Catatonic stupor after “ecstasy”BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6930.717b (Published 12 March 1994) Cite this as: BMJ 1994;308:717
EDITOR, - D L Maxwell and colleagues report two cases of catatonic stupor in patients who had taken 3,4-methylenedioxymethamphetamine (“ecstasy”).1 I doubt whether the patients exhibited sufficient features to justify the diagnosis of catatonic stupor.
Catatonia is a behavioural neurological syndrome characterised by abnormal motor behaviour and periods of extreme hyperactivity and hypoactivity.2 Mutism and stupor are common, but alone they are not pathognomonic. Several organic conditions associated with catatonia have been reported, but the catatonias were often not diagnosed according to strict criteria.3
To aid research and communication a consensus definition of diagnostic criteria for the catatonic syndrome is desirable. According to diagnostic guidelines in the International Classification of Diseases, tenth revision, organic catatonic stupor is a state (of assumed organic aetiology) of diminution or absence of spontaneous movement with partial or complete mutism, negativism, and rigid posturing; the presence of other catatonic phenomena such as stereotypies or waxy flexibility increases confidence in the diagnosis.4 Interestingly, specific operational criteria for catatonia, as a separate category, have also been suggested for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.5
The first patient reported on by the authors was drowsy and could be roused but was uncommunicative. She responded appropriately to pain but not to command. She intermittently opened her eyes but did not respond to or recognise anyone. This is a picture of organic (neurological) stupor, which may be associated with the absence of verbal response - mutism, when the subject aroused is incapable of normal alertness and interaction. There were no catatonic features other than stupor and mutism. The second patient became restless and uncommunicative after taking 3,4-methylenedioxymethamphetamine. She was apparently conscious. She did not speak. At times she sat up20and moved about spontaneously with a “wild eyed” look. She was not stuporous in the neurological or psychiatric sense. In psychiatric practice stupor is regarded as a syndrome whose central feature is a reduction in or absence of relational function (that is, action and speech). There were no catatonic features other than mutism. The diagnosis of catatonic stupor therefore seems unjustified in both cases.