Catatonia !
A treatable syndrome in which a person stops moving, speaking or responding normally. It can be caused by mental or medical illness and can be life-threatening.
Updated 2026-11-01
Structures involved
Tap one to see what it is and open it in 3D.
What it is
A neuropsychiatric syndrome of marked motor and behavioural abnormalities, such as stupor, mutism, rigid postures or purposeless agitation. It is not a diagnosis by itself: it occurs with mood disorders, psychotic disorders, autism and many medical conditions, and usually responds quickly to benzodiazepines.
Who gets it
Seen in roughly one in ten acute psychiatric inpatients in published series and under-recognised in general hospitals. Mood disorders, especially bipolar disorder, are the most frequent psychiatric cause. In Colombia and Latin America it appears in mental-health units, emergency departments and in medical wards with encephalitis, lupus or metabolic disease.
Causes
- Mood disorders (bipolar disorder and severe depression), the most common cause
- Schizophrenia and other psychotic disorders
- Medical causes: autoimmune (anti-NMDA receptor) or infectious encephalitis, lupus, epilepsy, metabolic and endocrine disorders
- Drugs: abrupt benzodiazepine or clozapine withdrawal, antipsychotics, some recreational drugs
- Autism spectrum disorder and neurodevelopmental conditions
Risk factors
- Bipolar disorder or major depression with psychotic features
- Previous episodes of catatonia
- Abrupt withdrawal of benzodiazepines
- Exposure to antipsychotics, especially during an episode
- Medical illness affecting the brain
Pathophysiology
The exact mechanism is unknown. Leading models propose reduced GABA-A inhibition, reduced dopamine signalling and excess glutamate (NMDA) activity in circuits linking the frontal cortex, basal ganglia and thalamus. This explains the rapid response to benzodiazepines (GABA-A enhancers), the response to ECT and NMDA antagonists, and why dopamine blockers can worsen it or precipitate a malignant form.
Classification
- Retarded (stuporous) catatonia: immobility, mutism, staring, posturing
- Excited catatonia: purposeless agitation and stereotyped movements
- Malignant (lethal) catatonia: catatonia with fever and autonomic instability, a medical emergency
- By cause: associated with a mental disorder, due to a medical condition, or unspecified
Symptoms and signs
- Stupor or very reduced response to the environment, and mutism
- Catalepsy and posturing: holding a position against gravity for long periods
- Waxy flexibility: slight, even resistance as the examiner repositions a limb
- Negativism: resisting instructions or doing the opposite
- Staring, grimacing, mannerisms and stereotypies
- Echolalia and echopraxia (repeating the examiner's words or movements)
- Refusal to eat or drink
Diagnosis
- Clinical
- Diagnosed by examination: DSM-5 requires at least 3 of 12 signs (such as stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypy, agitation, grimacing, echolalia, echopraxia). The Bush-Francis Catatonia Rating Scale is used to screen and rate severity. A clear improvement after a test dose of lorazepam (lorazepam challenge) supports the diagnosis.
- Tests
- Search for medical causes and complications: complete blood count, electrolytes, glucose, kidney, liver and thyroid function, creatine kinase, toxicology, and when indicated autoimmune studies, lumbar puncture with anti-NMDA receptor antibodies and EEG.
- Imaging
- Brain MRI when a neurological cause is suspected (first episode, focal signs, atypical course).
Differential diagnosis
- Neuroleptic malignant syndrome
- Delirium (hypoactive form)
- Non-convulsive status epilepticus
- Locked-in syndrome and akinetic mutism
- Severe parkinsonism or stiff-person syndrome
Goal of treatment
Recognise the syndrome early, relieve it quickly with benzodiazepines or ECT, avoid drugs that worsen it, prevent complications of immobility and treat the underlying cause.
Treatment
- Acute
- Medical stabilisation: fluids, nutrition (by tube if needed), and stopping antipsychotics and other dopamine blockers during the acute episode; malignant catatonia is managed in intensive care.
- Medical
- Benzodiazepines, most often lorazepam, are first-line and many patients improve within days.
- Procedure
- Electroconvulsive therapy (ECT) for malignant catatonia or when benzodiazepines fail; it is highly effective.
- Follow-up
- Nursing care: monitoring temperature and vital signs, intake and output, repositioning and pressure-injury prevention, thromboprophylaxis, aspiration precautions and a calm environment.
- Medical
- Treatment of the cause (mood or psychotic disorder, encephalitis, lupus, withdrawal), with cautious reintroduction of psychiatric medicines once catatonia resolves.
Complications
- Dehydration, malnutrition and electrolyte disorders
- Deep vein thrombosis and pulmonary embolism
- Aspiration pneumonia
- Pressure injuries and contractures
- Rhabdomyolysis and acute kidney injury
- Death in malignant catatonia
Prognosis
Most patients respond well to benzodiazepines or ECT, often within days. The outlook depends on the underlying cause; untreated catatonia, and especially the malignant form, carries a high risk of serious complications and death.
Test yourself
Think of the answer, then tap the question to see it.
Which drug class is first-line for catatonia?
Benzodiazepines, usually lorazepam.
Which treatment is indicated for malignant catatonia or catatonia that does not respond to benzodiazepines?
Electroconvulsive therapy (ECT).
Which psychiatric disorder most often causes catatonia?
Mood disorders, especially bipolar disorder.
Why are antipsychotics avoided during acute catatonia?
They can worsen it and raise the risk of neuroleptic malignant syndrome.
What is waxy flexibility?
A slight, even resistance when the examiner moves the patient's limb, which then stays in the new position.
Related conditions
- Bipolar disorder
- Major depressive disorder
- Schizophrenia
- Neuroleptic malignant syndrome
- Viral encephalitis (herpes simplex encephalitis)
- Systemic lupus erythematosus
- Delirium
- Antipsychotic-induced movement disorders (dystonia, akathisia, parkinsonism, tardive dyskinesia)
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Catatonia (Cleveland Clinic, 2025).
Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake
Representative model, for educational purposes only.
