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[Conditions](https://durgical.com/en/conditions/) · [Psychiatry](https://durgical.com/en/conditions/)

# 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.

- [Frontal lobe](https://durgical.com/en/anatomy/superior-frontal-gyrus/)
- [Globus pallidus](https://durgical.com/en/anatomy/globus-pallidus/)
- [Cingulate gyrus](https://durgical.com/en/anatomy/cingulate-gyrus/)
- [Thalamus](https://durgical.com/en/anatomy/thalamus/)
- [Caudate nucleus](https://durgical.com/en/anatomy/caudate-nucleus/)
- [Putamen](https://durgical.com/en/anatomy/putamen/)

## 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](https://durgical.com/en/anatomy/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

## Red flags

- Fever, tachycardia, blood pressure swings and sweating (malignant catatonia)
- Refusal of food and fluids with dehydration or weight loss
- Rigidity with a rising creatine kinase after antipsychotic exposure
- New catatonia with seizures, reduced consciousness or focal signs (possible encephalitis)

## 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](https://durgical.com/en/anatomy/kidney/), [liver](https://durgical.com/en/anatomy/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.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/catatonia/)

## Related conditions

- [Bipolar disorder](https://durgical.com/en/conditions/bipolar-disorder/)
- [Major depressive disorder](https://durgical.com/en/conditions/major-depressive-disorder/)
- [Schizophrenia](https://durgical.com/en/conditions/schizophrenia/)
- [Neuroleptic malignant syndrome](https://durgical.com/en/conditions/neuroleptic-malignant-syndrome/)
- [Viral encephalitis (herpes simplex encephalitis)](https://durgical.com/en/conditions/viral-encephalitis/)
- [Systemic lupus erythematosus](https://durgical.com/en/conditions/systemic-lupus-erythematosus/)
- [Delirium](https://durgical.com/en/conditions/delirium/)
- [Antipsychotic-induced movement disorders (dystonia, akathisia, parkinsonism, tardive dyskinesia)](https://durgical.com/en/conditions/antipsychotic-induced-movement-disorders/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Catatonia](https://my.clevelandclinic.org/health/diseases/23503-catatonia) (Cleveland Clinic, 2025).

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Source: https://durgical.com/en/conditions/catatonia/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/catatonia/