Catatonia: Symptoms, Types, Causes and Treatment

Catatonia is a complex neuropsychiatric syndrome that, while often misunderstood, is both common and highly treatable. It presents with a striking range of motor, behavioral, and affective symptoms, and can occur in the context of psychiatric, neurological, or medical conditions. Recognition and timely intervention are crucial, as catatonia can become life-threatening if not managed properly, especially in its malignant form. In this article, we explore the symptoms, types, causes, and treatment strategies for catatonia, synthesizing recent research findings to offer a comprehensive understanding of this multifaceted condition.

Symptoms of Catatonia

Catatonia is characterized by a spectrum of psychomotor disturbances that can be subtle or dramatic. Its symptoms may range from complete immobility to episodes of intense agitation, with many patients displaying both extremes at different times. Because catatonia is often under-recognized, understanding its key symptoms is essential for early diagnosis and effective treatment.

Symptom	Description	Prevalence/Significance	Source(s)
Mutism	Lack of verbal response or speech	Very common; a core sign	8 9 13
Stupor/Immobility	Lack of movement; unresponsiveness	Up to 70% of cases	8 9
Staring	Fixed gaze, reduced blinking	Up to 80% of cases; highly prevalent	8
Withdrawal	Social and emotional disengagement	Occurs in about 50% of patients	8 9
Excitement	Agitated, hyperactive, or restless behavior	Less common; occurs with immobility in some	9 10 13
Negativism	Resistance to instructions or external stimuli	Frequent; variable presentation	7 8 9
Posturing	Holding inappropriate or bizarre postures	Classic sign; variable frequency	8 13
Stereotypy	Repetitive, non-goal-directed movements	Seen in some patients	1 2 8
Echophenomena	Imitation of speech (echolalia) or movements (echopraxia)	Often present	8 13
Waxy Flexibility	Limbs remain in position after being placed there	Highly specific, less frequent	6 13

Table 1: Key Symptoms of Catatonia

Understanding the Symptom Spectrum

Catatonia's symptomatology is broad and can be divided into motor, behavioral, and affective categories 2. The most frequently observed symptoms are mutism, immobility or stupor, staring, and withdrawal 8 9 13. In large clinical samples, mutism and stupor were present in over half of patients, while excitement (psychomotor agitation) was seen in a smaller subset, sometimes alternating with immobility in the same episode 9 13.

Core Symptom Clusters

Research using rating scales such as the Bush-Francis Catatonia Rating Scale (BFCRS) and the Northoff Catatonia Scale (NCS) has identified clusters or components of symptoms:

• Hypokinetic signs: Mutism, stupor, withdrawal, posturing, waxy flexibility.
• Hyperkinetic signs: Excitement, agitation, stereotypy, impulsivity.
• Parakinetic or abnormal activity: Stereotypy, mannerisms, echophenomena 6 9.

Associated Features

Other features, such as autonomic disturbances (seen in malignant catatonia), negativism, and rigidity, further enrich the clinical picture 7 10 13. The combination of symptoms can fluctuate, making repeated assessments critical.

Phenomenology and Subjective Experience

While certain symptoms like mutism and stupor are externally observable, patients sometimes report internal experiences of intense fear or provide narrative explanations rooted in delusions, hallucinations, or rational responses to perceived threats 9. This highlights the importance of integrating clinical observation with patient-reported experiences.

Types of Catatonia

Catatonia is not a single, uniform entity. Over time, clinicians and researchers have identified several types or sub-syndromes, each with distinct clinical and sometimes prognostic implications. Understanding these distinctions supports targeted management and improved outcomes.

Type	Defining Features	Clinical Relevance	Source(s)
Akinetic (Retarded)	Immobility, mutism, staring, withdrawal	Most common; responds to BZDs	8 13
Hyperkinetic (Excited)	Agitation, motor excitement, impulsivity	Less common; risk of injury	3 7 13
Malignant	Catatonia with autonomic instability, fever	Life-threatening; urgent care	10 13
Periodic/Alternating	Fluctuates between stupor and excitement	Seen in some patients	9 13

Table 2: Major Types of Catatonia

Akinetic (Retarded) Catatonia

Akinetic catatonia is the classic and most prevalent form. It is defined by profound psychomotor slowing or immobility, mutism, staring, and withdrawal. Patients may maintain rigid postures and show little or no response to external stimuli 8 13. This form often responds well to benzodiazepines and, if untreated, can progress to more severe states.

Hyperkinetic (Excited) Catatonia

In contrast, hyperkinetic or excited catatonia presents with marked psychomotor agitation, restlessness, impulsivity, and disorganized movements 3 7 13. Though less common, it is important due to the risk of exhaustion, self-injury, or aggression.

Malignant Catatonia

Malignant catatonia is a severe, potentially fatal subtype characterized by catatonic symptoms alongside autonomic instability (fever, tachycardia, hypertension, labile blood pressure) and altered consciousness 10 13. It can resemble or overlap with neuroleptic malignant syndrome and requires urgent intervention to prevent death.

Periodic/Alternating Catatonia

Some patients experience alternating episodes of stupor and excitement, either within the same episode or over time 9 13. This variability underscores the need for ongoing assessment and flexible treatment strategies.

Causes of Catatonia

Catatonia is a transdiagnostic syndrome—it can arise in the context of various psychiatric, neurologic, and medical conditions. Recent research has highlighted that catatonia is not exclusive to schizophrenia; in fact, mood disorders and general medical conditions play a major role.

Cause Category	Examples	Relative Frequency	Source(s)
Psychiatric	Schizophrenia, mood disorders (depression, bipolar), autism	Mood disorders: ~45%; schizophrenia: ~20%	3 8 13
Neurological	Encephalitis, epilepsy, traumatic brain injury, dementia	CNS diseases are major contributors	8 14 15
Medical (systemic)	Lupus, porphyria, autoimmune encephalitis, infection	~20% of hospital catatonia is medical	8 14 15
Drug-related	Neuroleptic malignant syndrome, withdrawal states	Significant in acute/ICU settings	10 14

Table 3: Causes and Risk Factors for Catatonia

Psychiatric Causes

While once considered a subtype of schizophrenia, only about 20% of catatonia cases are now linked to this diagnosis 8 13. Mood disorders—especially bipolar disorder and major depression—actually underlie the largest proportion of catatonic syndromes (up to 45%) 3 8 13. Catatonia is also seen in autism spectrum disorders, with particularly high prevalence in children and adolescents 8.

Neurological and Medical Causes

Up to 20% of catatonia cases in hospital settings are due to general medical or neurological conditions 8 14. Central nervous system (CNS) disorders are especially important, accounting for two-thirds of medical catatonia. These include:

• Autoimmune encephalitis (especially anti-NMDA receptor encephalitis)
• Epilepsy
• Traumatic brain injury
• Dementia and other neurodegenerative diseases 14 15

Drug-Induced and Iatrogenic Catatonia

Catatonia can also result from exposure to or withdrawal from certain medications, notably antipsychotics (neuroleptic malignant syndrome), benzodiazepines, and other psychoactive agents 10 14. In critical care settings, these factors are particularly relevant.

Pathophysiology and Biological Insights

Emerging research suggests that catatonia is linked to dysfunction in neurotransmitter systems—especially GABAergic and glutamatergic pathways. Glutamate hypofunction, as seen in NMDA receptor encephalitis, is particularly implicated 13 15. Abnormalities in brain connectivity, white matter tracts, and cortical structure have been observed in catatonic patients, especially those with schizophrenia spectrum disorders 4 5.

Demographic and Clinical Factors

Catatonia affects all age groups and can occur in both psychiatric and general medical settings. In older adults and critically ill patients, medical causes predominate, making medical evaluation essential in these groups 14.

Treatment of Catatonia

Catatonia is highly treatable, often with rapid and dramatic response to appropriate interventions. However, delayed or inadequate treatment can lead to serious complications, especially in malignant cases. Evidence-based treatment options are available, though research remains limited.

Treatment	Approach/Details	Effectiveness/Notes	Source(s)
Benzodiazepines	Lorazepam is first-line; "lorazepam test" for response	Response rates 66–100%	16 18 19 20
Electroconvulsive Therapy (ECT)	Second-line or for severe/malignant cases	High efficacy, especially if BZD fails	16 18 19 20
Alternative agents	NMDA antagonists, antiepileptics, atypical antipsychotics	Used if BZD/ECT unavailable; variable evidence	17
Treat Underlying Cause	Address medical/psychiatric illness	Essential for full recovery	12 14 19

Table 4: Evidence-Based Treatments for Catatonia

Benzodiazepines

Lorazepam is the mainstay of catatonia treatment. The "lorazepam challenge" (usually 1–2 mg IV/IM) can not only confirm the diagnosis (via rapid improvement) but also initiates ongoing therapy 16 18 19. Response rates range from 66% to nearly 100% in some studies. Benzodiazepines are effective in both adult and pediatric populations 20.

• Practical points:
  • Start with a test dose; monitor for improvement within hours.
  • Continue and titrate as needed if positive response.
  • Side effects are generally minimal, but monitor for sedation.

Electroconvulsive Therapy (ECT)

ECT is the treatment of choice for malignant catatonia, severe cases, or when benzodiazepines fail 16 18 19 20. It is highly effective and often life-saving, with rapid resolution of symptoms. ECT should not be delayed in life-threatening situations.

Alternative and Adjunctive Treatments

When benzodiazepines and ECT are ineffective or unavailable, alternative treatments have been tried, including:

• NMDA antagonists (e.g., amantadine, memantine)
• Antiepileptic medications
• Atypical antipsychotics (in select cases, especially with psychotic features; caution advised) 17

Evidence for these is limited to case reports and small series, and more research is needed.

Addressing the Underlying Cause

Regardless of symptomatic treatment, the underlying psychiatric or medical illness must be identified and managed 12 14 19. This may involve stopping offending drugs, treating infections, or managing systemic disease.

Prognosis and Special Populations

• Catatonia generally has a good prognosis with prompt treatment 19.
• Children and adolescents respond similarly to adults; first-line is benzodiazepines, with ECT reserved for refractory cases 20.
• Medical catatonia may be less responsive to traditional treatments; careful medical workup is essential 10 14.

Conclusion

Catatonia is a multifaceted syndrome with diverse symptoms, types, causes, and treatment approaches. Timely recognition and evidence-based management are crucial for optimal outcomes.

Key takeaways:

• Catatonia presents with a mix of motor, behavioral, and affective symptoms; mutism, stupor, and staring are among the most common signs 8 9 13.
• Types include akinetic (retarded), hyperkinetic (excited), malignant, and periodic catatonia, each with distinct features and risks 8 10 13.
• Causes span psychiatric disorders (notably mood disorders), neurological disease, medical conditions, and drug effects, with a significant role for CNS pathology 3 8 13 14 15.
• Benzodiazepines (lorazepam) are first-line treatment, with ECT reserved for refractory or malignant cases; treating the underlying cause is essential for full recovery 16 18 19 20.
• Early detection and intervention can be life-saving, especially in malignant catatonia or medical cases.

By maintaining a high level of clinical suspicion and following evidence-based protocols, clinicians can greatly improve the quality of life and prognosis for patients with catatonia.