Malingering
When a patient is intentionally or purposefully producing catatonic symptoms, this is classified as malingering (if associated with material gain) or factitious disorder (if not associated with material gain). 1
Key Diagnostic Distinction
The critical differentiating factor between true catatonia and intentionally produced symptoms is motivation and intentionality:
- Factitious disorder: Symptoms are intentionally created but are NOT associated with material gain 1
- Malingering: Symptoms result in material gain (disability benefits, avoiding legal consequences, obtaining housing, etc.) 1
- True catatonia: Symptoms are NOT intentionally produced 1
Clinical Recognition Framework
Distinguishing intentionally produced catatonic symptoms from genuine catatonia is clinically challenging and crucial, as these conditions require fundamentally different treatments and the iatrogenic complications from treating factitious catatonia with high-dose benzodiazepines and electroconvulsive therapy are significant. 2
Red Flags for Intentional Production
Look for these specific clinical observations that suggest intentional symptom production:
- Inconsistent presentation: Multiple episodes of spontaneous purposeful movement when the patient is not under direct supervision of staff 2
- Selective symptom display: Symptoms that appear or disappear based on who is observing 2
- Lack of treatment response: Lorazepam ineffective at consistently reversing apparent catatonic symptoms (though this alone is not diagnostic) 2
- Pattern of healthcare utilization: History suggesting factitious disorder in available medical records 2
Genuine Catatonia Features
True catatonia presents with 1, 3, 4:
- Psychomotor disturbances including stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, psychomotor agitation, grimacing, echolalia, and echopraxia 1
- Consistent presentation across different observers and settings 3
- Rapid response to benzodiazepines (particularly lorazepam) in most cases 3, 4
Critical Clinical Pitfall
Rapid access to electronic health records is essential when evaluating patients who cannot provide medical history, especially when factitious disorder or malingering is in the differential diagnosis, as this can prevent unnecessary and potentially harmful treatments. 2