Catatonia

Catatonia is a neuropsychiatric syndrome defined by a cluster of motor, behavioral, and affective abnormalities. Core signs include stupor or marked psychomotor retardation, mutism, negativism, rigidity or waxy flexibility, posturing, and echolalia or echopraxia. The presentation is heterogeneous and can alternate between immobility and agitation. Catatonia can occur in the context of mood disorders, schizophrenia-spectrum disorders, or as a result of medical illness or substance effects.

Causes and associations: Catatonia most commonly occurs in mood disorders (bipolar disorder, major depressive disorder) and schizophrenia-spectrum illnesses, but it can also arise from autoimmune or infectious encephalitis, metabolic disturbances, head injury, or neurodegenerative disease. Drug effects or withdrawal—notably antipsychotics, benzodiazepines, or stimulants—can trigger or unmask catatonia. Malignant catatonia is a severe, life-threatening form with autonomic instability.

Diagnosis: Catatonia is diagnosed clinically, supported by rating scales such as the Bush-Francis Catatonia Rating Scale. The lorazepam challenge test (administering 1–2 mg IV or orally and observing for improvement) can aid both diagnosis and treatment planning. It is essential to exclude other medical conditions and syndromes that mimic catatonia, such as neuroleptic malignant syndrome or serotonin syndrome.

Treatment: Management begins with correcting medical problems and ensuring hydration, nutrition, and safety. Benzodiazepines, especially lorazepam, are first-line; many patients respond to scheduled doses. Electroconvulsive therapy is highly effective, particularly in malignant or benzodiazepine-refractory catatonia and when rapid improvement is required. Treating the underlying psychiatric or medical condition is essential for sustained recovery.

Prognosis and history: With prompt recognition and treatment, catatonia is often reversible. Untreated, it can lead to complications such as malnutrition, dehydration, and aspiration. The syndrome was first described by Karl Ludwig Kahlbaum in the 19th century and later linked to psychiatric disorders by Kraepelin.