Sir: Catatonia has been a poorly understood syndrome since psychodynamic theory struggled to explain its symptoms in the first half of the past century. The persistence of the nosologic confusion surrounding catatonia, malignant catatonia and neuroleptic malignant syndrome (NMS) is well illustrated by Carey et al's confused and uncertain case study (Psychiatric Bulletin, February 2002, 26, 68-70).

Did their patient have ‘no history of catatonia’ or did he suffer from ‘persistent stereotypies, mannerisms… dyskinesia and… dystonia’? Both statements cannot be true! It is unsurprising that in such a patient, with a possible history of encephalitis, the administration of high dose, high potency neuroleptics precipitated the malignant syndrome. This is a well-recognised clinical scenario. The association of catatonia with general medical conditions was emphasised by Kahlbaum in 1874 and has been reviewed in detail more recently (Reference Philbrick and RummansPhilbrick & Rummans, 1994; Reference Clark and RickardsClark & Rickards, 1999).

The important points to remember are:

1. (a) catatonia may be simple (motor symptoms only) or malignant (motor symptoms together with hyperthermia or autonomic instability)

2. (b) neuroleptic (and some other) medications may exacerbate simple catatonia and precipitate malignant catatonia, in which case it may be termed the NMS

3. (c) the most effective treatments for the catatonic syndrome are benzo-diazepines or electroconvulsive therapy.

A fuller, clinically orientated review, including a suggested management plan, has been provided by Clark and Rickards (Reference Clark and Rickards1999), while other authors have usefully considered the nosologic and dimensional status of the syndrome (for example, Reference Mann, Caroff and BleierMann et al, 1986; Reference Singerman and RahejaSingerman & Raheja, 1994; Reference FinkFink, 1996). It is unfortunate that Carey et al's discussion fails to aid understanding of a condition that is often iatrogenic and, as they point out, occasionally fatal.