Can catatonic symptoms come and go even without benzodiazepine (BZD) treatment?

Can Catatonic Symptoms Fluctuate Without Benzodiazepine Treatment?

Yes, catatonic symptoms can spontaneously wax and wane without benzodiazepine treatment, though this natural fluctuation is unpredictable and potentially dangerous given the high morbidity and mortality risk of untreated catatonia.

Natural Course and Spontaneous Resolution

• Catatonia can exhibit a variable course with symptoms that come and go, particularly when associated with underlying mood disorders or schizophrenia 1.
• In bipolar disorder specifically, catatonic features may appear during severe depressive or manic episodes and can fluctuate as the mood episode evolves, with some cases progressing to catatonia during severe presentations 1.
• The syndrome's presentation can range from stupor to agitation with prominent disturbances of volition, and these manifestations may shift over time even without intervention 2.

Critical Clinical Considerations

The unpredictability of untreated catatonia makes observation without treatment extremely risky. While symptoms may theoretically remit spontaneously, several factors make this approach dangerous:

• Life-threatening complications can develop rapidly, including refusal to eat or drink, severe metabolic derangements, and autonomic instability 1.
• Catatonia requires immediate recognition and treatment to prevent significant morbidity or mortality 3.
• Benzodiazepines (particularly lorazepam) and ECT remain the mainstays of treatment with high efficacy rates—combined treatment achieved 100% resolution in one case series 4.

Withdrawal-Induced Fluctuations

• Benzodiazepine withdrawal itself can precipitate or worsen catatonia in susceptible individuals, particularly those with mood disorders 3.
• Sudden benzodiazepine discontinuation or non-adherence can lead to loss of response or need for higher doses, demonstrating that the medication actively suppresses catatonic symptoms rather than simply masking naturally fluctuating symptoms 5.
• Some patients require indefinite benzodiazepine maintenance following failed tapering attempts, with relapses occurring when medication is stopped 5.

Practical Management Algorithm

Do not wait for spontaneous resolution. When catatonia is identified:

1. Immediate benzodiazepine challenge: Start lorazepam (typically 1-2 mg IV/IM) as both diagnostic and therapeutic intervention 4, 6.
2. If response occurs: Continue benzodiazepines and address underlying psychiatric or medical condition 6.
3. If inadequate response: Add ECT, which combined with benzodiazepines shows superior outcomes 4.
4. For refractory cases: Consider NMDA antagonists after lorazepam failure 6.

Common Pitfalls

• Never assume catatonic symptoms will spontaneously resolve without treatment—the risk of life-threatening complications is too high 1.
• Do not confuse parkinsonian side effects from antipsychotics with catatonia, as both can present with similar motor symptoms 1.
• Avoid discontinuing benzodiazepines abruptly once catatonia has responded, as this can trigger severe rebound catatonia, delirium, and seizures 3.