Catatonia is a complex syndrome that affects how a person moves and behaves. It is as if the body and mind get stuck or frozen in unusual ways. People with catatonia might become very still, almost statue-like, or they might repeat the same movements over and over. Sometimes, they have trouble speaking or responding to others. Imagine a pause button being pressed on someone’s usual actions and reactions. They might resist being moved, hold strange postures for long periods, or suddenly become very excited and agitated. It is as if the normal flow between thoughts and actions gets disrupted.

Catatonia can be part of various mental health conditions or medical issues. It is not a standalone illness but rather a set of symptoms that can appear in different situations. While it might look scary or confusing to others, it iss important to remember that people experiencing catatonia need understanding and proper medical care.

Table of Contents

• Catatonia includes the following:
• Decreased psychomotor activity
• Increased psychomotor activity
• Abnormal psychomotor activity
• Essential (required) features
• Course features
• Essential (required) features:
• Primary brain disorders (examples)
• General medical conditions affecting the brain (examples)  
  • Infectious diseases
  • Genetic conditions Differential diagnosis
  Cut to the chase plan for catatonia

  First phase:

  1.     Perform a comprehensive psychiatric evaluation – including risk assessment.

  2.     Assess nutritional status.

  3.     Assess capacity for medical treatment decision-making.

  4.     Involve family or caregivers for collateral information.

  5.     Conduct a thorough neurological examination.

  6.     Obtain a detailed medical history.

  7.     Review current medications and recent changes.

  8.     Assess for substance use or withdrawal.

  9.     Use standardised rating scales (e.g., Bush-Francis Catatonia Rating Scale).

  10.  Perform a physical examination, including vital signs.

  11.  Search for or order laboratory tests (FBC, U&E, CRP, thyroid function, B12, folate, CK, serum iron, ferritin, and transferrin levels, autoimmune antibodies etc).

  12.  Conduct a urine drug screen and CDT.

  Second phase:

  13.  Conduct a lorazepam challenge test – in the right setting.

  14.  Order brain imaging (MRI or CT).

  15.  Perform an electroencephalogram (EEG).

  16.  Consider lumbar puncture for CSF analysis.

  17.  Consult with a neurologist and/or endocrinologist where necessary.

  18.  Evaluate for infections (blood cultures, chest X-ray).

  19.  Assess for malignancy (tumour markers, whole-body imaging).

  20.  Consider genetic testing for rare disorders.

  21.  Consider toxicology consultation.

  22.  Evaluate for conversion disorder.

  23.  Consider electroconvulsive therapy (ECT) consultation.

  24.  Consider inpatient admission for close monitoring.

  25. Develop a comprehensive treatment plan.

   

  ICD-11 states,

  Catatonia is a syndrome of primarily psychomotor disturbances, characterised by the co-occurrence of several symptoms of decreased, increased or abnormal psychomotor activity. The assessment of catatonia is complex and requires observation, interview and physical examination. Catatonia can occur in the context of other mental disorders, such as schizophrenia and other primary psychotic disorders, mood disorders and neurodevelopmental disorders – especially autism spectrum disorder. Catatonia can also develop during or soon after intoxication or withdrawal from certain psychoactive substances, including phencyclidine (PCP), cannabis, hallucinogens such as mescaline or lysergic acid diethylamide (LSD), cocaine and MDMA or related drugs, or during the use of certain psychoactive and non-psychoactive medications (e.g. antipsychotic medications, benzodiazepines, steroids, disulfiram, ciprofloxacin). Finally, catatonia can occur as a direct pathophysiological consequence of a medical condition not classified under mental, behavioural and neurodevelopmental disorders. Examples of medical conditions that may be associated with catatonia include diabetic ketoacidosis, hypercalcaemia, hepatic encephalopathy, homocystinuria, neoplasms, head trauma, cerebrovascular disease and encephalitis.

  Catatonia includes the following:

  • 6A40 Catatonia associated with another mental disorder
  • 6A41 Catatonia induced by substances or medications
  • 6E69 Secondary catatonia syndrome
  • 6A4Z Catatonia, unspecified

  The category of secondary catatonia syndrome is a part of the grouping of secondary mental or behavioural syndromes associated with disorders or diseases classified elsewhere. Is is listed here, with diagnostic guidance provided, because of its diagnostic commonality with other forms of catatonia. Below are the general diagnostic requirements for catatonia, which apply to all four catatonia categories, followed by the essential features, additional clinical features (if applicable) and course features for each of the three specified types of catatonia listed above. After that, additional CDDR sections (developmental presentations, culture-related features, and boundaries with other disorders and conditions) are provided for all types of catatonia together.

  General Diagnostic Requirements

  The presence of three or more of the following symptoms of decreased, increased or abnormal psychomotor activity is required for diagnosis. The three symptoms may come from one or any combination of the following three symptom clusters. Note: symptoms that require assessment by physical examination are indicated below.

  Decreased psychomotor activity

  • Staring: fixed gaze; decreased blinking, often with widely opened eyes
  • Ambitendency: appearance of being “motorically stuck” in indecisive or hesitant movement
  • Negativism: opposing or behaving contrary to requests or instructions, which may lead to withdrawal from interaction with others (turning away) or refusal to take food or drink when offered
  • Stupor: immobility; no or markedly reduced psychomotor activity; minimally responsive to external stimuli
  • Mutism: no or very little verbal response; speech that is hushed or whispered to the point of being unintelligible (Note: do not count if speech symptoms are due to a disease of the nervous system, developmental speech or language disorder, or other disease or disorder affecting speech.)

  Increased psychomotor activity

  Any of the following: extreme hyperactivity or agitation for no reason with non-purposeful movements and/or uncontrollable, extreme emotional reactions; impulsivity (sudden engagement in inappropriate behaviour without provocation); combativeness (striking out against others usually in an undirected manner, with or without the potential for injury) (Note: multiple manifestations of increased psychomotor activity should only be counted as one of the required three symptoms in order to meet the requirements for catatonia.)

  Abnormal psychomotor activity

  • Grimacing: odd or distorted facial expressions; often inappropriate and irrelevant to the situation
  • Mannerisms: odd, purposeful movements that are not appropriate to the individual’s cultural context; exaggerated caricatures of mundane movements
  • Posturing: spontaneous and active maintenance of a posture against gravity; sitting or standing for long periods without reacting
  • Stereotypy: repetitive, non-goal-directed motor activity (e.g. finger-play, repeatedly touching, patting or rubbing self) (Note: the abnormality is not inherent in the action but relates to its frequency.)
  • Rigidity: resistance by way of increased muscle tone, which may range in severity from mildly increased tone to severe “lead pipe” rigidity (requires examination)
  • Echophenomena: mimicking examiner’s speech (echolalia) or movements (echopraxia) •
  • Verbigeration: continuous and directionless repetition of words, phrases or sentences
  • Waxy flexibility: slight and even resistance to positioning by examiner (requires examination)

  Catatonia may be accompanied by vital sign abnormalities not fully accounted for by a comorbid medical condition that may signal potentially life-threatening complications and therefore require immediate attention. These include tachycardia or bradycardia; hypertension or hypotension; and hyperthermia or hypothermia. In these cases, as many of the following symptom codes as applicable should be applied:
  MG26 Fever of other or unknown origin
  MG28 Hypothermia, not associated with low environmental temperature
  MC80.0 Elevated blood-pressure reading, without diagnosis of hypertension
  MC80.1 Nonspecific low blood-pressure reading
  MC81.0 Tachycardia, unspecified
  MC81.1 Bradycardia, unspecified.

  All the information below in accordions is from ICD-11.

  6A40 Catatonia associated with another mental disorder

  Essential (required) features

  • The general diagnostic requirements for catatonia are met.
  • The catatonic symptoms develop in the context of another mental disorder, such as schizophrenia or another primary psychotic disorder, a mood disorder or autism spectrum disorder.
  • The symptoms are not fully accounted for by delirium, the effects of a medication or substance – including withdrawal effects – or a primary movement disorder classified in
    Chapter 8 on diseases of the nervous system (e.g. Parkinson disease, Huntington disease).
  • The symptoms are sufficiently severe to be a specific focus of clinical attention.

  Note: the associated mental disorder should be diagnosed separately.

  Course features

  • Acute episodes of catatonia associated with another mental disorder typically develop rapidly within hours or days from single symptoms to full presentation.
  • In catatonia associated with another mental disorder, symptoms most commonly resolve within 4 weeks, although some episodes (e.g. in the context of acute psychosis) may remit spontaneously within hours. However, symptoms may also persist for months or even years with little variation of the clinical presentation and severity.
  • The individual may experience recurrent episodes of catatonia of several weeks’ duration that remit and recur throughout the course of the associated disorder. Most commonly, these catatonia episodes occur during some but not all of the episodes of the associated mental disorder (e.g. a bipolar disorder). Early signs of recurring episodes may include ambitendency or psychomotor slowing.
  • Persistent catatonia is most commonly associated with neurodevelopmental disorders or schizophrenia and other primary psychotic disorders. Adolescent onset is more frequent in these cases. Disturbances of volition – such as negativism, mannerisms or stereotyped movements – are more common in persistent catatonia, whereas stupor rarely persists over weeks. In some severe cases, persistent catatonia is characterised by severe, stable symptoms and massive global dysfunction for multiple years.
  6A41 Catatonia induced by substances or medications

  Essential (required) features:

  • The general diagnostic requirements for catatonia are met.
  • The catatonic symptoms develop during or soon after intoxication with or withdrawal from a specified psychoactive substance, or use of a medication. Substances that may
    be associated with catatonia include opioids, PCP, cannabis, cocaine, MDMA or related drugs, and hallucinogens such as mescaline or LSD. Catatonia may also be associated with certain psychoactive and non-psychoactive medications (e.g. antipsychotic medications, benzodiazepines, steroids, disulfiram, ciprofloxacin).
  • The intensity or duration of the catatonic symptoms is substantially in excess of similar symptoms that are characteristic of intoxication or withdrawal due to the specified
    substance (e.g. stupor during opioid intoxication; psychomotor agitation and autonomic hyperactivity during alcohol withdrawal).
  • The specified substance, as well as the amount and duration of its use, must be capable of producing catatonic symptoms.
  • The symptoms are not fully accounted for by delirium or another mental disorder (e.g. schizophrenia or another primary psychotic disorder, a mood disorder or autism spectrum disorder), and are not the direct pathophysiological consequence of a medical condition.
  • The symptoms are sufficiently severe to be a specific focus of clinical attention

  Course features

  The onset of catatonia induced by substances or medications is typically rapid, often with fast deterioration. The duration of catatonia strongly depends on the inducing substance. Catatonia is more often induced by substance withdrawal than intoxication. Once the effects of the substance or medication (including a withdrawal syndrome) have subsided, catatonia typically remits within days.

  6E69  Catatonia | Secondary catatonia syndrome

  Essential (required) features

   The general diagnostic requirements for catatonia are met.

   The catatonic symptoms are judged to be the direct pathophysiological consequence of a medical condition, based on evidence from the history, physical examination or laboratory findings. This judgement depends on establishing that:

  •  the medical condition is known to be capable of producing the symptoms of catatonia;

  •  the course of the catatonic symptoms (e.g. onset, remission, response of the symptoms to treatment of the etiological medical condition) is consistent with causation by the medical condition;

  •  the symptoms are not fully accounted for by delirium, another mental disorder (e.g. schizophrenia or another primary psychotic disorder, a mood disorder or autism spectrum disorder), the effects of a medication or substance – including withdrawal effects – or a primary movement disorder classified in Chapter 8 on diseases of the nervous system (e.g. Parkinson disease, Huntington disease).

   The symptoms are suficiently severe to be a specific focus of clinical attention.

  Additional clinical features

  Catatonia symptoms that often cluster together in critically ill adults with secondary catatonia include mutism, staring and immobility.

  Course features

   The onset of secondary catatonia syndrome is related to the underlying medical condition, and duration is also determined by the underlying medical condition and its treatment.

  In cases in which the underlying disease course is severe and progressive (e.g. Alzheimer disease), secondary catatonia syndrome due to a disease of the nervous system or other medical condition may be chronic (lasting for weeks or months) and may fail to resolve fully with treatment of the underlying medical condition.

  Potentially explanatory medical conditions

  The identified etiological medical condition should be diagnosed separately.

  Medical conditions that have been shown to be capable of producing catatonia syndromes include the following.

  Primary brain disorders (examples)

  •  Neoplasms

  •  Cerebrovascular lesions, including cortical venous thrombosis, subarachnoid haemorrhage, subdural haematoma, bacillar aneurysms

  •  Anoxias, including stroke

  •  Viral encephalitis, encephalitis lethargica

  •  Brain stem, diencephalic and basal ganglia disorders, as well as frontal lobe or parietal lobe lesions

  •  Epilepsy

  •  Traumatic brain injury

  •  Dystonia

  •  Multiple sclerosis

  •  Parkinson disease

  •  Lewy body disease

  •  Human prion diseases

  General medical conditions affecting the brain (examples)

  Autoimmune conditions

  •  Systemic lupus erythematosus

  •  Hashimoto encephalopathy or autoimmune encephalitis

  Infectious diseases

  •  Typhoid fever

  •  Infectious mononucleosis

  •  Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)

  •  HIV/AIDS

  Genetic conditions

  • Prader-Willi syndrome
  • Fatal familial insomnia
  • Tay-Sachs disease
  • Wilson disease
  • Metabolic conditions
  • Hypercalcaemia from a parathyroid adenoma
  • Hepatic encephalopathy
  • Homocystinuria
  • Diabetic ketoacidosis
  • Acute intermittent porphyria
  • Membranous glomerulonephritis
  • Hypo- and hyperthyroidism
  • Hypo- and hyperadrenalism
  6A4Z – Catatonia unspecified

  Catatonia may occur throughout the entire lifespan, but rarely develops before adolescence.
  However, severe cases in children aged 8–11 years have been reported.

  • Early onset of catatonia (before age 20) is associated with underlying medical conditions,
    particularly diseases of the nervous system, or neurodevelopmental disorders (e.g. autism
    spectrum disorder).
  • Secondary catatonia syndrome or catatonia induced by substances or medications is more
    likely to occur after age 40; risk increases considerably after age 65.
  • In medically ill adults, the prevalence of secondary catatonia syndrome increases with age
    and is strongly associated with co-occurring delirium or coma.
    Catatonia | Catatonia, unspecified
    6

  Investigating Catatonia: A Systematic Approach

  When catatonia is suspected, a thorough investigation is crucial. This process involves several key steps below.

  1. Clinical Assessment:

  • Detailed observation of the patient’s behaviour and movements
  • Use of standardised rating scales like the Bush-Francis Catatonia Rating Scale
  • Comprehensive medical history, including recent life events and medication use

  2. Physical Examination:

  • Check for signs of underlying medical conditions
  • Assess vital signs, as catatonia can sometimes be associated with autonomic instability

  3. Laboratory Tests:

  • Complete blood count
  • Comprehensive metabolic panel
  • Thyroid function tests
  • Toxicology screening
  • Vitamin B12 and folate levels

  4. Brain Imaging: MRI or CT scan to rule out structural brain abnormalities
  5. Electroencephalogram (EEG): To check for seizure activity, as catatonia can sometimes be related to epilepsy
  6. Psychiatric Evaluation: Assessment for underlying mental health conditions like schizophrenia, bipolar disorder, or severe depression
  7. Medication Review: Checking for any drugs that might induce catatonic symptoms
  8. Lorazepam Challenge Test: A diagnostic test where a benzodiazepine is administered to see if it temporarily relieves catatonic symptoms
  9. Consultation with Specialists: Involving neurologists, psychiatrists, and other relevant specialists for a comprehensive evaluation

  The goal of this investigation is to identify any underlying causes, rule out other conditions that might mimic catatonia, and guide the most appropriate treatment approach. It is important to note that catatonia can be a medical emergency in some cases, so prompt and thorough evaluation is essential.

  Treatment Options for Catatonia

  Treating catatonia involves addressing both the symptoms and any underlying causes. The approach can vary depending on the severity and specific presentation, but generally includes:

  Benzodiazepines:

     – First-line treatment, especially lorazepam.

     – Often provides rapid relief of symptoms.

     – Can be used for both diagnosis and treatment.

  2. Electroconvulsive Therapy (ECT):

     – Highly effective, especially in severe or medication-resistant cases

     – May be used earlier in treatment if symptoms are life-threatening

  3. Addressing Underlying Conditions:

     – Treating associated psychiatric disorders (e.g., depression, bipolar disorder, schizophrenia)

     – Managing medical conditions that may be causing or contributing to catatonia

  4. Supportive Care:

     – Ensuring proper nutrition, often through feeding tubes if necessary

     – Preventing complications like deep vein thrombosis

     – Maintaining hydration and electrolyte balance

  5. NMDA Receptor Antagonists:

     – Medications like memantine or amantadine

     – Can be effective in some cases, especially when other treatments fail

  6. Atypical Antipsychotics:

     – Used cautiously, as they can sometimes worsen catatonia

     – May be helpful in specific cases, particularly when psychosis is present

  7. Mood Stabilisers:

     – Such as valproic acid or carbamazepine

     – Can be beneficial, especially in bipolar-related catatonia

  8. Repetitive Transcranial Magnetic Stimulation (rTMS):

     – An emerging treatment option

     – Shows promise in some cases, though more research is needed

  9. Environmental Modifications:

     – Creating a calm, structured environment

     – Minimizing stressors that may exacerbate symptoms

  10. Rehabilitation:

      – Physical therapy to prevent muscle atrophy and maintain mobility

      – Occupational therapy to help regain daily living skills

  The treatment plan is typically tailored to each individual, considering the severity of symptoms, underlying causes, and response to initial interventions. Close monitoring and adjustment of the treatment approach are often necessary.

  Differential diagnosis

  When considering these differential diagnoses, it’s important to conduct a thorough clinical evaluation, including a detailed history, physical examination, and appropriate laboratory and imaging studies to rule out underlying medical conditions. The pattern of symptoms, their onset, and associated features can help distinguish catatonia from these other conditions.

  1. Psychiatric disorders:

     – Schizophrenia

     – Bipolar disorder (especially manic or depressive episodes)

     – Major depressive disorder

     – Autism spectrum disorders

  2. Neurological conditions:

     – Encephalitis (especially anti-NMDA receptor encephalitis)

     – Parkinson’s disease

     – Stroke (especially affecting the frontal lobe)

     – Seizure disorders (including non-convulsive status epilepticus)

  3. Medical conditions:

     – Neuroleptic Malignant Syndrome (NMS)

     – Serotonin syndrome

     – Hyponatremia

     – Hypercalcemia

     – Hepatic encephalopathy

     – Wernicke’s encephalopathy

     – Systemic lupus erythematosus (SLE)

  4. Substance-related:

     – Benzodiazepine withdrawal

     – Alcohol withdrawal

     – Substance intoxication or withdrawal (various drugs)

  5. Other conditions:

     – Stiff person syndrome

     – Locked-in syndrome

     – Akinetic mutism

     – Conversion disorder (functional neurological symptom disorder)

     – Malignant hyperthermia

  6. Rare causes:

     – Wilson’s disease

     – Prion diseases (e.g., Creutzfeldt-Jakob disease)

     – Cerebral venous sinus thrombosis

  Summary and takeaway points

  1. Nature of Catatonia:

     – A complex syndrome affecting movement and behaviour

     – Characterised by “frozen” states or repetitive movements

     – Can involve difficulty in speaking or responding

     – Not a standalone illness, but a set of symptoms

  2. Presentation:

     – May appear as extreme stillness or agitation

     – Can involve unusual postures or repetitive movements

     – Affects the normal flow between thoughts and actions

  3. Occurrence:

     – Can be part of various mental health conditions

     – May also be associated with certain medical issues

  4. Investigation Process:

     – Requires a thorough, multi-faceted approach

     – Includes clinical assessment, physical exams, and various tests

     – Brain imaging and EEG may be necessary

     – Psychiatric evaluation is crucial

     – May involve a diagnostic lorazepam challenge test

  5. Treatment Options:

     – Benzodiazepines (especially lorazepam) as first-line treatment

     – Electroconvulsive Therapy (ECT) for severe cases

     – Addressing underlying psychiatric or medical conditions

     – Supportive care for nutrition and complication prevention

     – Other options include NMDA receptor antagonists, mood stabilisers, and emerging therapies like rTMS

  6. Importance of Comprehensive Care:

     – Treatment plans are individualised

     – May require a combination of approaches

     – Ongoing monitoring and adjustment of treatment is often necessary

  7. Perception and Understanding:

     – While catatonia may appear confusing or alarming, it’s a medical condition requiring compassion and proper care

     – Raising awareness can help in early recognition and treatment