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Catatonia – What You Need to Know

December 13, 2023

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Written by Julie Brown

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Catatonia is a psychiatric condition with variable and unpredictable clinical features. Let’s dive into how to recognize, diagnose, and manage it in the ED.

Who let the catatonia out of the bag?
Catatonia has been classically understood as a feature of schizophrenia; however, it is now recognized as its own diagnostic entity. The mechanism behind it remains poorly understood. Episodes may arise acutely or develop gradually, be transient or persist for years, and are recognized by many diagnostic signs including:

  • Staring
  • Stupor*: absence of any motor activity
  • Mutism*: no speech/incomprehensible speech
  • Posturing & Catalepsy
  • Rigidity
  • Echolalia/Echopraxia: repetition of provider’s words/actions
  • Waxy flexibility: resistance to provider’s positioning

(* most common presentations of catatonia in EDs)

There are several diagnostic tools including the Bush-Francis Catatonia Rating Scale that may be used by providers to identify this clinical diagnosis. Once other causes of abnormal psychomotor behaviors or poor interaction (trauma-related dissociation, failure to thrive, substance intoxication, drug interactions) are ruled out, catatonia should be suspected, and prompt treatment is indicated. Known as the “Lorazepam Challenge,” the administration of 1 to 2 mg of lorazepam has been found to be both diagnostic and therapeutic for patients with catatonia. Patients respond to lorazepam by becoming more mobile if previously stuporous, verbal if previously mute, or resume oral intake if previously rejecting. If successful, lorazepam can be continued or increased to up to 16 mg daily. Electroconvulsive therapy (ECT) may be an effective treatment of catatonia that is refractory to benzodiazepines.

Catatonia may be difficult to distinguish from delirium, a separate but common process encountered in EDs. Unlike catatonia, delirium is defined by fluctuating levels of attention and cognition. Providers should also be aware of malignant catatonia, a severe form of catatonia characterized by abnormal vital signs and metabolic disturbances, with complications including malnutrition, infection, dehydration, pressure injuries, thromboembolism, contractures, and death. If catatonia is suspected, psychiatry should be engaged to guide management; however, patients with severe catatonia may require inpatient medical admission for rehydration, vital sign monitoring, and nutrition.

How will this change my practice?
Patients with catatonia often present to the ED, so it’s important for us to recognize this diagnosis, its variable features, and its management. I include primary psychiatric disturbances in my differential diagnosis for altered mental status, but moving forward, I will specifically think about catatonia, particularly in patients with minimal or absent motor and verbal activity.

Editor’s note: I found it helpful to go through the MDCalc Bush-Francis score to learn more about some of the clinical features. ~Clay Smith

Catatonia. N Engl J Med. 2023 Nov 9;389(19):1797-1802. doi: 10.1056/NEJMra2116304.

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