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Catatonia

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

Author:Anna Hernández, MD

Editors:Alyssa Haag,Emily Miao, PharmD,Kelsey LaFayette, DNP, ARNP, FNP-C

Illustrator:Jessica Reynolds, MS

Copyeditor:David G. Walker


What is catatonia?

Catatonia is a neuropsychiatric syndrome where an individual becomes very nonreactive to their environment due to an underlying medical condition. Individuals with catatonia often appear withdrawn and unaware of their surroundings; they also may hold odd positions, sit still or stand in the same position for hours, and be unable to speak or eat. For many years, catatonia was considered to be a subtype of schizophrenia; however, it is now known that symptoms of catatonia can be seen in a variety of medical disorders, including both psychiatric and non-psychiatric conditions

Individual sitting in a chair nonreactive to surroundings.

What causes catatonia?

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. 

Although catatonia is more commonly seen in individuals with bipolar disorder or schizophrenia, almost any kind of mental health disorder can lead to catatonia, including depression, obsessive-compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. In addition, catatonia has been linked to several non-psychiatric conditions, including infections and autoimmune disorders affecting the central nervous system (e.g., anti-NMDAR encephalitis). Individuals taking benzodiazepines or antipsychotic medications are also at risk of catatonia either as a side effect or after withdrawal from these medications. Likewise, some case studies suggest catatonia may be caused by substance abuse or as a result of the withdrawal syndrome associated with certain abuse substances, like alcohol or cocaine

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What are the signs and symptoms of catatonia?

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. 

The last and most severe type is malignant catatonia, a life-threatening situation where catatonia is accompanied by autonomic dysfunction. Symptoms of malignant catatonia include fever, psychomotor agitation, altered consciousness, muscle rigidity, respiratory failure, and dangerous changes in blood pressure. If left untreated, malignant catatonia can progress to coma and death in the most severe cases. 

How is catatonia diagnosed?

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. 

How is catatonia treated?

Treatment of catatonia is typically performed in hospitals or in specialized units, as individuals generally require a high level of nursing care. Catatonia treatment focuses on addressing the underlying cause as well as administering benzodiazepines (e.g., lorazepam), which act by enhancing GABA, the main inhibitory neurotransmitter of the brain. When catatonia symptoms do not improve after benzodiazepine treatment, electroconvulsive therapy (ECT) may be offered as an alternative option. During electroconvulsive therapy, a small and controlled electric current is passed through the brain while the individual is under general anesthesia, which induces a brief seizure. Studies suggest ECT may be effective in some cases; however, the reason why electrically-induced seizures improve catatonia symptoms is not well understood.

What are the most important facts to know about catatonia?

Catatonia is a neuropsychiatric condition where an individual becomes nonreactive to their environment due to an underlying medical condition. With catatonia, individuals may sit or stand in the same position for hours, hold odd positions, and resist movement of their extremities. The most severe form of catatonia, called malignant catatonia, is characterized by fever; psychomotor agitation; and autonomic dysfunction, which may be life-threatening. Diagnosis of catatonia is achieved through a complete neuropsychiatric assessment and can be assisted with the use of several rating scales. Benzodiazepine medications, like lorazepam, and electroconvulsive therapy (ECT) are used to treat catatonia. While catatonia is a serious medical condition, early recognition and treatment of the disease can help decrease the risk of complications. 

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Related links

Anticonvulsants and anxiolytics: Benzodiazepines
Bipolar disorder
Schizophrenia

Resources for research and reference

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.

Edinoff AN, Kaufman SE, Hollier JW, et al. Catatonia: clinical overview of the diagnosis, treatment, and clinical challenges. Neurology International. 2021;13(4):570-586. doi:https://doi.org/10.3390/neurolint13040057

Oldham MA. The Probability that catatonia in the hospital has a medical cause and the relative proportions of its causes: a systematic review. Psychosomatics. 2018;59(4):333-340. doi:https://doi.org/10.1016/j.psym.2018.04.001

‌Sienaert P, Dhossche DM, Gazdag G. Adult catatonia: etiopathogenesis, diagnosis and treatment. Neuropsychiatry. 2013;3(4):391-399. doi:https://doi.org/10.2217/npy.13.41

‌Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag Gã. A clinical review of the treatment of catatonia. Frontiers in Psychiatry. 2014;5. doi:https://doi.org/10.3389/fpsyt.2014.00181

‌Tandon R, Heckers S, Bustillo J, et al. Catatonia in DSM-5. Schizophrenia Research. 2013;150(1):26-30. doi:https://doi.org/10.1016/j.schres.2013.04.034