Catatonia is a neuropsychiatric syndrome characterized by psychomotor, neurological, and behavioral abnormalities — most commonly presenting with mutism, stupor, staring, and posturing. [1] It is diagnosed clinically when ≥3 of 12 DSM-5-TR features are present, and it requires urgent recognition because delayed treatment can lead to life-threatening malignant catatonia. [1-2]
1. History
- Key HPI questions: Onset and tempo of psychomotor changes (acute vs. insidious); recent medication changes (especially antipsychotic initiation/dose change, benzodiazepine or clozapine withdrawal); substance use (cannabis, cocaine, alcohol, opioids) [1]
- Symptom characterization: Decreased speech output (mutism), decreased movement (stupor), fixed gaze (staring), maintenance of unusual postures, repetitive purposeless movements (stereotypies), echoing speech/actions (echophenomena) [1]
- Timing/triggers: Can emerge within hours (acute) or over days to weeks; may recur periodically; postpartum period, infections (especially UTIs in elderly), and substance intoxication/withdrawal are common precipitants [1]
- Associated symptoms: Refusal to eat/drink, incontinence, rigidity, waxy flexibility, negativism (resistance to passive movement or instructions) [1]
- Important negatives: Absence of fever, diaphoresis, recent neuroleptic exposure (to differentiate from NMS); absence of serotonergic drug exposure (to differentiate from serotonin syndrome) [1][3]
2. Alarm Features
- Malignant catatonia: Hyperthermia, tachycardia, labile blood pressure, diaphoresis, rigidity — carries significant mortality if untreated [1-2]
- Neuroleptic malignant syndrome (NMS): Lead-pipe rigidity, fever >38°C, autonomic instability in the setting of dopamine-blocking agent exposure [3-4]
- Elevated CK suggesting rhabdomyolysis and risk of renal failure [1][3]
- Refusal of oral intake leading to dehydration, malnutrition, aspiration risk [1]
- Seizure-like movements or focal neurologic signs suggesting anti-NMDA receptor encephalitis or structural lesion [1][5]
- Rapid deterioration despite lorazepam — warrants urgent ECT consideration [5-6]
3. Medications
- First-line treatment: Lorazepam (IV preferred; 2 mg for lorazepam challenge test, 1 mg in children/elderly/respiratory-compromised). Maintenance dosing up to 16 mg/day, sometimes higher in chronic catatonia or schizophrenia [1][5]
- Second-line: Amantadine, memantine (NMDA receptor antagonists) [1]
- ECT: For benzodiazepine-refractory cases or malignant catatonia — response rates 80–100% [5]
- Medication contributors/causes: Antipsychotics (especially first-generation/high-potency), benzodiazepine withdrawal, clozapine withdrawal, pembrolizumab [5][7]
- Contraindicated/caution: Dopamine antagonists (antipsychotics) can worsen catatonia and precipitate NMS — hold or avoid if catatonia is suspected. If antipsychotics are needed for co-occurring psychosis, second-generation agents (especially clozapine) are preferred over first-generation [1]
- Maintenance: Benzodiazepine taper should be slow (10–25% per day inpatient, up to 25% per week outpatient); maintenance ECT may be needed for chronic/recurrent cases [5]
4. Diet
- Acute management: Ensure adequate hydration and nutrition — patients with stupor/mutism frequently refuse oral intake [1]
- IV fluids and NG tube feeding may be necessary in severe cases
- Monitor electrolytes closely given risk of dehydration and metabolic derangement
5. Review of Systems
- Neurologic: Seizures, focal deficits, tremor, asterixis, headache
- Psychiatric: Mood symptoms (mania, depression), psychotic symptoms (hallucinations, delusions), prior catatonic episodes
- Autonomic: Fever, diaphoresis, tachycardia, blood pressure lability
- GI/GU: Dysphagia, urinary incontinence or retention
- MSK: Rigidity, muscle pain (rhabdomyolysis)
- Infectious: Recent illness, UTI symptoms (especially in elderly) [1]
6. Collateral History and Family History
- Collateral is essential: Patients are often mute — obtain history from family, caregivers, outpatient providers regarding baseline function, psychiatric diagnoses, medication list, recent changes, substance use [1]
- Family history: Mood disorders, schizophrenia, autism spectrum disorder — all associated with catatonia [1]
- Social context: Living situation, substance access, recent psychosocial stressors, perinatal status in women of childbearing age [1]
7. Risk Factors
- Psychiatric disorders: Mood disorders (most common association), schizophrenia, autism spectrum disorder, dementia [1]
- Medical conditions: Anti-NMDA receptor encephalitis, metabolic encephalopathy, focal cerebral lesions, infections [1][5]
- Substances: Cannabis and cocaine intoxication; alcohol, opioid, and benzodiazepine withdrawal [1]
- Medications: Antipsychotic use (especially high-potency FGAs), benzodiazepine/clozapine discontinuation [5][7]
- Demographics: Younger age and male sex identified as predictors in some studies [8]
- Peripartum period: Postpartum psychosis is a recognized precipitant [1]
8. Differential Diagnosis
- Neuroleptic malignant syndrome: Lead-pipe rigidity, hyperthermia, autonomic instability after dopamine-blocking agent exposure [3][5]
- Serotonin syndrome: Serotonergic drug exposure, hyperreflexia, clonus, diaphoresis, fever [1]
- Anti-NMDA receptor encephalitis: Psychiatric symptoms, seizures, dyskinesias, autonomic instability; may have incomplete lorazepam response [5]
- Delirium: Fluctuating attention/cognition — can co-occur with catatonia [1][9]
- Non-convulsive status epilepticus: Requires EEG to differentiate [5]
- Acute psychosis without catatonia [1]
- Akinetic mutism/abulia: Frontal lobe lesions [10]
- Locked-in syndrome: Preserved consciousness with quadriplegia and anarthria (pontine lesion) [10]
- Stiff-person syndrome, late-stage Parkinson disease [10]
- Substance intoxication mimicking catatonia (cannabis, PCP, cocaine) [1]
9. Past Medical History
- Prior catatonic episodes (recurrence is common)
- Psychiatric diagnoses: bipolar disorder, schizophrenia, major depression, autism spectrum disorder
- History of NMS
- Autoimmune conditions (risk for autoimmune encephalitis)
- Neurodevelopmental disorders
- Recent hospitalizations, ICU stays (delirium overlap) [1-2]
10. Physical Exam
- Vital signs: Temperature, HR, BP (look for autonomic instability suggesting malignant catatonia or NMS) [1]
- Motor exam: Rigidity (lead-pipe vs. waxy flexibility), posturing, catalepsy (passively position a limb and observe if held against gravity), gegenhalten (oppositional resistance to passive movement) [1]
- Behavioral observation: Staring, mutism, stereotypies, grimacing, echolalia/echopraxia, mannerisms, negativism, withdrawal [1]
- Neurologic exam: Assess for focal deficits, clonus, hyperreflexia (serotonin syndrome), tremor, asterixis
- Standardized assessment: Bush-Francis Catatonia Rating Scale (BFCRS) — score ≥2 on the 14-item screening instrument is positive [5]
The following figure shows the prevalence of individual BFCRS signs across adult and pediatric populations, highlighting that staring is the most common sign (~78%), followed by immobility/stupor and mutism: [11]
11. Lab Studies
- All patients: CBC, CMP, creatine kinase (CK — monitor serially for rhabdomyolysis), urinalysis [1]
- Rule out medical causes: TSH, ammonia, blood glucose, LFTs, toxicology screen, blood cultures if febrile [5]
- If autoimmune encephalitis suspected: Anti-NMDA receptor antibodies (serum and CSF), CSF studies [5]
- NMS workup: CK (often markedly elevated ≥4× ULN), WBC (leukocytosis common), renal function, myoglobin [3-4]
- Monitoring parameters: Serial CK, electrolytes, renal function, vital signs [1]
12. Imaging
- First-line: Brain MRI preferred over CT — may reveal inflammation, cytotoxic edema, or space-occupying lesions; CT is unlikely to significantly inform care except to rule out acute hemorrhage [5]
- When to image: First-lifetime episode, focal neurologic signs, suspicion for structural lesion or encephalitis [1][5]
- When imaging is unnecessary: Recurrent catatonia with known psychiatric etiology and prior adequate workup, unless new focal findings emerge [5]
13. Special Tests
- Lorazepam challenge test (LCT): 2 mg IV lorazepam → reassess BFCRS at 5–30 minutes; ≥50% reduction = positive response, supporting diagnosis and guiding treatment. A positive response can occur within minutes of IV administration [1][5]
- Bush-Francis Catatonia Rating Scale (BFCRS): 23-item clinician-administered scale; 14-item screening version includes all DSM-5-TR criteria [5]
- EEG: Rule out non-convulsive status epilepticus; extreme delta brush pattern is pathognomonic for anti-NMDA receptor encephalitis [5]
- Lumbar puncture: When autoimmune encephalitis is suspected — guided by clinical picture, ideally in collaboration with neurology [5]
14. ECG
- Indications: Baseline ECG in all patients, especially if autonomic instability is present
- Monitor for: QTc prolongation (relevant if antipsychotics are being used or considered), arrhythmias from electrolyte derangements (hypokalemia, hypomagnesemia from dehydration/poor intake)
- Pre-ECT: ECG is part of standard pre-ECT evaluation
15. Assessment
- Clinical summary: Catatonia is a clinical diagnosis requiring ≥3 of 12 DSM-5-TR features. It exists on a spectrum from mild (subtle psychomotor slowing) to life-threatening malignant catatonia [1][5]
- Severity stratification: Use BFCRS serially to track severity and treatment response. Malignant catatonia is defined by autonomic instability (fever, tachycardia, BP lability) superimposed on catatonic features [2][5]
- Typical presentation: Mutism + stupor + staring in the ED; may present with fluctuating psychomotor states or with stereotypies in patients with autism/schizophrenia [1]
- Complications: DVT/PE (immobility), aspiration pneumonia, pressure ulcers, rhabdomyolysis, renal failure, malnutrition, dehydration, death [1]
16. Treatment Plan
- Initial stabilization: ABCs, IV access, continuous monitoring of vitals, ensure hydration/nutrition, DVT prophylaxis, pressure ulcer prevention [1]
- Lorazepam challenge: 2 mg IV → if positive, continue scheduled IV lorazepam (e.g., 2 mg q6–8h), titrate up as needed (max ~16 mg/day, sometimes higher). Maintain IV for 24–48 hours after improvement before transitioning to PO [5]
- Benzodiazepine response rates: Overall remission ~55%, overall response ~77%; median effective dose 8 mg/day lorazepam [12]
- If no response in 7 days or malignant features present: Initiate ECT — bilateral electrode placement preferred, thrice weekly; daily sessions for severe/malignant cases. Response rates 80–100% [1][5]
- Hold dopamine antagonists — if antipsychotics are necessary for psychosis, use second-generation agents (clozapine preferred, <150 mg/day for chronic catatonia) [1]
- Second-line pharmacotherapy: Amantadine or memantine as adjuncts [1]
- Treat underlying cause: Autoimmune encephalitis → immunotherapy; substance withdrawal → appropriate management; mood disorder → mood stabilizers after catatonia resolves [1]
- Supportive care: Thromboembolism prophylaxis, infection prevention, contracture prevention, nutritional support [1]
17. Disposition
- Admission criteria: All new-onset catatonia warrants admission; malignant catatonia requires ICU-level care [2][6]
- Observation: Patients with mild catatonia responding briskly to lorazepam challenge may be managed on a psychiatric unit with close monitoring
- Discharge criteria: Resolution of catatonic signs on stable oral benzodiazepine regimen, adequate oral intake, stable vitals, underlying cause addressed or plan in place [5]
- Specialist consultation triggers:
- Psychiatry: All cases
- Neurology: Focal deficits, seizure concern, suspected autoimmune encephalitis [5]
- Critical care/ICU: Malignant catatonia, autonomic instability, need for intubation [2]
- ECT service: Benzodiazepine-refractory or malignant catatonia [5]
18. Follow Up / Return Precautions
- Follow-up timing: Psychiatry follow-up within 1 week of discharge; sooner if on high-dose benzodiazepine taper [5]
- Benzodiazepine taper: Slow — 10–25% per day inpatient, up to 25% per week outpatient; premature discontinuation risks catatonia recurrence [5]
- Return precautions (patient/family counseling):
- Return immediately for: fever, new rigidity, refusal to eat/drink, decreased responsiveness, confusion, autonomic symptoms (racing heart, sweating)
- Monitor for recurrence: slowed speech, decreased movement, staring, posturing [1]
- Expected recovery: Most acute catatonia responds within days to lorazepam; chronic catatonia (especially with schizophrenia/autism) may require months of treatment including maintenance ECT and/or clozapine [1][5]
- Maintenance therapy: Ongoing benzodiazepines and/or maintenance ECT recommended for chronic or recurrent catatonia [5]
References
1. Catatonia. — Heckers S, Walther S. The New England Journal of Medicine. 2023.
2. Malignant Catatonia: A Review for the Intensivist. — Connell J, Oldham M, Pandharipande P, et al. Journal of Intensive Care Medicine. 2023.
3. Neuroleptic Malignant Syndrome. — Wijdicks EFM, Ropper AH. The New England Journal of Medicine. 2024.
4. Diagnostic and Statistical Manual of Mental Disorders. — Dilip V. Jeste, Jeffrey A. Lieberman, David Fassler, et al American Psychiatric Association (2022). 2022.
5. Resource Document on Catatonia. — Jo Ellen Wilson, Mark A. Oldham, Andrew Francis, et al American Psychiatric Association (2025). 2025.
6. A Case Report of Malignant Catatonia in a Patient With Apparent Intoxication. — Theobald T, Sayed O, Pettis C, Klinger JA, Baker SP. The American Journal of Emergency Medicine. 2026.
7. What Clinical Analysis of Antipsychotic-Induced Catatonia and Neuroleptic Malignant Syndrome Tells Us About the Links Between These Two Syndromes: A Systematic Review. — Virolle J, Redon M, Montastruc F, et al. Schizophrenia Research. 2023.
8. A Prospective Descriptive Study on Prevalence of Catatonia and Correlates in an Acute Mental Health Unit in Nelson Mandela Bay, South Africa. — Zingela Z, Stroud L, Cronje J, Fink M, Van Wyk S. PloS One. 2022.
9. Resource Document on Acute Neuropsychiatric Sequelae of COVID-19 Infection. — Scott Beach, Nadia Cacodcar, Erica Baller, Jon Levenson American Psychiatric Association (2023). 2023.
10. Catatonia: American Psychiatric Association Resource Document. — Wilson JE, Oldham MA, Francis A, et al. Journal of the Academy of Consultation-Liaison Psychiatry. 2025.
11. The Catatonia Quick Screen ( CQS ): A Rapid Screening Tool for Catatonia in Adult and Pediatric Populations. — Luccarelli J, Kalinich M, Wilson JE, et al. Acta Psychiatrica Scandinavica. 2025.
12. The Effect of Benzodiazepines on Catatonia: A Systematic Review and Meta-Analysis. — Bot L, Schotsman B, Oostra E, et al. Acta Psychiatrica Scandinavica. 2026.