Catatonia, a complex neuropsychiatric condition characterized by a wide spectrum of motor, behavioral, and affective abnormalities, has long challenged psychiatrists and clinicians regarding its classification and diagnosis. Recent advances and revisions in the International Classification of Diseases, 11th Revision (ICD-11), mark a pioneering shift in how the psychiatric community conceptualizes and approaches catatonia. This overhaul offers clearer diagnostic criteria and reflects a more nuanced understanding of the disorder, shedding light on its diverse clinical manifestations and underlying conditions. These changes are poised to transform clinical practice and research around catatonia globally.
Originally described by the German psychiatrist Karl Kahlbaum in 1874, catatonia was initially framed as a distinct syndrome with characteristic motor abnormalities and behavioral symptoms. However, following Emil Kraepelin’s early 20th-century work, catatonia became entangled within the broader diagnostic umbrella of dementia praecox, today known as schizophrenia. This Kraepelinian influence persisted for decades and influenced the editions of the ICD up to ICD-9, which exclusively classified catatonia as a subtype of schizophrenia. This psychiatric framework obscured the recognition of catatonia in other diagnostic categories and limited therapeutic options.
The transition from ICD-9 to ICD-10 brought some advancement by introducing the diagnosis of “organic catatonic disorder,” acknowledging that catatonia could emerge secondary to medical conditions. Despite this, ICD-10 did not fully incorporate emerging evidence from clinical studies showing catatonia’s prevalence and relevance in mood disorders, autism spectrum disorders, and other psychiatric illnesses. This constrained approach left clinicians grappling with ambiguous boundaries and inconsistent treatment approaches, underscoring the need for a more robust diagnostic framework.
The release of ICD-11 represents a paradigm shift. Catatonia is now conceptualized as an independent disorder with a characteristic clinical phenotype, transcending rigid diagnostic categories. This contemporary view acknowledges catatonia’s occurrence across a wide range of psychiatric and medical conditions. Crucially, ICD-11 diagnostic guidelines emphasize the presence of at least three distinct clinical features that capture changes in psychomotor activity, which may be decreased, increased, or abnormal in quality. This more flexible and symptom-focused approach enhances the ability to detect catatonia accurately and promptly.
Importantly, the ICD-11 criteria stipulate that only one symptom from the increased psychomotor activity category should be counted, refining the threshold for diagnosis and avoiding over-diagnosis. This subtle yet critical adjustment underscores the precision with which catatonic signs must be identified, promoting diagnostic specificity. The proposed framework includes four diagnostic subtypes: catatonia associated with another mental disorder, catatonia induced by substances or medication, secondary catatonia syndrome linked to general medical conditions, and catatonia unspecified. These categories capture the clinical heterogeneity of catatonia and facilitate tailored clinical management.
This refined classification brings ICD-11 more closely in line with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), which similarly acknowledges catatonia’s association with a wide range of psychiatric and medical illnesses. By harmonizing criteria with DSM-5-TR, ICD-11 promotes international consistency in clinical diagnosis, research, and epidemiological tracking of catatonia, a previously elusive entity. The crosswalk between these systems fosters collaboration and advances evidence-based treatment paradigms.
Beyond diagnostic criteria, ICD-11 offers nuanced guidance to distinguish catatonia from overlapping conditions with superficially similar motor or behavioral features. For example, psychomotor retardation in depressive disorders and delirium manifestations often resemble catatonic signs, yet require entirely different clinical approaches. Recognizing factitious disorder as a differential diagnosis further sharpens diagnostic accuracy. This emphasis on differential diagnosis enhances clinical precision and reduces misdiagnosis risks that can compromise patient outcomes.
One of the most promising implications of ICD-11’s revised catatonia classification lies in improved clinical recognition and consequent treatment. Historically, under-recognition of catatonia has hindered timely intervention, despite the availability of effective treatments such as benzodiazepines and electroconvulsive therapy (ECT). Clarifying diagnostic boundaries enables earlier identification and rapid initiation of appropriate therapies, which can dramatically improve patient prognosis, reduce morbidity, and lower healthcare costs.
This evolution in classification also offers fertile ground for future research directions. The expanded diagnostic framework encourages exploration into the neurobiological and genetic underpinnings of catatonia across diverse patient populations. Understanding pathophysiological mechanisms that traverse traditional diagnostic silos opens avenues for novel therapeutics and personalized medicine. ICD-11’s inclusive approach anticipates integrative research that may illuminate the shared and distinct substrates of catatonic presentations.
Furthermore, ICD-11’s reconceptualization acknowledges the multidimensional nature of catatonia, capturing motor, behavioral, and affective elements within a unified diagnostic framework. This holistic perspective challenges clinicians to consider catatonia beyond isolated motor phenomena, embracing its complex and dynamic symptomatology. Emphasizing clinical heterogeneity facilitates more comprehensive assessment and fosters nuanced interventions addressing broad symptom domains.
Clinically, these advances encourage multidisciplinary collaboration among psychiatrists, neurologists, general physicians, and allied health professionals. The recognition of catatonia in diverse settings—psychiatric wards, general hospitals, and intensive care units—requires broad-based awareness and training. ICD-11 guidance equips healthcare providers with standardized language and criteria, promoting early consultation and integrated care pathways that optimize patient outcomes.
As healthcare systems worldwide begin to implement ICD-11, the ripple effects on education, policy, and clinical practice will be profound. Standardized documentation and coding of catatonia will improve epidemiological surveillance and resource allocation. Policymakers may harness this data to prioritize training initiatives and research funding. Ultimately, the updated classification offers a framework not just for diagnosis but for fundamentally reshaping the clinical and scientific landscape of catatonia.
The reconceptualization presented by ICD-11 is thus more than a mere diagnostic update; it reflects a maturation in psychiatric nosology that acknowledges complexity and heterogeneity without sacrificing clinical utility. By providing a rigorous yet flexible criteria set, ICD-11 invites a broader appreciation of catatonia’s place within neuropsychiatry, encouraging a departure from outdated paradigms. This shift stands to enhance patient care, inspire research innovation, and propel the field toward more precise, compassionate, and effective mental health practice.
In summary, ICD-11’s revised catatonia classification represents a landmark development in psychiatric diagnostics. By disentangling catatonia from schizophrenia-centric views, incorporating a symptom-based diagnostic framework, aligning with contemporary manuals, and emphasizing differential diagnosis, ICD-11 paves the way for improved recognition, treatment, and innovation. This enhanced understanding holds the promise of transforming outcomes for patients worldwide afflicted by this enigmatic yet treatable syndrome.
Subject of Research: Catatonia classification and diagnostic criteria revisions in ICD-11
Article Title: Catatonia in ICD-11
Article References:
Rogers, J.P., Wilson, J.E. & Oldham, M.A. Catatonia in ICD-11. BMC Psychiatry 25, 405 (2025). https://doi.org/10.1186/s12888-025-06857-6
Image Credits: AI Generated