Psych · General adult psychiatry
Catatonia
Also known as Catatonic syndrome · Retarded catatonia · Excited catatonia · Malignant catatonia · Bush-Francis catatonia · Lorazepam challenge
Exam-exhaustive fellowship topic on catatonia — DSM-5-TR and ICD-11 nosology, Bush-Francis screening and severity scales, retarded versus excited phenotypes, malignant catatonia, medical and autoimmune causes, lorazepam challenge and high-dose benzodiazepine therapy, ECT, NMS overlap, and special populations. FRANZCP-primary, globally tagged.
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Target exams
FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Fever and autonomic instability with catatonic signs — malignant catatonia pathway; escalate medically and plan early ECT
- Not eating or drinking with mutism and immobility — dehydration, VTE, and aspiration risk; treat as medical urgency
- Treating pure catatonia with antipsychotics alone — may precipitate NMS and delays definitive benzos/ECT
- Assuming catatonia equals schizophrenia — mood disorders and medical causes are common
- Ignoring medical and autoimmune work-up in first-episode or atypical catatonia (anti-NMDA encephalitis)
- NMS overlap after dopamine antagonists — stop neuroleptics; still use benzodiazepines and consider ECT
- Delayed ECT while waiting days for oral improvement in malignant or life-threatening catatonia
Meet the patient
A 24-year-old woman, three days into a manic relapse, stops speaking. Then stops moving. She stands in the corridor holding one arm in the air like a traffic cop. She has not eaten or drunk since yesterday. Her obs: T 38.7, HR 130, BP swinging. Yesterday she had IM olanzapine.[16][17]
Every registrar's first instinct on that ward round: "she's being difficult." Every examiner's first question: "What do you do in the next ten minutes?" This topic is the answer to that question.[16][17]
References24ShowHide
- [1]Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination Acta Psychiatr Scand, 1996.PMID 8686483
- [2]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
- [3]Fink M, Taylor MA The catatonia syndrome: forgotten but not gone Arch Gen Psychiatry, 2009.PMID 19884605
- [4]Fink M, Shorter E, Taylor MA Catatonia is not schizophrenia: Kraepelin's error and the need to recognize catatonia as an independent syndrome in medical nomenclature Schizophr Bull, 2010.PMID 19586994
- [5]Tandon R, Heckers S, Bustillo J, et al. Catatonia in DSM-5 Schizophr Res, 2013.PMID 23806583
- [6]Heckers S, Tandon R, Bustillo J Catatonia in the DSM--shall we move or not? Schizophr Bull, 2010.PMID 19933711
- [7]Walther S, Stegmayer K, Wilson JE, et al. Structure and neural mechanisms of catatonia Lancet Psychiatry, 2019.PMID 31196794
- [8]Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2023.PMID 37039129
- [9]Rosebush PI, Mazurek MF Catatonia and its treatment Schizophr Bull, 2010.PMID 19969591
- [10]Oldham MA The Probability That Catatonia in the Hospital has a Medical Cause and the Relative Proportions of Its Causes: A Systematic Review Psychosomatics, 2018.PMID 29776679
- [11]Solmi M, Pigato GG, Roiter B, et al. Prevalence of Catatonia and Its Moderators in Clinical Samples: Results from a Meta-analysis and Meta-regression Analysis Schizophr Bull, 2018.PMID 29140521
- [12]Pelzer AC, van der Heijden FM, den Boer E Systematic review of catatonia treatment Neuropsychiatr Dis Treat, 2018.PMID 29398916
- [13]Luchini F, Medda P, Mariani MG, et al. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response World J Psychiatry, 2015.PMID 26110120
- [14]Raveendranathan D, Narayanaswamy JC, Reddi SV Response rate of catatonia to electroconvulsive therapy and its clinical correlates Eur Arch Psychiatry Clin Neurosci, 2012.PMID 22207031
- [15]Tibrewal P, Narayanaswamy J, Zutshi A, et al. Response rate of lorazepam in catatonia: a developing country's perspective Prog Neuropsychopharmacol Biol Psychiatry, 2010.PMID 20804808
- [16]Philbrick KL, Rummans TA Malignant catatonia J Neuropsychiatry Clin Neurosci, 1994.PMID 7908547
- [17]Connell J, Oldham M, Pandharipande P, et al. Malignant Catatonia: A Review for the Intensivist J Intensive Care Med, 2023.PMID 35861966
- [18]Northoff G Catatonia and neuroleptic malignant syndrome: psychopathology and pathophysiology J Neural Transm (Vienna), 2002.PMID 12486486
- [19]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
- [20]Perry PJ, Wilborn CA Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and management Ann Clin Psychiatry, 2012.PMID 22563571
- [21]Daniels J Catatonia: clinical aspects and neurobiological correlates J Neuropsychiatry Clin Neurosci, 2009.PMID 19996245
- [22]Rogers JP, Zandi MS, David AS The diagnosis and treatment of catatonia Clin Med (Lond), 2023.PMID 37236789
- [23]Rasmussen SA, Mazurek MF, Rosebush PI Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology World J Psychiatry, 2016.PMID 28078203
- [24]Gunther M, Tran N, Jiang S Zolpidem for the Management of Catatonia: A Systematic Review J Acad Consult Liaison Psychiatry, 2025.PMID 39522949