Refresher on catatonia: An oft-forgotten but common disorder

Though often dismissed as a relic of Victorian asylums, catatonia is far from obsolete—it’s a real and pressing condition that modern physicians can’t afford to overlook due to its morbidity and mortality.“This is an extremely important, often unrecognized, and eminently treatable disorder,” Dr. Patricia Rosebush, a neuropsychiatrist widely known for her work in catatonia and mood disorders, said in an interview with the Medical Post. An April 2025 U.S.-based paper, “What Internists and Neurologists Know and Think About Catatonia,” identified large gaps in catatonia-related knowledge among internists and neurologists, especially in identifying individual catatonia features. The authors noted that catatonia can be the chief presenting clinical manifestation of many medical or neurological conditions in addition to primary psychiatric conditions, noting that psychiatrists have been shown to miss catatonia in up to 90% of cases—and nonpsychiatric practitioners probably more.Miraculous recoveryOnce she began her practice in the late 1980s and saw her first patient with catatonia—and the patient’s rapid response to simple treatment—Dr. Rosebush's interest in the disorder grew. “I had a patient on the psychiatric ward who was immobile, you had to look at the bedsheets to see if she was moving to see if she was alive. She was staring and not eating or drinking, not able to cooperate. I remembered an article I had read, and gave her lorazepam and it was like a walking-on-water moment—in about an hour she came alive had a miraculous recovery.”In a December 2016 benchmark paper called “Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology,” Dr. Rosebush and colleagues Dr. Sean Rasmussen and Dr. Michael Mazurek synthesized decades of clinical experience, reviewed 220 cases of catatonia the team had assessed as well as current literature. The paper noted that catatonia is a complex clinical syndrome occurring in more than 10% of patients with acute psychiatric illnesses, and it is associated with multiple life-threatening complications.Published in the World Journal of Psychiatry, the paper played a pivotal role in moving catatonia beyond its historical association with schizophrenia and outlining the importance of prompt treatment.A psychomotor disturbance characterized by abnormalities in movement, speech and behaviour, catatonia was long considered a subtype of schizophrenia and was defined as such in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as such until 2013.“Now it is considered more of a standalone syndrome. More recently, mood disorders, especially bipolar disorder, as well as major depression, have been shown to be the primary underlying disorders, at about 60% of cases,” with schizophrenia at about 20% of cases, estimates Dr. Rosebush, also the head of Consultation-Liaison Psychiatry Service at St. Joseph’s Healthcare Hamilton, which works at the interface of medicine and psychiatry and provides psychiatric consultation for patients admitted to medical/surgical units.“It is very common on medical wards, so when you have a person who is not eating or drinking, not moving, you have to you have to think broadly about the medical conditions that could underlay,” she said.Catatonia is considered an emergency, said Dr. Rosebush, and acute care practitioners in internal medicine and neurology will often be the first clinicians to encounter patients with catatonia—and need to know the symptoms.Two primary subtypes have been identified: The most common is retarded catatonia. Less common is excited catatonia, characterized by episodes of severe psychomotor agitation, in addition to the many of the common characteristics of retarded catatonia. Some patients cycle through the two types. A rare third type, malignant excited catatonia can occur, usually evolving from retarded catatonia, and includes a fever, tachycardia and hypertension.Dr. Rosebush said she and her colleagues have found the following clinical features are the most frequently seen and most readily observed in catatonia (retarded type). They also predict a good response to treatment with lorazepam. Immobility (in 97%)Mutism (in 97%)Refusal to eat or drink (in 91%)Staring (in 87%)Negativism (in 67%)Posturing (in 58%)Rigidity (in 54%)“If you see the first three or four of these, it is likely catatonia. Sometimes, someone is so immobile, they look dead or dying. Other times, someone who comes in holding a bizarre, fixed posture, though that's less common.”Although they are cited in the DSM-5 (see sidebar), “Waxy flexibility, stereotypy, echolalia and echopraxia are present in 25% cases or less,” she said.Most patients respond rapidly to low-dose benzodiazepines, particularly lorazepam, while electroconvulsive therapy (ECT) remains an effective option for refractory cases, notes Dr. Rosebush.Diagnosis and treatment are key, she says, because in many cases, treatment of the catatonic symptoms is necessary before an accurate diagnosis of the underlying disorder, be it psychiatric or non-psychiatric, can be made.“There’s such morbidity and mortality associated with catatonia. You can’t get a history or do certain tests or take care of patients in that state,” said Dr. Rosebush, who was recently an expert witness for a coroner's case in which a complication of undiagnosed catatonia was the likely cause of death.Catatonia is often linked to other disorders and requires prompt diagnosis and treatment. It can increase the risk of neuroleptic malignant syndrome—a life-threatening condition that closely resembles malignant catatonia. The immobility and refusal to eat or drink seen in catatonia can also lead to serious medical complications, such as dehydration, malnutrition, blood clots, infections, pressure sores and muscle contractures.When catatonic symptoms are present, the cause is likely psychiatric, but neurological diseases like strokes, neoplasms or Parkinson’s Disease can lead to catatonia; as can autoimmune, paraneoplastic, infectious or metabolic disorders. So can certain drug or poison exposure or even withdrawal from regular benzodiazepine use or a side-effect of antipsychotics.Catatonia is primarily a clinical diagnosis that does not require specific lab tests or imaging, but certain testing can help determine the underlying etiology of the catatonia. An electroencephalogram EEG is recommended when a patient appears to be in a state of retarded catatonia, to rule out other neurological conditions, like seizures. The EEG in catatonia is typically normal unless there is a concurrent condition that may be causing the abnormality. Brain imaging, preferably an MRI is recommended, and lab investigations should include a complete blood count to assess for comorbid conditions.A hallmark of catatonia is its remarkable response to low doses of benzodiazepines. “An EEG is a very good distinguishing test, and fortunately, there’s not much downside to administering benzodiazepines even if you’ve got the diagnosis wrong,” said Dr. Rosebush. “We recommend starting with 2 mg of lorazepam, given intramuscularly, as many catatonic patients are unable or unwilling to take oral medications. For patients who are very young, elderly, or fragile—especially those with diagnosed or suspected sleep apnea—a lower dose is advisable.” She added that if there is no initial response two more rounds of the same can be administered after three hours—but if there is still no response, physicians need to rethink the diagnosis.About 80%-to-90% of patients respond within three hours if they do in fact have catatonia. The patient is then put on an ongoing lower dose while they undergo diagnosis or treatment for underlying illnesses.But, there's still mystery surrounding the cause of catatonia, said Dr. Rosebush. "But because it causes so much mortality and morbidity, it is important to be aware of its symptoms so that it can be treated, and afterward any underlying conditions can be addressed."References and further reading: What Internists and Neurologists Know and Think About Catatonia(Dr. Japsimran Kaur, Daniel D. Maeng, PhD, Dr. Joshua R. Wortzel, Dr. Mark A. Oldham; Primary Care Companion CNS Disorders, April 2025)Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology(Sean A Rasmussen, Michael F Mazurek, Patricia I Rosebush, World Journal of Psychiatry, December 2016) Catatonia(Dr. Jeffrey P. Burrow, Dr. Benjamin C. Spurling, Dr. Raman Marwaha, StatPearls, May 2023)

Refresher on catatonia: An oft-forgotten but common disorder

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