EEGs than normal control subjects.

Daily behavioral observations were made for several years on 10 male schizophrenic patients and on three male patients with organic brain disorders. Analysis of these data showed strong cyclic components in the five schizophrenic patients with predominantly hebephrenic symptomatology. Period lengths noted were about 2 days, 5 to 6 days, 30 days, and a longer cycle of 40 to 100 days duration. Antipsychotic medications appear to have a suppressant effect, but tricyclic antidepressants may enhance pre-existing rhythms.

Post-treatment WAIS scores of 36 hospitalized schizophrenics were analyzed according to diagnostic subdivisions elsewhere validated. Significant differences emerged between Verbal and Performance Scales and among the 11 subtests, which transcended diagnostic subclasses. The results implied a reliable schizophrenic WAIS pattern supportive of Wechsler's (1958) proposal.

Because catatonic psychosis in childhood and adolescence is rare we have only scanty knowledge about the clinical picture, treatment and prognosis. Based on a single case study these aspects are discussed with respect to treatment course and outcome. A multidimensional treatment concept integrating neuroleptic treatment, individual and family therapy, and physical and occupational therapy seems to be the best approach to the severe affective and cognitive deficits.

Two patients are described here who showed exacerbation of psychotic behavior during treatment with folic acid. The authors conclude that further investigations are warranted, since some reports indicate the antipsychotic potential of folic acid.

Subject of the report is methodics for a circadian analysis in case of psychotical diseases. Acquisition and filing of psychopathological phenomenona is effected by means of Strukturiertes Psychopathologisches Erfassungssystem (SPES) and other self-or outside-rating-scales. The diurnal variation of body-temperature is taken as physiological reference function. The results of the analysis, which show an internal rhythmic desynchronization in case of phasic as well as in case of non-phasic psychoses, are given by way of exemplary instances.

Reinstitution of antipsychotic medication is problematic in patients with a history of neuroleptic malignant syndrome (NMS). In this case, a patient with a history of probable neuroleptic malignant syndrome caused by administration, as single agents, of haloperidol, molindone, and lithium was later treated successfully with the novel antipsychotic clozapine. The propensity of various antipsychotic agents to cause NMS is discussed.

The finding of marked disorganization of the hippocampal pyramidal cell layer in the brains of schizophrenic patients has recently been reported. The present study was undertaken to determine whether similar abnormalities could be found in the brains of a population of schizophrenic patients, most of whom were never exposed to neuroleptics. Though statistical analysis of 2808 pyramidal cells failed to reveal significantly greater disorganization in a group of seven alleged schizophrenic brains than in brains of age-matched, nonpsychotic controls, the data suggest a relationship between the degree of pyramidal cell disarray and the severity of behavioral impairment due to psychosis. The implications and pitfalls in interpreting these findings are discussed.

Methylphenidate eliminated mutism in a catatonic schizophrenic after Amytal had failed. Response permitted an adequate clinical evaluation and temporary resumption of eating, self-care and sociability. This suggests that methylphenidate has a useful role in the clinical evaluation of the mute patient who fails to respond to Amytal and that 2 psychopharmacological varieties of catatonic mutism may exist.

The case report describes two 20-year-old monozygotic twin sisters who have been suffering from the symptoms of primary anorexia nervosa for the last 10 years. Usually the disease manifested itself in such a manner that the twin who was currently in the mother's favour showed no signs of anorexia, whereas the other was severely afflicted. Occasionally, however, both girls suffered from the same anorectic symptoms at the same time. For the moment the condition of one of the twins seems to have become stable. Up to now the other twin has suffered three times from schizophrenic episodes which seem to be closely connected with the problems of anorexia. The most recent severe catatonic state, in particular, appeared to be a gradual transition from anorectic behaviour to psychotic experience so that the close relationship between primary anorexia and schizophrenic disturbances, as discussed in literature, becomes increasingly evident.

Pointer dogs learn complex hunting tasks such as vigorous aim-directed activity in tracking specific birds and sudden rigid immobility "on point" at appropriate distance from the prey. In the presence of a human, dogs of the Arkansas Line of Nervous Pointers show markedly reduced activity. In close quarters, where they cannot flee, they usually react to humans by freezing. These responses do not extinguish. The breed demonstrates a strong capacity to inhibit motion. In our nervous dogs, this trait is greatly exaggerated. In the search for an objective and rapidly modifiable target motor sign to correlate with biochemical and pharmacological events, we discovered that 10 of 10 nervous dogs, in contrast to kennel mates of a normal line, developed tonic immobility (TI) which was induced by manual inversion into a sling and stroking. This is the first systematic demonstration of TI in mature dogs. The TI was accompanied by reduced telemetered heart rate (HR) compared to baseline. Release from the inverted position was accompanied by marked HR increase. In the absence of humans, both before and after the inversion, all nervous dogs showed little or no movement about the testing area. This was in contrast to the nine normal line dogs, which were comparable in age and sex. These normal dogs were very active before and after inversion into the sling. Five of the normals remained in the sling but did not show head and neck immobility and were generally relaxed. Their HRs increased slightly while in the inverted position, thereafter returning to baseline. The four normals which righted themselves soon after the inversion showed reduced HR with the resumed activity. We discuss possible mechanisms and review some of the implications for psychiatry and behavioral biology.

A theory of the schizophrenias must take account of the varieties of symptomatology and courses of illness which occur. Neglect of nosography has led to controversy about object relations in the schizophrenias. At the onset of all schizophrenic psychoses real object relations are replaced by 'psychotic' identifications. The object is retained despite its regressed state. Absence of remission and courses to end states can be attributed to loss of the object. This leads to delusional object relations based on fantasy.

Catatonia, which until 1874 was called atonic melancholia, has remained a relative mystery despite many advances in the understanding of schizophrenia. Its typical symptoms are certainly distinctive: a motionless stupor, bizarre posturing, waxen flexibility, religious delusions, stereotyped movements, negativism, loss of will, confusion, and recurrent frenzy (Kahlbaum 1874). The processes which motivate this particular derailment of self and body have been sought in various organic etiologies, with little success. Arieti (1974) proposes several reasons for the paucity of case studies of the treatment of catatonic schizophrenia. First, catatonic schizophrenia has been declining in occurrence. Second, the symptoms themselves, such as mutism and excitement, make verbal therapy extremely difficult. Finally, catatonics often have no memory of their psychotic experiences. Psychotherapists have therefore had to rely on highly personal intuitions of their patients' crisis-in-being. Despite therapists' attention to nonverbal behavior, mutism and stupor are particularly effective hindrances to communication in psychotherapy. Psychotherapy is often not begun until the patient's symptoms ameliorate through chemotherapy and milieu support. The centrality of the verbal medium of communication in psychotherapy suggests that other approaches, using nonverbal media, may be indicated in the study of catatonia. This paper describes a treatment of a catatonic schizophrenic man which utilized movement and drama therapy. These methods were successful in evoking representations of the patient's inner life.

Intravenous diazepam rapidly relieved catatonic immobility in two schizophrenic patients, and oral diazepam maintained this therapeutic effect. Diazepam may be an immediately available and effective treatment for some patients with life-threatening catatonic disorders.

The authors examined the reliability, frequency, concordance, and demographic characteristics of subtypes of schizophrenia in patients from the Iowa 500 study as defined by four major diagnostic systems: DSM-III, Research Diagnostic Criteria (RDC), ICD-9, and the Tsuang-Winokur criteria. Reliability was higher in diagnostic systems with operationalized than in those with unoperationalized criteria and consistently higher for the paranoid subtype. The frequency of individual subtypes varied widely for the different systems. Concordance for subtype diagnoses between systems ranged from quite high to quite low. Demographic characteristics of the individual subtypes were similar according to all systems.

A case of treatment-resistant catatonic stupor responding to combined lithium-neuroleptic medications is described. As there are no reports in the literature of combined lithium-neuroleptic medications being effective for this potentially life-threatening disorder, the course of recovery is detailed and the risks and complications are noted.

All hospital records, interviews, and notes are reviewed on a group of 52 chronic hebephrenic/catatonic schizophrenics who were institutionalized before the era of antipsychotic medications. The authors catalog the presence or absence of individual symptoms of schizophrenia on a year by year basis over a span of 25 years and present this data in a series of bar graphs. Symptoms such as avolition, impaired social interaction, and flat affect become more frequent over the 25 years of follow-up. Hallucinations and delusions become less frequent. Eighteen of the patients are noted to have had a DSM-III personality disorder premorbidly and eight of these are characterized as schizoid personality disorder. Level of insight is found to be poor at the onset of schizophrenia and deteriorates further over the next 5 years. Although the study design contains a sampling bias in favor of chronically institutionalized cases, several lines of evidence suggest that the trends reported here are not artifacts of institutionalization but are due to schizophrenia.