Overview

Catatonia is a severe and disabling condition associated with a range of psychiatric disorders such as schizophrenia and bipolar disorder, as well as other medical conditions including dementia and autism.¹ The symptoms of catatonia vary depending on the individual and include abnormal movement, speech, and behavioural symptoms. Catatonia has historically been associated with psychosis and used to be grouped as a symptom of schizophrenia; however, it is now recognised as a disorder that happens alongside other illnesses.

Catatonia is characterised by the presence of the following symptoms: resistance to movement, lack of speech, withdrawal, refusal to eat, repetitive and purposeless movements, and catalepsy, where the individual will show muscular rigidity and a fixed posture, for example, being stuck in an awkward position with their arms above their head but unable to move.² Catatonia is still poorly understood, and the failure to diagnose and treat it leads to poor outcomes for the individual. This article explains how to diagnose and subsequently treat catatonia.

Understanding catatonia

Catatonia is a serious condition that needs quick treatment. A lack of treatment can lead to problems such as being unable to move for long periods of time and not eating. Understanding catatonia is crucial in improving our ability to diagnose it and developing targeted treatments to prevent further complications. 

What causes catatonia? 

Catatonia is almost always developed after another underlying illness. There are many different causes of catatonia:

• Mental Health Disorders: Conditions like autism, ADHD, schizophrenia, depression, or bipolar disorder can lead to a person developing catatonia³
• Medical Conditions: Certain medical issues, such as infections, autoimmune disorders, or metabolic problems, can cause catatonia⁴
• Neurological Disorders: Brain-related conditions, for example, traumatic brain injuries, epilepsy or strokes, can also lead to catatonia^{5, 6}
• Substance Abuse: The abuse of drugs or alcohol has been identified as a trigger for catatonia in some individuals 

Types of catatonia

Catatonia can present in different ways, with different symptoms depending on the type a person has:

• Withdrawn Catatonia: This is a more common type, where individuals have almost no response to external stimuli, for example, standing or sitting in the same, often odd, position for hours⁵
• Excited Catatonia: Characterised by restlessness, agitation, and excessive movements, individuals are often extremely hyperactive, and aggressive, and may experience delusions and hallucinations⁵
• Malignant Catatonia: People with this type will experience fever, abnormal blood pressure, and confusion, with the condition progressing rapidly and potentially becoming life-threatening. Considered a medical emergency, rapid treatment is essential⁵

Diagnosis of catatonia

To diagnose catatonia, doctors will check for a range of symptoms (typically needing three or more) that can be grouped into three main categories:¹

Motor symptoms

• Stupor: Where the person is not moving and is unresponsive
• Catalepsy: Holding a rigid posture for a long period, even against gravity, for example, holding their arms above their head
• Waxy Flexibility: If someone moves the person’s limbs, they will stay in the new position as if they are made of wax
• Mutism: Not speaking at all, even when spoken to
• Grimacing: Maintaining the same, fixed facial expression

Behavioural symptoms

• Negativism: Not following any instructions or doing the opposite of what is asked
• Posturing: Holding odd or unusual positions
• Mannerisms: Performing repetitive or exaggerated movements
• Stereotypy: Repeated, meaningless movements, like rocking back and forth
• Agitation: Being unusually irritable or aggressive
• Odd mannerisms, such as mimicking someone else’s speech or movements

Autonomic symptoms

• Tachycardia: An unusually fast heart rate
• Hypertension: High blood pressure
• Hyperthermia: High body temperature or a fever

How is catatonia diagnosed?

Doctors will typically use the DSM-5 criteria to diagnose catatonia. It is a manual that includes a checklist of symptoms for different mental disorders, for example, those listed above. Unfortunately, catatonia is underdiagnosed as most patients have an underlying psychiatric disorder which doctors will focus on more, therefore overlooking the symptoms due to the severity of the mental illness they have.

Lots of the common signs of catatonia are also associated with other psychiatric disorders; for example, excited catatonia has similarities to the manic portion of bipolar, or perhaps ADHD. Furthermore, there is no specific way to test for catatonia in a lab. Certain tests can be used to determine the cause, for example, an EEG detecting seizure activity or a CT or MRI scan showing abnormalities in the brain that may cause the condition.⁷ Due to this, catatonia can be commonly misdiagnosed.⁸

Rating scales can also be used, but are not as reliable as other methods. The Bush-Francis Catatonia Rating scale consists of 23 criteria, with the first 14 being used to screen for the disorder. If 2 of the first 14 are positive, further tests can be carried out to complete the remaining 9 to positively identify catatonia.⁹

Ruling out other conditions

Symptoms of catatonia often overlap with those of other conditions, for example:

• Delirium: a sudden change in attention and thinking that can be caused by illness, infections, or medicine
• Neuroleptic malignant syndrome: a life-threatening reaction to some psychiatric medications, where a person may be rigid, feverous, and delirious
• Akinetic mutism: a condition where a person is alert but is unable to move or speak, and seems uninterested in eating or drinking

By examining the patient’s history, medication, and physical exam, doctors can rule out the possibility of other disorders, accurately diagnose catatonia, and begin the correct treatment.

Treatment of catatonia

The first step in treating the condition is to identify and address any potential causes. This might mean stopping certain medicines or treating any existing infections or other health issues. Basic care is essential, for example, making sure the person is getting enough food and water whilst also preventing problems from staying still for too long, such as bed sores.

Medicines to help catatonia

Benzodiazepines

The medicine Lorazepam is often the first medicine doctors choose to try. It helps calm the person down and will quickly reduce the symptoms. The doctor can adjust the amount needed based on how well the medicine works.¹⁰ Most patients will respond very positively to Lorazepam within the first 15–30 minutes of the first dose. This is known as a ‘lorazepam challenge’, where a small dose is given to determine their response, which helps doctors to diagnose the condition. If no improvement is seen, a second dose will be given, and the patient will be examined again. If an improvement is seen, lorazepam can be used at set times until the patient is no longer experiencing catatonia.

Antipsychotics

If benzodiazepines like Lorazepam don’t work, antipsychotics can be used instead. They are typically used to manage psychosis, though they are also used in other psychotic and mood disorders. Doctors will need to monitor their use carefully, as they can have bad side effects.¹¹

Electroconvulsive therapy (ECT)

If medicines don’t help or the catatonia is very severe, electroconvulsive therapy may be used. ECT is a treatment where small electric currents are passed through the brain to help reset its activity. It is usually carried out a few times a week in a hospital until the person gets better.¹² ECT is also commonly used alongside Lorazepam, being far more likely to improve the patient's condition together rather than separately.

It is very important for doctors to keep an eye out for any bad reactions to the treatments so they can be stopped or managed accordingly. 

Other ways to help

Therapy

While medicine is the primary treatment for catatonia, therapy can be crucial in addressing any underlying mental health issues that might contribute to the disorder.

Activity

Having a structured routine and carrying out regular physical exercise can help the person get back to their normal activities over time.

Prognosis and outcomes

Short-term outlook

Most people with catatonia get better with treatment, especially if it’s started early on, with many responding very quickly to medicines like lorazepam or treatments like ECT. After treatment, roughly 25% of people will experience catatonia again in their lives, but with proper care and follow-up, these chances can be reduced.

Long-term outlook

With effective treatment, many people can return to their normal activities and routines. Recovery can vary from person to person, but many see significant improvement. For those with an underlying condition such as schizophrenia or a lack of response to the treatments, the prognosis is much poorer, often requiring continuous long-term mental health care.

Catatonia can impact a person’s quality of life, but with the right support and early intervention, people can manage their symptoms and live fulfilling lives.

Summary

Catatonia is a serious condition that affects movement and behaviour. Understanding the symptoms and getting early treatment is very important for recovery. Medications and therapies can help manage and improve the disorder. Recognising the symptoms early and starting treatment quickly can prevent complications and lead to better outcomes. Ongoing research is essential to better understand catatonia and improve treatments, therefore improving a person’s outcomes.