Catatonia: Definition, Diagnosis, and Management
Catatonia is a syndrome of primarily psychomotor disturbances characterized by the occurrence of several symptoms including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia. 1
Clinical Presentation and Subtypes
Catatonia presents with distinct motor, affective, and cognitive-behavioral signs that can last from hours to days. There are two main subtypes:
- Retarded catatonia: Characterized by immobility, mutism, staring, rigidity, and other inhibitory signs 2
- Excited catatonia: Less common presentation featuring prolonged periods of psychomotor agitation 2
The syndrome is no longer regarded as merely a subtype of schizophrenia but is now recognized as an independent diagnosis in the ICD-11 since 2022 3. Catatonia can occur in association with:
- Psychiatric disorders (particularly affective disorders)
- Medical conditions (especially neurological disorders)
- Medication side effects
- Substance use or withdrawal
Epidemiology
Catatonia is more common than previously thought:
- Found in 5-18% of psychiatric inpatients
- Present in 3.3% of medical inpatients 3
- Overall prevalence estimated at 9.2% across various settings 4
Diagnosis
Diagnosis requires recognition of key clinical features. At times, differentiating between Parkinson's side effects and catatonia may be difficult 1. The condition is often underdiagnosed, putting patients at risk for life-threatening complications 3.
Key diagnostic features include:
- Stupor (profound unresponsiveness)
- Catalepsy (passive induction of posture)
- Waxy flexibility (slight, even resistance to positioning)
- Mutism (minimal or no verbal response)
- Negativism (resistance to instructions or passive movements)
- Posturing (spontaneous maintenance of posture)
- Mannerisms and stereotypies (repetitive movements)
- Psychomotor agitation
- Grimacing
- Echolalia (pathological repetition of words)
- Echopraxia (imitation of movements)
The use of validated rating scales is recommended to measure severity and response to treatment 4.
Differential Diagnosis
Important conditions to differentiate from catatonia include:
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Malignant hyperthermia
- Delirium
- Parkinsonism
- Acute psychosis without catatonia
Workup
Once catatonia is identified, a systematic diagnostic evaluation ("Catatonia Workup") should be performed to identify underlying causes 4, including:
- Metabolic disorders
- Traumatic injuries
- Infections
- Degenerative conditions
- Autoimmune disorders
- Drug-related causes
- Psychiatric conditions
Treatment
Prompt treatment is essential to avoid complications like dehydration or deep vein thromboses 5. The three cornerstones of therapy are:
Benzodiazepines: First-line treatment
- Lorazepam and diazepam are most commonly used
- Most patients respond rapidly to low-dose benzodiazepines 2
Electroconvulsive therapy (ECT):
- Indicated when benzodiazepines fail
- Particularly effective for severe or malignant catatonia
- Should be administered in a specialized setting with appropriate monitoring 1
NMDA antagonists:
Additional options include dopamine-modulating second-generation antipsychotics like clozapine and aripiprazole for specific patient populations 3.
Prognosis
With early recognition and appropriate treatment, the prognosis for catatonia is generally favorable. However, patients with longstanding catatonia or a diagnosis of schizophrenia may be less likely to respond to treatment 2. Untreated catatonia carries significant morbidity and mortality risks 2.
Clinical Pearls
- Catatonia must often be treated before any underlying conditions can be accurately diagnosed 2
- Maintain a high index of suspicion for this syndrome, as it is common and highly treatable
- Patients with catatonia may be at risk for complications such as dehydration, malnutrition, and thromboembolism
- The syndrome can be confused with other conditions like delirium or primary psychotic disorders
- Treatment should address both the catatonic symptoms and the underlying illness 6