CatatoniaMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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690 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp62

Immediate priorities

›Airway and breathing assessment

›Aspiration risk from stupor or mutism

›Inability to handle secretions

›Absent gag reflex

›Respiratory compromise in malignant catatonia

›Hyperthermia driving tachypnea

›Muscular rigidity limiting chest expansion

›If unable to protect airway, proceed to definitive airway management

›Rapid sequence intubation preparation

›Avoid succinylcholine if prolonged immobility or rhabdomyolysis suspected

›Circulation and autonomic instability

›Malignant catatonia triggers

›Temperature > 38.5 C

›Heart rate > 120 beats per minute

›Labile blood pressure

›IV access and volume resuscitation

›Two large bore peripheral IVs

›Isotonic crystalloid for dehydration from oral refusal

›Hemodynamic monitoring targets

›MAP >= 65 mmHg

›Urine output >= 0.5 ml/kg/hour

Malignant catatonia recognition

›Malignant catatonia features

›Hyperthermia

›Temperature > 38.5 C or higher

›Distinguishing from NMS: both carry overlapping features

›Autonomic instability

02History/hx70

Presenting symptoms

›Core psychomotor features

›Mutism

›Complete absence of speech or near-total verbal output reduction

›Duration of onset

›Stupor

›Marked decrease in reaction to environment

›Unresponsive to verbal or painful stimuli in severe cases

›Staring

›Most prevalent BFCRS sign (~78% prevalence)

›Fixed gaze unresponsive to visual stimulation

›Posturing

›Maintenance of unusual positions against gravity

›Catalepsy present

›Stereotypies

›Repetitive purposeless movements

›Non-goal directed behavior

Symptom timeline and triggers

›Onset and tempo

›Acute onset within hours

›NMS and substance-related causes

›Sudden benzodiazepine or clozapine withdrawal

›Subacute over days to weeks

›Mood disorder or psychosis-related catatonia

›Autoimmune encephalitis

›Recurrent episodic pattern

›Prior catatonic episodes suggest psychiatric etiology

›Frequency and duration of prior episodes

03Physical Exam/exam64

Vital signs and general appearance

›Vital sign targets and alarm thresholds

›Temperature

›Hyperthermia > 38.5 C suggests malignant catatonia or NMS

›Temperature trending upward is an escalation trigger

›Heart rate

›Tachycardia > 120 beats per minute with fever suggests malignant catatonia

›Bradycardia in patients on beta-blockers may mask tachycardia

›Blood pressure

›Labile BP (wide swings) suggests autonomic instability

›Hypotension from dehydration due to oral refusal

›Respiratory rate

›Tachypnea with fever and rigidity in malignant catatonia

›General appearance

›Level of responsiveness to environment

›Degree of psychomotor slowing vs. agitation

›Signs of dehydration from oral refusal

Motor examination

›Rigidity assessment

›Waxy flexibility (catalepsy)

›Passively position limb and observe if held against gravity

›Distinct from lead-pipe rigidity of NMS

›Gegenhalten (paratonia)

›Oppositional resistance to passive movement proportional to examiner force

›Distinguishable from voluntary resistance

›Lead-pipe rigidity

›Uniform resistance throughout range of motion

›Suggests NMS overlap or malignant catatonia

04Differential Diagnosis/ddx51

Life-threatening mimics

›Neuroleptic malignant syndrome

›ICD-10 G21.0

›Lead-pipe rigidity, hyperthermia, autonomic instability after dopamine-blocking agent

›CK markedly elevated >= 4x upper limit of normal

›Overlap with malignant catatonia possible

›Non-convulsive status epilepticus

›ICD-10 G41.2

›Requires EEG to differentiate from catatonia

›May present with staring, mutism, and unresponsiveness

›Anti-NMDA receptor encephalitis

›ICD-10 G04.81

›Psychiatric prodrome, seizures, orofacial dyskinesias, autonomic instability

›Incomplete lorazepam response common

›CSF anti-NMDA receptor antibodies diagnostic

›Malignant catatonia itself

›ICD-10 F20.2 or mood-related code depending on underlying etiology

›Highest mortality if untreated

Psychiatric mimics

›Acute psychosis without catatonia

›ICD-10 F29

›Agitation, hallucinations, delusions without psychomotor features

›BFCRS score < 2

›Severe major depressive episode

›ICD-10 F32.2

›Psychomotor retardation without full catatonic features

›Stiff-person syndrome

›ICD-10 G25.82

05Laboratory Tests/lt43

Core workup

›Complete blood count

›Leukocytosis in NMS and malignant catatonia

›Leukopenia with autoimmune or viral causes

›Anaemia as concurrent finding

›Comprehensive metabolic panel

›Electrolytes for metabolic encephalopathy (sodium, potassium, magnesium)

›Renal function as rhabdomyolysis complication monitor

›Hepatic panel for encephalopathy assessment

›Glucose to exclude hypoglycaemia

›Creatine kinase

›Key marker for rhabdomyolysis in prolonged immobility or rigidity

›>= 4x upper limit of normal associated with NMS and malignant catatonia

›Serial monitoring every 6 to 12 hours if elevated

Extended medical workup

›Thyroid stimulating hormone

›Thyroid storm and hypothyroid encephalopathy as rare causes

›Ammonia

›Hepatic encephalopathy consideration

›Toxicology screen

›Urine and serum for substance-related causes

›Specific testing for PCP, cannabis, cocaine, opioids

›Blood cultures

›Febrile patient with autonomic instability

›Before empiric antibiotics if infection suspected

Autoimmune and CSF workup

›Anti-NMDA receptor antibody panel

›Serum and CSF testing recommended when suspected

06Diagnostic Tests/dt80

Scoring Systems

›Bush-Francis Catatonia Rating Scale (BFCRS)

›23-item clinician-administered scale

›14-item screening version includes all DSM-5-TR criteria

›Score >= 2 on screening version positive for catatonia

›Serial scoring tracks treatment response

›Staring is most prevalent sign (~78% across adult and pediatric populations)

›DSM-5-TR diagnostic criteria

›Clinical diagnosis requiring >= 3 of 12 features

›Features include: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, agitation, grimacing, echolalia, echopraxia

›Specifier added to underlying psychiatric or medical diagnosis

›Catatonia Quick Screen (CQS)

›Rapid bedside screening tool validated in adult and pediatric populations

›Derived from BFCRS items

›Useful in emergency settings with time constraints

›Lorazepam Challenge Test (LCT)

›2 mg IV lorazepam administered

›Reassess BFCRS at 5 to 30 minutes post-administration

›>= 50% reduction in BFCRS score is positive response

›Positive response confirms diagnosis and guides treatment

›Response can occur within minutes of IV administration

MRI

›Brain MRI indications in catatonia

›First-lifetime episode of catatonia

›Preferred over CT for superior soft tissue characterization

›Rule out structural lesion, encephalitis, demyelination

›Focal neurologic signs on examination

›Any lateralizing motor or sensory findings

›Suspected autoimmune encephalitis

›FLAIR hyperintensity in limbic structures supports anti-NMDA receptor encephalitis

›Medial temporal lobe signal change in LGI1 encephalitis

›MRI findings in specific conditions

›Anti-NMDA receptor encephalitis

›FLAIR cortical or subcortical signal changes (often subtle or absent)

›Hippocampal signal change possible

›Structural catatonia

›Focal infarct, tumour, or demyelinating lesion

›Normal MRI does not exclude catatonia or autoimmune encephalitis

›Clinical diagnosis remains primary

›MRI protocol considerations

›DWI sequence for cytotoxic edema

›FLAIR for inflammatory and encephalitic changes

›Gadolinium contrast for leptomeningeal or parenchymal enhancement

›Sedation may be required given psychomotor disturbance

›CT head indications

›Rapid assessment when MRI not immediately available

›Rule out acute intracranial hemorrhage

›Identify gross structural lesion or hydrocephalus

›Acute first episode with focal neurologic signs

›Bridge to MRI when MRI delayed

›Pre-ECT assessment

›Structural lesion exclusion before ECT

›Contraindication to ECT if elevated intracranial pressure

›CT limitations in catatonia

›CT is unlikely to significantly inform care in most catatonia cases

›Low sensitivity for early encephalitis

›Low sensitivity for limbic system changes

›CT body if paraneoplastic syndrome suspected

›Chest-abdomen-pelvis CT for occult malignancy

›Teratoma is associated with anti-NMDA receptor encephalitis in young women

Ultrasound

›Pelvic ultrasound

›Anti-NMDA receptor encephalitis is strongly associated with ovarian teratoma

›Transvaginal ultrasound preferred in females of reproductive age

›Identification and removal of teratoma is part of definitive treatment

›Point-of-care ultrasound (POCUS) for hemodynamic assessment

›IVC assessment in dehydrated patients from oral refusal

›Cardiac function in patients with autonomic instability

›Fluid responsiveness assessment before volume loading

›Ultrasound-guided procedures

›IV access guidance when peripheral access difficult in rigid patient

›Central venous access if required for monitoring or medication delivery

EEG

›EEG indications

›Rule out non-convulsive status epilepticus

›May be indistinguishable clinically from catatonia

›Suspected anti-NMDA receptor encephalitis

›Extreme delta brush pattern is pathognomonic for anti-NMDA receptor encephalitis

›Generalized slowing common in encephalitis

›Failure to respond to lorazepam

›Consider EEG to exclude epileptic encephalopathy

›EEG interpretation in catatonia

›Normal EEG does not exclude catatonia

›Nonspecific slowing may reflect underlying metabolic or encephalitic etiology

07Disposition/dispo40

Admission criteria

›All new-onset catatonia requires inpatient admission

›Diagnostic workup cannot be safely completed outpatient

›Monitoring for lorazepam response and escalation required

›Oral refusal, dehydration, and DVT risk require inpatient management

›Psychiatric inpatient unit indications

›Catatonia with clear psychiatric etiology (mood disorder, schizophrenia)

›Positive lorazepam challenge with rapid improvement

›Hemodynamically stable, no fever or autonomic instability

›Medical inpatient unit indications

›Medical cause under investigation (encephalitis, metabolic)

›Elevated CK requiring IV fluid management

›Comorbid medical illness requiring concurrent management

ICU indications

›Malignant catatonia features

›Hyperthermia > 38.5 C with autonomic instability

›Hemodynamic instability requiring vasopressors

›Rhabdomyolysis with renal compromise

›Airway compromise

›Inability to protect airway

›Aspiration event or high aspiration risk

›Mechanical ventilation requirement

›ECT delivery in ICU setting

›Available in facilities with appropriate anesthesia support

›Bilateral electrode placement for severe or malignant cases

Transfer criteria

›Transfer to tertiary center triggers

›ECT service not available at admitting facility

08Treatment/t109

Initial stabilization

›Supportive care bundle

›IV access and hydration

›Isotonic normal saline for dehydration from oral refusal

›Rate guided by urine output and electrolytes

›DVT prophylaxis

›Low molecular weight heparin from day 1

›Sequential compression devices if anticoagulation contraindicated

›Pressure ulcer prevention

›Repositioning every 2 hours

›Protective padding for bony prominences

›Nutritional support

›NG tube feeding if oral intake refused

›Nutrition consultation for prolonged catatonia

Lorazepam challenge and titration

›Lorazepam challenge test

›2 mg IV lorazepam for adults

›1 mg IV in children, elderly, or respiratory-compromised patients

›Reassess BFCRS at 5 to 30 minutes

›Positive response (>= 50% BFCRS reduction)

›Continue scheduled IV lorazepam

›Initiate 2 mg IV every 6 to 8 hours

›No response to initial challenge

›Repeat challenge at higher dose (up to 4 mg)

›Consider alternative diagnoses

›Lorazepam maintenance dosing

›Standard titration range 4 to 16 mg per day

›Median effective dose ~8 mg/day based on meta-analysis

›Some cases require higher doses especially in chronic catatonia

›Maintain IV route for 24 to 48 hours after initial improvement

›Then transition to oral lorazepam at equivalent dose

›Benzodiazepine response rates

›Overall remission rate ~55%

›Overall response rate ~77% (Bot et al., Acta Psychiatrica Scandinavica 2026)

›Alternative benzodiazepines if lorazepam unavailable

›Diazepam IV 5 to 10 mg

›Longer half-life with active metabolites

›Clonazepam 0.5 to 2 mg PO or IV

›Useful for maintenance and taper

Electroconvulsive therapy (ECT)

›ECT indications

›No response to adequate lorazepam trial (7 days at therapeutic doses)

›Malignant catatonia with fever and autonomic instability

›ECT initiation should not await lorazepam failure in life-threatening cases

›Life-threatening complications (severe aspiration, renal failure from rhabdomyolysis)

›ECT protocol

›Bilateral electrode placement preferred for catatonia

›Higher efficacy vs. unilateral in catatonic presentations

›Frequency

›Thrice weekly for standard cases

›Daily sessions for severe or malignant catatonia

›Response rates 80 to 100% (NEJM 2023)

›Number of sessions

›Initial course typically 6 to 12 sessions

›Maintenance ECT for chronic or recurrent catatonia

›Pre-ECT checklist

›Brain imaging to exclude elevated intracranial pressure

›ECG for QTc and arrhythmia assessment

›Anaesthesia consultation and clearance

›Hold anticholinergic agents that increase seizure threshold

Medication management

›Dopamine antagonists

›Hold all antipsychotics when catatonia suspected

›Antipsychotics can worsen catatonia

›Risk of precipitating or worsening NMS

›If antipsychotic required for underlying psychosis

›Second-generation agents preferred over first-generation

›Clozapine preferred for chronic catatonia

›Dose < 150 mg/day for catatonic patients

›Monitor ANC and metabolic parameters

›Second-line pharmacotherapy

›Amantadine

›100 mg PO every 8 to 12 hours

›NMDA receptor antagonist mechanism

›Adjunct when benzodiazepine response incomplete

›Memantine

›5 mg PO daily, titrate to 10 to 20 mg daily

›NMDA receptor antagonist

›Particularly useful in autism-related catatonia

›Medications to avoid

›First-generation antipsychotics (haloperidol, fluphenazine)

›High-potency dopamine D2 blockade worsens catatonia

›Metoclopramide and droperidol

›Dopamine antagonist antiemetics carry same risk

›Rapid benzodiazepine tapering

›Premature withdrawal risks catatonia recurrence

Treatment of underlying cause

›Autoimmune encephalitis

›First-line immunotherapy

›IV methylprednisolone 1000 mg daily for 3 to 5 days

›IV immunoglobulin 2 g/kg over 5 days

›Plasma exchange as alternative first-line

›Second-line immunotherapy if no response within 2 weeks

›Rituximab 375 mg/m2 IV weekly for 4 weeks

›Mycophenolate mofetil for maintenance

›Teratoma removal essential in anti-NMDA receptor encephalitis

›Dramatically improves neurological outcome

›Substance withdrawal catatonia

›Alcohol withdrawal

›Symptom-triggered lorazepam with CIWA protocol

›Benzodiazepine withdrawal

›Reinstatement of prior benzodiazepine and gradual taper

›Mood disorder-related catatonia

›Mood stabilizers initiated after catatonia resolves

›Lithium for bipolar disorder

›Antidepressant when depressive episode confirmed

Benzodiazepine taper

›Taper principles

›Inpatient taper rate 10 to 25% per day

›Outpatient taper rate up to 25% per week

›Slow taper essential to prevent catatonia recurrence

›Monitoring during taper

›Daily BFCRS assessment during taper

›Any BFCRS score increase should pause taper

›Psychiatric follow-up within 1 week of discharge on taper

09Special Populations/sp63

Pregnancy

›Pregnancy considerations in catatonia

›Peripartum period is a recognized precipitant

›Postpartum psychosis most common trigger

›First 2 weeks postpartum highest risk

›Lorazepam safety in pregnancy

›Category D; crosses placenta

›Benefits generally outweigh risks in acute catatonia

›Neonatal benzodiazepine withdrawal if used near delivery

›Fetal monitoring

›Viable gestation: fetal heart rate monitoring during treatment

›Neonatology notification if delivery anticipated

›ECT in pregnancy

›ECT is safe and effective in pregnant patients with catatonia

›Preferred over prolonged high-dose benzodiazepine near delivery

›Continuous fetal monitoring during ECT sessions

›Positioning considerations to avoid aortocaval compression

›Medication adjustments in pregnancy

›Avoid first-generation antipsychotics

›If antipsychotic needed, second-generation agents preferred

›Mood stabilizer selection in consultation with maternal-fetal medicine

›Valproate avoided in pregnancy (teratogenic)

Geriatric

›Atypical presentations in older adults

›Catatonia may present with delirium overlap

›Both can cause psychomotor slowing, mutism, unresponsiveness

›BFCRS helps differentiate from pure delirium

›UTIs and other infections common precipitants in elderly

10Background/b58

Epidemiology

›Prevalence and setting

›Catatonia identified in 7 to 38% of inpatient psychiatric populations depending on diagnostic threshold

›Under-recognized in medical and ED settings

›Male sex and younger age identified as risk factors in some studies

›Psychiatric associations

›Mood disorders are the most common psychiatric cause

›Bipolar disorder and major depression account for majority of cases

›Schizophrenia spectrum less commonly the primary cause than historically believed

›Autism spectrum disorder: substantially elevated rates compared to general population

›Medical and toxic causes

›Anti-NMDA receptor encephalitis is the leading autoimmune cause

›Substance intoxication and withdrawal significant contributors

›Medication-induced catatonia increasingly recognized (antipsychotics, pembrolizumab)

›Recurrence

›High recurrence rate particularly in mood disorders and schizophrenia

›Chronic catatonia with incomplete remission between episodes in some patients

Pathophysiology

›Neurotransmitter models

›GABAergic hypofunction

›Reduced GABA-A receptor activity in basal ganglia and thalamo-cortical circuits

›Explains lorazepam efficacy (positive allosteric GABA-A modulator)

›Dopaminergic dysregulation

›Dopamine D2 receptor blockade precipitates catatonia

›Explains why antipsychotics worsen catatonia

›Glutamatergic excitotoxicity

›NMDA receptor hypofunction in autoimmune encephalitis

›Explains memantine and amantadine efficacy

11Patient Discharge Instructions/pdi30

copy discharge instructions

›Catatonia home care instructions

›Take all medications exactly as prescribed

›Do not stop benzodiazepines abruptly

›Missing doses may cause symptoms to return quickly

›Slow taper under psychiatric supervision only

›Do not self-adjust doses

›Adequate sleep, nutrition, and hydration at home

›Avoid alcohol and recreational substances

›Alcohol interacts dangerously with benzodiazepines

›Cannabis and cocaine can trigger catatonia

›Warning signs to return to the emergency department immediately

›Stopping speaking or becoming very difficult to communicate with

›Freezing in unusual postures or unable to move voluntarily

›Staring spells lasting more than a few minutes

›Fever (temperature above 38 C)

›Heart racing, heavy sweating, or blood pressure swings

›Refusing to eat or drink for more than 12 hours

›Confusion or significant change from baseline function

›Muscle pain or very dark urine (signs of muscle breakdown)

›Follow-up appointments

›Psychiatry appointment within 1 week of discharge

›Benzodiazepine taper review at that visit

›Underlying psychiatric disorder management plan

›If on immune-related treatment, neurology follow-up as scheduled

›Laboratory tests as instructed by your team (CK, renal function)

›Lifestyle and prevention

›Notify all doctors of catatonia history before any new medication

12References/r20

Guidelines and key sources

›Primary references

›Heckers S, Walther S. Catatonia. The New England Journal of Medicine. 2023

›Comprehensive review including DSM-5-TR criteria, BFCRS, treatment evidence

›Connell J, Oldham M, Pandharipande P, et al. Malignant Catatonia: A Review for the Intensivist. Journal of Intensive Care Medicine. 2023

›ICU management, malignant catatonia recognition, ECT protocols

›Wilson JE, Oldham MA, Francis A, et al. Catatonia: American Psychiatric Association Resource Document. Journal of the Academy of Consultation-Liaison Psychiatry. 2025

›APA consensus recommendations, diagnostic criteria, management algorithms

›Supporting references

›Bot L, Schotsman B, Oostra E, et al. The Effect of Benzodiazepines on Catatonia: Systematic Review and Meta-Analysis. Acta Psychiatrica Scandinavica. 2026

›Remission rate 55%, response rate 77%, median effective dose 8 mg/day lorazepam

›Virolle J, Redon M, Montastruc F, et al. Antipsychotic-Induced Catatonia and NMS: Systematic Review. Schizophrenia Research. 2023

›Pathophysiological continuum between catatonia and NMS

›Luccarelli J, Kalinich M, Wilson JE, et al. The Catatonia Quick Screen (CQS). Acta Psychiatrica Scandinavica. 2025

›Rapid screening tool validation in adult and pediatric populations

Coding references

›Diagnostic coding

›ICD-10 F20.2 catatonic schizophrenia

›ICD-10 F30.2 manic episode with psychotic symptoms including catatonic features

›ICD-10 F32.3 severe depressive episode with psychotic symptoms

›ICD-10 G21.0 neuroleptic malignant syndrome

›DSM-5-TR catatonia specifier applied to underlying psychiatric or medical diagnosis

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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