What are the psychiatric, neurologic, metabolic, infectious, drug‑related, and systemic causes of catatonia?

Causes of Catatonia

Catatonia is a psychomotor syndrome caused by psychiatric disorders (especially mood disorders), neurologic conditions, metabolic derangements, infections, drug-related states, and systemic medical illnesses—with mood disorders being the most common psychiatric cause and benzodiazepine withdrawal being a critical drug-related trigger that requires immediate recognition. 1, 2

Psychiatric Causes

• Mood disorders (bipolar disorder and major depression) are the most common psychiatric causes of catatonia, occurring more frequently than schizophrenia, which was historically overemphasized. 1
• Schizophrenia and schizoaffective disorder remain important psychiatric causes but account for a smaller proportion of cases than previously believed. 1, 2
• Psychotic depression can present with catatonic features, requiring differentiation from primary catatonia. 3

Neurologic Causes

• Cerebrovascular disease (stroke, cerebral venous sinus thrombosis) can precipitate catatonia, particularly in elderly patients. 4, 2
• Seizure disorders, including nonconvulsive status epilepticus and postictal states, are recognized neurologic triggers. 3, 4
• CNS lesions such as brain tumors (oligodendroglioma, glioblastoma, meningioma), congenital malformations, and head trauma can cause catatonia. 3, 4
• Neurodegenerative disorders including Huntington's chorea and lipid storage disorders are documented causes. 3
• Anti-NMDA receptor encephalitis is a prominent autoimmune cause of catatonia that must be considered in new-onset cases. 2
• Autoimmune encephalitis more broadly represents a reversible neurologic cause requiring urgent identification. 5, 4

Metabolic and Endocrine Causes

• Hyponatremia is a specific metabolic derangement reported to induce catatonia. 2
• Endocrinopathies (thyroid dysfunction and other hormonal disorders) can precipitate catatonic states. 3, 5
• Wilson's disease and other metabolic disorders affecting copper metabolism are recognized causes. 3
• Nutritional deficiencies can contribute to catatonia development. 4

Infectious Causes

• CNS infections (encephalitis, meningitis) typically present with fever, altered mental status, and catatonic features, particularly in elderly patients. 3, 4
• HIV-related syndromes can manifest with catatonia. 3
• Systemic infections with sepsis can precipitate delirium with catatonic features. 4
• Urinary tract infections and pneumonia are common infectious precipitants in elderly patients. 5

Drug-Related Causes

Medication-Induced Catatonia

• Corticosteroids (particularly high-dose dexamethasone) can cause acute catatonia with psychotic features, requiring close monitoring when prescribed. 6
• Antipsychotic medications can induce catatonia, and Neuroleptic Malignant Syndrome represents a life-threatening form of drug-induced catatonia. 2
• Stimulants and anticholinergic agents are documented medication triggers. 3

Withdrawal States

• Benzodiazepine withdrawal is a critical cause of catatonia that requires immediate recognition and treatment with benzodiazepines to prevent seizures—the prolonged use increases GABA activity, and discontinuation increases excitatory neurotransmission. 2
• Clozapine withdrawal can precipitate catatonia through similar mechanisms of altered GABA activity. 2
• Alcohol withdrawal states can manifest with catatonic features. 3

Substance Intoxication

• Substances of abuse including amphetamines, cocaine, hallucinogens, phencyclidine, marijuana, and solvents can cause toxic encephalopathies presenting with catatonia. 3
• Heavy metal toxicity is a recognized toxic cause. 3

Systemic Medical Conditions

• Paraneoplastic syndromes associated with malignancy (such as multiple myeloma) can present with catatonia, particularly when corticosteroid treatment is involved. 5, 6
• Liver transplantation and hepatic dysfunction have been reported to induce catatonia. 2
• Neoplasms (brain tumors and systemic cancers) can cause catatonia through direct or paraneoplastic mechanisms. 4

Critical Diagnostic Pitfalls

• Missing benzodiazepine or alcohol withdrawal is life-threatening—these require immediate benzodiazepine treatment to prevent seizures and mortality. 5, 2
• Failing to distinguish catatonia from delirium doubles mortality—catatonia maintains intact consciousness while delirium involves fluctuating awareness, disorientation, and inattention. 5, 4, 7
• In approximately 20-39% of catatonia cases, a somatic (medical) illness is the underlying cause, yet this diagnosis is frequently missed. 6
• Patients with longstanding catatonia or schizophrenia may be less likely to respond to standard benzodiazepine treatment, requiring consideration of electroconvulsive therapy. 1

Age-Specific Considerations

• In elderly patients presenting with catatonia, delirium is the most common cause and must be ruled out first, with infection being a frequent precipitant. 5, 4
• In children and adolescents, substance abuse comorbidity occurs in up to 50% of cases, but if catatonic symptoms persist longer than one week despite documented detoxification, consider a primary psychiatric disorder. 3, 5