Factor analysis of the catatonia rating scale and catatonic symptom distribution across four diagnostic groups

Factor Analysis of the Catatonia Rating Scale and CatatonicSymptom Distribution Across Four Diagnostic Groups

Stephanie Kruger, R. Michael Bagby, Jurgen Hoffler, and Peter Braunig

Catatonia is a frequent psychomotor syndrome,

which has received increasing recognition over the

last decade. The assessment of the catatonic syn-

drome requires systematic rating scales that cover

the complex spectrum of catatonic motor signs and

behaviors. The Catatonia Rating Scale (CRS) is such

an instrument, which has been validated and which

has undergone extensive reliability testing. In the

present study, to further validate the CRS, the items

composing this scale were submitted to principal

components factor extraction followed by a varimax

rotation. An analysis of variance (ANOVA) was per-

formed to assess group differences on the extracted

factors in patients with schizophrenia, pure mania,

mixed mania, and major depression (N � 165). Four

factors were extracted, which accounted for 71.5% of

the variance. The factors corresponded to the clinical

syndromes of (1) catatonic excitement, (2) abnormal

involuntary movements/mannerisms, (3) disturbance

of volition/catalepsy, and (4) catatonic inhibition. The

ANOVA revealed that each of the groups showed a

distinctive catatonic symptom pattern and that the

overlap between diagnostic groups was minimal. We

conclude that this four-factor symptom structure of

catatonia challenges the current conceptualization,

which proposes only two symptom subtypes.

© 2003 Elsevier Inc. All rights reserved.

CATATONIA IS A PSYCHOMOTOR syn-drome, which has received increasing atten-

tion over the last two decades. It has been associ-ated with a variety of mental and medicaldisorders, including schizophrenia, affective disor-ders, and neurological and medical disorders, aswell as with drug-induced syndromes.1,2 While itsprevalence in medical disorders is not known, ithas been reported to occur in up to 13% of adultpsychiatric samples.3-7 The increased interest incatatonia has led to an effort to establish reliablediagnostic criteria for it and three rating scales6,8,9

and a number of checklists10-13 have been devel-oped to facilitate the assessment of catatonia. Al-though many of these scales and checklists havebeen evaluated psychometrically, only two studieshave employed factor analytic procedures.9,13 Thisstatistical method is important, as it allows one toidentify clusters of symptoms or subsyndromes,which can subsequently help delineate more pre-

cisely those components, which compose a clinicalsyndrome.

In this vein, Abrams and Taylor performed afactor analysis on their eight-item catatonia check-list and identified two factors: negativistic stuporand catatonic mania.13 While this investigation wasan important effort toward systematically charac-terizing catatonia, even the authors recognized themethodological limitations of their study, includingthe no-systematic structure of their checklist, thesmall sample size, and the preponderance of pa-tients with affective disorders in their sample. Theydid, however, emphasize the importance of furtherinvestigation of the different “subsyndromes” ofthe catatonic syndrome. Northoff et al.9 performeda factor analysis of the Northoff Catatonia RatingScale (NCRS) after having it administered to 34acutely catatonic subjects. As predicted, four fac-tors were derived, best characterized as affective,hypoactive, hyperactive, and behavioral.

The Catatonia Rating Scale (CRS)6 provides acomprehensive and quantifiable measure of catato-nia, which assesses both frequency and severity ofsymptoms. As such, it can be used diagnosticallyand the score also has the potential to be applied asan outcome measure to assess change in treatmentstudies. It differs from the NCRS in that it does notinclude the relatively unspecific category of affec-tive symptoms, but is restricted to catatonic coresigns and behaviors. The CRS (see Appendix) iscomposed of 21 items. Sixteen items correspond tocatatonic motor symptoms and five correspond tocatatonic behaviors. Ratings range from 0 (absent)to 4 (severe). To reach the diagnostic threshold for

From the Klinik fur Psychiatry, Verhaltensmedizin und Psy-chosomatik am Klinikum Chemnitz, University of Dresden,Dresden, Germany; Department of Psychiatry, Westf. Klinik furPsychiatrie, Psychotherapie, Psychosomatik und Neurologie,University of Witten/Herdecke, Gutersloh, Germany; and theDepartment of Psychiatry, Centre for Addiction and MentalHealth, University of Toronto, Toronto, Canada.

Address reprint requests to Stephanie Kruger, M.D., Klinikfur Psychiatrie und Psychotherapie der UniversitatsklinikDresden, Fetscherstr. 74, 01307, Dresden, Germany.

© 2003 Elsevier Inc. All rights reserved.0010-440X/03/4406-0011$30.00/0doi:10.1016/S0010-440X(03)00108-1

472 Comprehensive Psychiatry, Vol. 44, No. 6 (November/December), 2003: pp 472-482

catatonia, the presence of four or more symptomsmust be rated at least moderate. Previous investi-gation has indicated that the CRS has excellentreliability, with inter-rater agreement (intraclasscorrelations) greater than 0.83 for each item. ACronbach’s alpha of 0.89 indicated that the itemsof the CRS were homogenous and mean inter-itemcorrelations revealed that each item contributedindividually to the total score. The establishment ofreliability indicates that the major contribution toobserved differences in test scores is likely to bedue to real differences in scores rather than inmeasurement error.6

The validity of the CRS has been evaluated indifferent patient populations and in comparisonwith other motor scales and clinician-based diag-noses of catatonia.5,6,15,16

Here, we extend our efforts to establish thevalidity of the CRS by examining its factor struc-ture. To this end, the primary purpose of this studywas to determine if the items composing the CRScorrespond to the symptom structure of catatonia.It was hypothesized that the items of the CRSwould pattern themselves into four distinct symp-tom domains or factors, including (1) catatonicmotor excitement, (2) catatonic motor inhibition,(3) abnormal involuntary movements, and (4) dis-turbance of volition. A subsidiary aim was to ex-amine whether the scales extracted from the factorstructure could differentiate a specific set of psy-chiatric patient groups, in which the specific fea-tures of catatonia are known to occur. This analysisprovides for further evaluation of the validity ofthe CRS.

METHOD

SubjectsThe study was conducted at the Zentrum fur Psychiatrie und

Psychotherapie, University of Bochum, Germany, which is atertiary care center, servicing an area of 200,000 people.

The CRS was routinely administered to a total of 1,424admissions diagnosed according to DSM-IV with schizophre-nia, pure mania, mixed mania, or major depression. The diag-nosis of schizoaffective disorder was an exclusion criterion,because of the symptom overlap between schizophrenia andbipolar disorder with psychotic symptoms. None of the patientshad evidence of neurological disorders. CRS ratings were per-formed by the senior author (P.B.), one of the authors (S.K.,J.H.), or psychiatric residents specifically trained in its use. Bythat method, 167 subjects fulfilled criteria for schizophrenia,152 for mixed mania, 405 for pure mania, and 700 for majordepression. Of these, 164 subjects (11.6%) were identified whofulfilled CRS criteria for a catatonic syndrome (at least four

symptoms rated at least moderate or higher). The number ofcatatonic symptoms rated moderate or higher ranged from 5 to18. The mean CRS score was 34 (SD � 12.6). Among the 164catatonic subjects, 34 fulfilled criteria for schizophrenia, 77 forpure mania, 14 for major depression, and 39 for mixed maniaaccording to the Structured Clinical Interview for DSM-IV.17

The total sample of catatonic subjects comprised 75 femalesand 89 males; the mean age was 38.2 (SD � 15) years. Onsetof illness was 26.5 (SD � 5.0) years for patients with recurrentaffective disorders and 21.3 (SD � 3.4) years for patients withschizophrenia. Bipolar patients had a history of 4 (SD � 6.0)manic/mixed states and 6 (SD � 4.0) depressive episodes.Patients with schizophrenia had a mean number of 11 (SD �7.0) hospitalizations.

All subjects participated voluntarily in the current projectafter informed consent was obtained.

Factor AnalysisIn order to examine the factor structure of the CRS, the 21

items composing this scale were intercorrelated and the result-ing covariance matrix was submitted to prinicpal componentsfactor extraction followed by a varimax rotation. Scree tests,eigenvalue criteria (i.e., �1.00) and parallel analyses were usedto determine the number of factors for rotation. Any itemloading greater than 0.40 was considered significant.18 An anal-ysis of variance (ANOVA) was performed to assess for overallgroup differences for the three groups of patients describedabove. Differences between patient groups were assessed usingthe Scheffe test for unplanned comparisons (P � .05).

RESULTS

Factor Analysis

The Kaiser-Meyer-Olkim of sampling adequacy(KMO) was 0.709, suggesting the matrix was suit-able for factor analysis.18 Eigenvalue greater than1.0 and scree test criteria indicated the relativesuitability of either a four- or five-factor solution.The parallel analysis routine19 indicated that nomore than five factors could be reliably extracted.To this end, both four and five factors were rotatedto a varimax solution. The five-factor model ac-counted for 75.9% of the variance. However, thefifth factor in this solution accounted for less than5% of the variance (4.4%) and was composed ofonly two items with significant factor loadings—mannerisms and rituals; moreover, only one ofthese items (rituals) loaded uniquely on this fifthfactor. Based on these latter results, we consideredthis factor to be “trivial”18 and a four-factor solu-tion was accepted as the most suitable. The four-factor model accounted for 71.5% of the variance.

Table 1 displays the four factors and their re-spective significantly loading items. Factor 1 waslabeled “catatonic excitement“ and included theitems verbigerations, motor excitement, iterations,

FACTOR ANALYSIS OF THE CATATONIA RATING SCALE 473

groping, and impulsivity. It accounted for 39.6% ofthe variance. Factor 2 was labeled “abnormal in-voluntary movements/mannerisms“ and comprisedblinking, stereotypies, grimacing, jerky move-ments, and mannerisms. It accounted for 14.1% ofthe variance. Factor 3 was labeled “volitional dis-turbance/catalepsy“ and included rituals, waxyflexibility, automatic obedience, exaggerated re-sponsiveness, posturing, and negativism. It ac-counted for 11.8% of the variance. Factor 4 waslabeled “catatonic inhibition“ and comprised rigid-ity, motor inhibition, mutism, gegenhalten, andparakinesias. It accounted for 6.2% of the variance.Some items had significant loadings on more thanone factor; these items were attributed to the factorfor which they loaded the highest.

ANOVA for Group Differences

Next, we examined for group differences amongand between the three groups of patients on thefour-factor scales derived from the factor analysis.The scales were calculated by summing the residu-alized factor weights for each item as derived fromthe varimax rotation. There was a significant over-all effect for all four factors with F values rangingfrom 9.64 (factor 2) to 47.77 (factor 1) with Pvalues for all analyses less than .001. Table 2displays the means, standard deviations, and test ofsignificance for each of the four factors across thethree patient groups. Catatonic schizophrenia wasdistinct from other diagnoses by primarily exhib-iting symptoms represented in factors 2 and 3

Table 1. Rotated Factor Loadings for the 21-Item CRS

Items Factors

Factor 1 Factor 2 Factor 3 Factor 4

Verbigerations .841 .171 �.146 .182Motor excitement .848 .102 .114 �.056Impulsivity .830 �.065 .183 .171Iterations .658 .440 �.104 .399

Groping .597 .418 .296 .200Blinking .492 .557 �.117 .010Stereotypies .520 .659 .124 .299Rigidity .073 .012 �.113 .805

Motor inhibition .103 .188 �.055 .872

Mutism .039 .196 .385 .808

Gegenhalten .282 �.048 .462 .712

Parakinesias .117 .062 .366 .519

Grimacing .247 .851 .215 .128Jerky movements .050 .770 .379 .014Mannerisms .018 .676 .351 .074Rituals �.120 .478 .559 �.015Waxy flexibility .089 .247 .828 .050Automatic obedience .048 .202 .695 .051Exaggerated responsiveness .211 .534 .570 .203Posturing �.042 .145 .730 .194Negativism .306 �.003 .524 .502

NOTE. Item loadings are bolded at a significance level of �.40.

Table 2. Means, Standard Deviations, and Test of Significance for Each of the Four Factors Across Patient Groups

Variable

Patient Group

F (2, 65)

Schizophrenia (n � 34) Pure Mania (n � 77) Major Depression (n � 14) Mixed Mania (n � 39)

Mean SD Mean SD Mean SD Mean

Factor 1 �.39ac .85 .40bd .95 �.49ac .73 .62bd .94 11.63*Factor 2 .86ad 1.36 �.49bc .59 �.45bc .64 .60ad 1.18 22.12*Factor 3 1.55a 1.24 �.22bd .43 .47c 1.11 �.63bd .69 55.73*Factor 4 .16abd 1.24 �.44ab .69 2.12c .79 .20ad .62 38.36*

NOTE. Means and standard deviations are weighted factor scores. Higher scores represent greater severity of symptoms. Groupswith similar superscripts did not differ from one another (P � .01). *P � .001.

474 KRUGER ET AL

(abnormal involuntary movements/mannerismsand volitional disturbance/catalepsy). Catatonicmania was most significantly represented by theitems in factor 1 (catatonic excitement) and cata-tonic depression was characterized by the itemsrepresented by factor 4 (catatonic inhibition),whereas catatonic mixed mania was distinct fromthe other groups by exhibiting items represented byfactors 1 and 2 (catatonic excitement and abnormalinvoluntary movements/mannerisms).

DISCUSSION

To further evaluate the psychometric propertiesof the CRS, this scale was subjected to principalcomponents analysis and an ANOVA was per-formed comparing the different diagnostic patientgroups (schizophrenia, pure mania, major depres-sion, and mixed mania) across the four extractedfactors. Factor analysis can provide two types ofinformation. It adds evidence for the constructvalidity of the scale itself and it complementsclinical knowledge by outlining the pattern ofthose symptoms, which the scale is intended toassess.

The CRS items patterned themselves into fourfactors or syndromes that were predicted: (1) cata-tonic excitement, (2) abnormal involuntary move-ments/mannerisms, (3) volitional disturbance/cata-lepsy, and (4) catatonic inhibition. This findingindicates that the CRS is comprised of four do-mains related to the catatonic syndrome. The fourfactors are an indicator of the multidimensionalityof the catatonic syndrome. Previous research hasconceptualized catatonia as being composed of twotypes: excited and retarded.13 Abrams et al.14 foundthat their checklist was composed of two factors.Factor 1 comprised the items mutism, negativism,and stupor and corresponded to the clinical syn-drome of negativistic stupor. Factor 2 comprisedthe items mutism, stereotypy, catalepsy, and auto-matic obedience and was associated with catatonicmania. There are, however, some limitations asso-ciated with the design of this previous factor anal-ysis. The checklist comprises only eight catatonicitems and as such may not capture comprehen-sively the entire range of catatonic symptomatol-ogy. In addition, the checklist does not provide aseverity rating format, i.e., symptom ratings aresimply based on the presence or absence of a

catatonic symptom. The patient sample used in thisstudy had a preponderance of patients with cata-tonic affective disorder and may thus not have hadenough power to detect symptom patterns in pa-tients with catatonic schizophrenia and other dis-orders. However, our findings suggest that theremay be as many as four symptom clusters associ-ated with catatonia. Northoff et al.9 have alsofound a four-factor solution for their catatonia rat-ing scale and these factors comprised affective,hypoactive, hyperactive, and behavioral compo-nents. This confirms the assumption that the syn-drome of catatonia is not sufficiently characterizedby the two types (excited v retarded), because theyonly cover the motor aspects of the syndrome.

Our finding that catatonia occurs in more thantwo dimensions is supported by clinical observa-tions and documentation of catatonia in the pub-lished literature. These sources have consistentlyidentified several subtypes of catatonia, each asso-ciated with a specific symptom pattern comprisingprincipal and secondary symptoms.20-28

The ANOVA provided some interesting findingsabout the patterns of catatonic symptom distribu-tion across diagnoses. The schizophrenic patientgroup scored highest on factor 3—the volitionaldisturbance/catalepsy factor—and also on factor2—the abnormal involuntary movements/manner-isms factor. Patients with pure mania scored high-est on factor 1—the catatonic excitement factor;patients with depression scored highest on factor4—the catatonic inhibition factor—whereas pa-tients with mixed mania scored highest on factors1 and 3. These findings suggest that the catatonicsymptom profile may vary across disorders andthat the overlap regarding shared symptoms is lim-ited. This assumption is confirmed by the findingof negative weighted factor scores in all four dis-orders. The results also support earlier observa-tions that catatonia in schizophrenia is pre-dominantly characterized by grimacing, jerkymovements, mannerisms, rituals, exaggerated re-sponsiveness, and posturing,20,21,24,27,29,30 whereascatatonic mania is associated with catatonic excite-ment, iterations, blinking, groping, verbigerations,and impulsivity.21-23,25

Historically, mixed mania with catatonic fea-tures was termed “stereotyped-iterative catato-nia.”22,23 This wording reflects the predominant


catatonic symptoms seen in mixed mania. It issupported by the results of our factor analysis, inwhich high loadings on factors 1 and 2 (catatonicexcitement and abnormal involuntary movements/mannerisms) were associated with mixed mania.

Depression with catatonic symptoms was pri-marily observed in association with stupor, mut-ism, and motor inhibition.20,21 These symptomswere represented by factor 4, which had the highestloading in patients with major depression.

Very few recent studies have attempted to verifythese earlier observations on the catatonic symp-tom profile in affective disorders5,31 by assessingthe type and frequency of catatonic symptoms inthese disorders and none have been performed toinvestigate whether there is a distinct symptompattern of catatonia in schizophrenia.

In summary, our results suggest that catatoniaas measured by the CRS consists of four symp-tom domains, and that each of these four do-mains or a combination thereof is associatedwith a specific disorder. While at this stage, ourresults are still tentative and need to be repli-

cated in larger studies, they have important clin-ical implications. There is evidence that 30%of all patients demonstrating catatonic symp-toms do not respond to treatment with eitherlorazepam or electroconvulsive therapy (ECT)32

and that contrary to acute catatonic symptomsof excitement and inhibition, which in mostcases respond to either lorazepam or ECT,7,8,32-38

chronic catatonia is reported to respond poorlyto these treatments.39 It would be of interestto investigate whether the group of treatmentnonresponders exhibits a specific symptompattern, consistent with factors 2 or 3 of theCRS.

A limitation of our study includes that patientswith organic brain disorders or with medical dis-orders with catatonia were not represented in oursample. In this respect, it would be important todetermine whether catatonia in these disorders alsoexhibits a specific symptom pattern. This mightprovide clues as to the brain pathology underlyingcatatonia and might lead to a more refined under-standing of this syndrome.

Appendix 1: CATATONIA-RATING SCALE (CRS)

InstructionsThis checklist is designed to rate the overall severity of catatonic symptoms across a range of dimensions (number, frequency,

and severity). The scale comprises 16 catatonic motor symptoms and 5 catatonic behavioral symptoms (21 items). Thepresence and severity of each of the motor symptoms and behaviors is rated during a 45-min semistructured examination.Ratings of behavioral symptoms are confirmed or modified by obtaining observations by one or more third parties wheneveravailable (nurses, spouses, family members). This procedure is to ensure that behaviors, which are complex actions andmanifest under various circumstances, are thoroughly observed and reliably rated. In circumstances where third parties arenot available, the clinician will assign a score based on his/her examination only. All items are scored absent (0), minimal (1),moderate (3), or severe (4). Catatonia is confirmed by ratings of 2 or more in at least 4 items.

Definitions and rating procedures

CATATONIC MOTOR SYMPTOMS

1. Groping Restless movements of hands and/or fingers. Playing with hands and/or fingers, perplexedtouching of one’s body or objects. Tugging at bedsheet or clothes. Trying to toucheverything within touching distance.

2. Stereotypies Simple or complex, uniform, repetitive,apparently purposeless movements oractions (movements/gestures of head,arms, hands, trunk, toe, foot, or leg;rubbing, crossing oneself, rotating) carriedout for long periods of time. Movementsappear to be under relatively littlevoluntary control.

3. Iterations Rhythmic, repetitive movements, e.g., rockingmotion of head, upper body, foot, or lowerleg, rhythmic twisting of lower arms.

476 KRUGER ET AL

4. Verbigerations Stereotyped repetition of words or phrases.To score items 1–4 use the following rating format:

Absent Symptom not present.Minimal Symptom occurs for up to 2 min in total during

45 minute examination.Moderate Symptom occurs for more than 2 min, but not

for more than 10 min in total during 45-minexamination.

Marked Symptom occurs for more than 10-min, but notfor more than 20 min in total during 45-minexamination.

Severe Symptom occurs for more than 20 min in totalduring 45-min examination.

5. Grimacing Maintainence of odd facial movements,hyperkinetic (short, simple, rapid) ordystonic (longer lasting, complex, slow).May involve a single facial muscle, amuscle group or many facial muscles atonce.

6. Jerky movements Simple, abrupt and rapid movements ofhead, shoulder, arms or hands. Frequentlyassociated with expressive movements.

To score items 5–6, use the following rating format:

Absent Symptom not present.Minimal Symptom is sustained for up to 10 sec at a

time.Moderate Symptom is sustained for up to 30 sec at a

time.Marked Symptom is sustained for up to 60 sec at a

time.Severe Symptom is sustained for more than 60 sec at a

time.7. Posturing Spontaneous, habitual and stereotyped

maintainence of postures. Includes mundanepostures (e.g., sitting, standing), or odd,bizarre, socially inappropriate postures. Bycontrast to rigidity, muscular tone is limp.

8. Rigidity Maintainence of a fixed position withmarkedly decreased or absentspontaneous movements. By contrast toposturing, there is a perceptible increasein muscular tone.


Absent Symptom not present.Minimal Symptom is sustained for up to 2 min at a time.Moderate Symptom is sustained for up to 10 min at a

time.Marked Symptom is sustained for up to 20 min at a

time.Severe Symptom is sustained for more than 20 min at

a time.9. Blinking Increased blinking rate.

Absent Symptom not present.Minimal Rate more than 30/min.Moderate Rate more than 50/min.Marked Rate more than 70/min.Severe Rate more than 90/min.


10. Motor excitement Generalized, uniform, apparently nonpurposeful motor activity, not attributed to akathisia orgoal directed activity.

Absent Symptom not present.Minimal Intermittent motor excitement. Patient can

easily be calmed down for over 5 min byrater’s intervention.

Moderate Moderate motor excitement. Can be interruptedfor 3 to 5 min by rater’s intervention.

Marked Pronounced motor excitement. Can beinterrupted for under 3 min.

Severe Intense excitement and outbursts continuewhen intervention is attempted.

11. Motor inhibition A state of hypoactivity. Voluntary acts are performed with delay, very slowly, or not at all.Absent Symptom not present.Minimal Decreased motor activity. Eye contact, eye

movements and spontaneous reactions arestill present. Patient may sit still, but interactswith rater. Performs simple tasks (getting up,sitting down). Reacts to painful stimuli.

Moderate Pronounced decrease and slowing ofspontaneous movements. No eye contact.Eye movements still present. Simple tasks(getting up, sitting down) are performed veryslowly. Delayed reaction to painful stimuli.

Marked No spontaneous interactions with outsideworld. Some eye movements. Tasksperformed extremely slowly. Slow reaction tointense painful stimuli.

Severe Stuporous, no interaction with outside world.Very few or no eye movements (staring).Minimal, or no reaction to intense painfulstimuli.

12. Exaggeratedresponsiveness, copying

The symptom comprises three aspects:Mitgehen/mitmachen: Exaggerated

movements in response to light pressure.Gegengreifen: Repeated inviting gestures

(e.g., extending one’s hands) despiteinstructions to the contrary.

Echophenomena: Mimicking of another’s movements, gestures, expressions, postures orspeech.

Absent Symptom not present.Minimal Mitgehen/mitmachen or gegengreifen or

echophenomena can be induced by repeatedintervention.

Moderate Mitgehen/mitmachen or gegengreifen or echo-phenomena can be promptly induced byrater’s intervention or occur spontaneously

Marked Two of the symptoms can be promptly inducedby rater’s intervention or occurspontaneously.

Severe All symptoms can be promptly induced byrater’s intervention or occur spontaneously.

478 KRUGER ET AL

13. Gegenhalten Resistance to passive movements, apparently not willful. May remain restricted to certainbody parts (e.g., stiffening of neck or upper body, fist clenching, shutting of eyes ormouth), but may also affect the whole body. Jaws, eyelids, mouth, neck, upper body, fists,flexors, and adductors are predominantly affected. The resistance increases proportional tothe external pressure.

Absent Symptom not present.Minimal Symptom occurs spontaneously or as a reaction

to repeated passive movements. Symptom isrestricted to one body part and can easily beinterrupted by rater’s intervention.

Moderate Symptom occurs spontaneously, affects morethan one body part and can be interrupted byrater’s intervention.

Marked Symptom occurs spontaneously, affects morethan one body part and cannot be interruptedby rater’s intervention.

Severe Symptom occurs spontaneously, affects morethan three body parts or the whole body andcannot be interrupted by rater’s intervention.

14. Parakinesia All voluntary movements, including gait are awkward, disconnected or appear bizarre.Absent Symptom not present.Minimal Movements appear mildly awkward and

clumsy.Moderate Movements appear disrupted and noticeably

awkward.Marked Movements appear distorted and disjointed.Severe Movements appear bizarre. Complete loss of

individual style of motion.15. Waxy flexibility Patient may be passively moved and will remain even in uncomfortable positions until

muscles are tired or patient is again moved into a different position. During positioning ofthe patient, a “waxy” muscular resistance may be felt.

Absent Symptom not present.Minimal Symptom is sustained for up to 10 sec at a

time.Moderate Symptom is sustained for up to 20 sec at a

time.Marked Symptom is sustained for up to 30 sec at a

time.Severe Symptom is sustained for more than 30 sec at a

time.16. Mutism Verbally unresponsive or minimally responsive when spoken to (no organic speech

impediment).Absent Symptom not present.Minimal Slightly reduced rate of spontaneous speech

with intermittent periods of delayed responseor verbal unresponsiveness. Intonation islow.

Moderate Noticeably reduced rate of spontaneous speech,with longer periods of verbal unresponsive-ness. “Telegraphic-style” answers, andincomprehensible whispers.

Marked No spontaneous speech. Verbally unresponsiveto most questions. One-word answers.

Severe Neither spontaneous nor responsive speech.CATATONIC BEHAVIORAL SYMPTOMS

17. Mannerisms A set of behaviors characterized by an odd,stilted, ornate or circumstantial caricatureof normal actions or behaviors.


18. Automatic A set of behaviors characterized byexaggerated compliance, obediencesuggestibility and tendency to affirm.Patient obligingly follows requests and isexcessively polite and submissive.

19. Negativism A set of behaviors characterized byapparently motiveless active or passiveresistance to requests or instructions.Patient may even do the opposite of whatis requested. External pressure to performa task or comply with an instruction is metby refusal, hostility, dysphoria, oraggressive behavior (e.g., refusal to eat, todrink, to communicate or to interact).

20. Impulsiveness Patient exhibits sudden acts of inappropriatebehavior, often accompanied byrestlessness or motor excitement. Acts areoften characterized by loss of control andmay be aggressive or self-aggressive.Patient may also show frenzied motoractivity or start screaming, he may take offhis clothes, binge on uneatable things, ormay be sexually disinhibited.

21. Rituals Monotonous, driven, and stereotypedrepetition of complex behaviors andpatterns of action. The habitual repetitionof behaviors and actions is performed ona regular daily basis. Patient does notresist the compulsion to perform the sameact repeatedly and he does not feeldistressed by it. Patient actively resistsattempts to stop him from performing therituals.


Absent Behavior not present.Minimal Behavior occurs for up to 5 min at a time.Moderate Behavior occurs for more than 5 min but not

more than 15 min at a time. Interactions aresomewhat impaired.

Marked Behavior occurs for more than 15 min but notmore than 30 min at a time. Interactions areconsiderably impaired.

Severe Behavior occurs for more than 30 min at a time.Interactions are seriously impaired.

Additional comments on items 8, 9, 10, 19 and 20:

Item 8 (jerky movements):

In 1874, Kahlbaum described involuntary movement disorders. They were subsequently reported by many other traditionalauthors (Wernicke, 1900; Kraepelin, 1913; Kleist, 1908, 1934; Bleuler, 1911: Mayer-Gross, 1932; Leonhard, 1957). The authorsused various terms to describe the spectrum of involuntary movement disorders (pseudospontaneous movements, pseudo-expressive movements, involuntary hyperkinetic movements, uniform restlessness).

Items 9 and 19:

Kraepelin (1899; 1913; 1916) described an abnormal suggestibility of will in catatonia. He differentiated between a motor aspect(echophenomena, abnormal motor suggestibility � Gegengreifen, Mitgehen) and a behavioral aspect (automatic obedience).

Kahlbaum (1874) observed a tendency to imitate behaviors in catatonia.Item 9 (Nachahmungs-, Anstoßautomatie):Why are Gegengreifen, Mitgehen, and Echophenomena subsumed under one item?Traditional authors regarded these catatonic symptoms as closely related (Kraepelin 1899, 1913, 1916; Kleist, 1908, 1934;

Leonhard 1957, 1986). The spectrum of echophenomena was called Nachahmungsautomatie by Kraepelin (1899, 1913, 1916).Mitgehen and Gegengreifen were regarded as symptoms of abnormal motor suggestibility and were called Ansto�automatie(Kleist, 1908, 1934).

480 KRUGER ET AL

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Item 19 (automatic obedience):This term describes the behavioural aspect of abnormal suggestibility of volition.Items 10 and 20:

Catatonia was defined as a disturbance of volition accompanied by an instinctive resistance to external influence (Kahlbaum,1874; Kraepelin, 1899, 1913, 1916; Bleuler, 1911; Kleist, 1908, 1934). The instinctive resistance was regarded as having a motor(Gegengreifen) and a behavioral aspect (negativism).

Item 10 (Gegenhalten):This symptom is also called motor negativism (Kleist, 1934).Item 20 (negativism):Negativism may occur spontaneously or in response to an external stimulus.It may affect some or all behaviors.Examples of negativism include:–Social situations:

-refusing contact-averting one’s head or not establishing eye-contact when spoken to-not shaking hands when being greeted-absence of positive judgement of people or positive assessment of situations-inability to agree-refusal to participate in social situations-resistance to follow instructions

-Ambivalence or inability to make a decision-Refusal to eat, to drink or to swallow-Befehlsnegativismus: patients do the opposite of what is requested of them


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Factor analysis of the catatonia rating scale and catatonic symptom distribution across four diagnostic groups