Catatonia · What Is It, Signs and Symptoms, Treatment, and More

Catatonia can have a number of different causes; however, the exact reason as to why an individual develops catatonia is not well understood. Some theories suggest it may run in families, which points to a genetic basis. Catatonia is also thought to be related to trauma, stress, infections, and autoimmune disorders. Although it is unclear how, neurotransmitter dysfunction involving gamma-aminobutyric acid (GABA) may also play a role in the development of the condition.

Catatonia is most often seen in individuals with psychiatric disorders, particularly bipolar disorder and schizophrenia. Bipolar disorder is a mood disorder that causes an individual to have dramatic shifts in emotions, mood, and energy levels—moving from extreme lows to extreme highs. On the other hand, schizophrenia is a psychotic disorder where individuals experience symptoms like hallucinations, delusions, and disorganized thinking. 

Signs and symptoms of catatonia vary widely between individuals. Overall, it is considered there are three main types of catatonia: akinetic catatonia, excited catatonia, and malignant catatonia. 

Akinetic catatonia is characterized by extreme negativism or resistance to movement. For example, it may be characterized as maintaining a rigid and bizarre body posture, like a twisted limb or being completely still or unresponsive. Individuals with akinetic catatonia may answer questions with monosyllables or be unable to speak for long periods of time, even when asked direct questions. They may appear to be still and staring into space or hold their arms and legs in the exact position that someone else moved them into. Additional symptoms can include grimacing or maintaining odd facial expressions; echolalia, which is when someone repeats the last word or phrase they heard from others; and stereotypies, which are repetitive movements or sounds with no specific purpose. The lack of response to external stimuli seen in individuals with catatonia should not be interpreted as a lack of awareness of their surroundings, as many individuals report being completely aware and able to recall their catatonic state after they recover.

Unlike akinetic catatonia, excited catatonia is characterized by psychomotor agitation and restlessness. With catatonic excitement, individuals may appear unreasonably agitated, defensive, or delirious. Oftentimes, their movements can seem pointless or impulsive to the point that excessive and uncontrolled motor activity can become a risk to themselves or others. 

Catatonia is a collection of signs and symptoms that occur due to an underlying condition. Its diagnosis is clinical and based on a neuropsychiatric evaluation, a type of structured interview that provides information to assess the individual's behavior, personality, thought processes, and cognitive abilities to identify any disturbances. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), diagnosis of catatonia requires at least three of 12 proposed symptoms, including stupor, mutism, negativism, posturing, echolalia, echopraxia, stereotypies, and others. Several rating scales have also been proposed to aid in the early recognition of this condition. 

Once catatonia has been recognized, additional tests may be done to assess the underlying cause and rule out other conditions that may present similarly to catatonia, including neuroleptic malignant syndrome, serotonin syndrome, or malignant hyperthermia, among others. Diagnostic tests may include laboratory tests, such as blood, urine, and cerebrospinal fluid (CSF) analysis; as well as imaging techniques, such as magnetic resonance imaging (MRI) of the brain or an electroencephalogram (EEG) to monitor the brain’s activity. 

If there are doubts about the diagnosis, clinicians may perform a benzodiazepine challenge, which involves administering the usual catatonia treatment to monitor for improvement. A positive response increases the likelihood of catatonia; however, no improvement of symptoms may not necessarily rule out catatonia.