All About Catatonia

Catatonia falls under the umbrella of psychomotor disorders, which reflect the connection between brain function and bodily movements.

Mental and emotional distress can disrupt regular motor functions and lead to movements (or lack of movement) that are noticeably different than usual.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists catatonia with schizophrenia and other psychotic disorders.

But catatonia can occur with other mental health and medical conditions.

No matter how it’s categorized or diagnosed, catatonia remains a real and complex condition that can involve a wide range of symptoms.

Learning how to identify catatonia can lead to timely treatment and lower the chances of major health consequences.

Catatonia can be both a symptom and a condition.

Formally, the DSM-5 doesn’t classify catatonia as a standalone condition, though. But it does recognize three different subtypes:

• catatonia with another mental health condition
• catatonia with another medical condition
• unspecified catatonia

In the past, medical and mental health experts recognized three types of catatonia:

• excited catatonia, which involved fast, agitated movement
• akinetic catatonia, which involved slow movement and often, loss of speech
• malignant catatonia, which involved delirium and fever

Some care providers still use these terms although it’s no longer the rule.

You might also hear it called catatonic schizophrenia or catatonic depression. That said, most clinicians will now diagnose these conditions as “schizophrenia with catatonia” or “depression with catatonia.”

The DSM-5 doesn’t identify a specific cause of catatonia but it associates it with symptoms of other conditions.

Mental health conditions that may include catatonia include:

• depression
• bipolar disorder
• conditions that involve psychosis, such as schizophrenia
• neurodevelopmental disorders, such as ADHD or autism
• substance use disorders

Catatonia can also happen with certain medical conditions, including:

• head trauma
• cerebral folate deficiency
• certain autoimmune disorders
• diabetic ketoacidosis

Some evidence suggests that experiencing trauma, particularly in childhood, could eventually prompt symptoms of catatonia. Older research also suggests it might develop in response to fear.

For the moment, research exploring catatonia as a response to trauma and fear remains limited.

What about catatonia’s physiological cause?

Experts believe the cause of catatonia may have something to do with irregular function in the brain’s neurotransmitters, or chemical messengers — namely dopamine, glutamate, and gamma-aminobutyric acid (GABA).

The signs and symptoms of catatonia can vary from person to person, based on what caused it.

The DSM-5 lists 12 key symptoms.

To reach a diagnosis, a health professional will try to identify three or more of these:

1. Stupor. There’s no movement or interaction with surroundings.
2. Catalepsy. The person may hold a fixed posture when someone moves their limbs.
3. Wavy flexibility. There may be slight resistance to the new position when the limbs are moved.
4. Mutism. This means speaking very little, if at all.
5. Negativism. The person ignores or resists directions, not responding to stimuli.
6. Posturing. This means taking and holding a fixed posture.
7. Mannerism. The person makes unusual, often exaggerated, movements, gestures, and speech.
8. Stereotypy. This means making repeated, frequent movements that have no purpose.
9. Agitation. The person has increased, restless movement.
10. Grimacing. The person moves their face in a way that expresses disapproval or pain.
11. Echolalia. This means repeating what other people say.
12. Echopraxia. This means copying other people’s movements.

You can generally tell someone is catatonic.

For example, they might stare at a fixed point without moving or saying a word, even if you gently tap their shoulder or shake them to get their attention.

You notice that they hold their exact posture, even though their legs seem awkwardly positioned.

Or maybe they first seem agitated and restless, almost as if they can’t stop moving.

They don’t speak, but when you move, they copy your movements.

You also notice that their face seems fixed in a grimace. Then, their behavior changes. They repeatedly jerk their hands at the same unusual angle. You try to help them sit down, but they resist you.

Someone experiencing catatonia may also hold the same fixed posture to the point of neglecting basic needs, like eating, drinking, or going to the bathroom.

Fever and delirium can also develop, putting their overall health in jeopardy.

Mental health professionals will typically diagnose catatonia based on DSM-5 criteria. To make the diagnosis, they’ll need to identify at least three symptoms.

Since they typically won’t diagnose catatonia on its own, they’ll also consider other mental health or medical symptoms in order to make the correct diagnosis.

They might, for example:

• diagnose bipolar I disorder with catatonia if someone shows symptoms of catatonia during an episode of mania and has a history of mania, depression, and psychosis
• diagnose peripartum depression with catatonia when someone develops catatonia along with depression shortly after childbirth

When it comes to medical conditions, a doctor will also rule out things like:

• mental health conditions
• delirium from another cause
• side effects of antipsychotic medications
• severe seizures
• stroke

While there’s no hard and fast way to identify catatonia, healthcare professionals may use a few different tests to help with diagnosis, such as:

• a blood test
• the Bush-Francis Catatonia Rating Scale (BFCRS)
• a CT scan or MRI

They’ll also monitor behavioral symptoms for at least a full day to rule out other possible causes.

Catatonia symptoms might last for an hour or two, but they can also linger for a longer period of time — weeks, months, and sometimes even years.

Symptoms could also last for several days, improve, and then return. This pattern can recur over a period of months or years.

Often, symptoms of catatonia appear very obviously, but they can also show up more subtly.

When symptoms go untreated, they can worsen.

During an episode of catatonia, someone may not be able to eat, drink, or get themselves to safety in an emergency. Longer episodes, then, carry a high chance of dehydration or starvation.

A psychiatrist or medical doctor may recommend one of the following catatonia treatments:

Medication

Care providers who suspect catatonia may first treat symptoms with lorazepam (Ativan). This benzodiazepine tends to be the first line of treatment.

Other medications often used in catatonia treatment include:

• muscle relaxers
• the sedative zolpidem
• tricyclic antidepressants
• mood stabilizers, including valproic acid and lithium
• N-methyl-D-aspartate (NMDA)

Health professionals may also recommend temporarily stopping antipsychotic medications, just until catatonia symptoms improve.

Electroconvulsive therapy (ECT)

When medication doesn’t help improve symptoms, care professionals may recommend ECT to treat catatonia.

While ECT has something of a stigmatized reputation, the procedure is considered a highly effective treatment for catatonia.

While sedated and anesthetized, the person with catatonia receives an electric shock. This triggers a seizure, which, experts believe, prompts the release of neurotransmitters in the brain.

ECT may prove particularly helpful for cases of untreated catatonia, where symptoms have progressed to the point of a medical emergency.

Catatonia can put your safety in jeopardy, especially when it involves:

• stupor
• refusal of food or water
• fever
• repeated movements that lead to injury or self-injury, such as kicking or head-banging

It often requires hospitalization until symptoms improve, especially when the person with catatonia:

• has other serious medical or mental health symptoms
• can’t eat or drink
• can’t take care of basic needs

A healthcare team can treat catatonia while also monitoring vital signs and providing hydration and nutrients.

Severe or untreated catatonia can have severe health effects, including:

• high blood pressure
• blood clots in the lungs
• severe swelling
• muscle tissue breakdown
• high fever
• eye infection
• kidney failure

If you believe a loved one may have catatonia, you may want to get medical support for them.

While catatonia can become serious, even life threatening, the right treatment can lead to rapid improvement.

Getting support from a trained and experienced psychiatrist or doctor can help prevent misdiagnosis. They can quickly identify symptoms of catatonia and prescribe the most helpful treatments.

Also, you may want to keep in mind that symptoms may come back over time. As a result, it’s a good idea to continue working with a health professional so they can monitor symptoms and treat any underlying conditions that might play a part.