Catatonia is a neuropsychiatric syndrome manifested by non-volitional alterations in behavior, motor activity, and speech which can mimic delirium. As its treatment is different and can be life-saving, it should be in the differential diagnosis for all seriously ill patients who present with an altered mood or mental status.

The proposed physiology involves dopamine and GABA hypoactivity, and glutamate hyperactivity. So, dopamine antagonists (e.g., haloperidol, metoclopramide) can exacerbate these perturbations, as can the abrupt withdrawal of benzodiazepines.

It is characterized by three or more or the symptoms, classified into four groups.

Limited activity

Mutism - decreased speech production or volume (not necessarily fully mute).
Stupor - minimal responsiveness, muscles and posture often appear rigid.
Negativism - opposition or no response to instructions or passive movements.
Unusual positioning

Catalepsy - abnormal posturing or maintenance of an abnormal position with repositioning.
Waxy flexibility - Slight but even resistance to positioning by examiner.
Abnormal behaviors

Mannerism - unusual purposeful actions or behaviors (e.g., ambulating on one foot).
Stereotypy - repetitive, frequent, non-goal directed movements
Grimacing - exaggerated facial expressions
Paroxysmal hyperactivity - short episodes of agitation, excited motor movements, echolalia (mimicking of examiner’s speech), and/or echopraxia (mimicking movements).

Catatonia can clinically resemble delirium and many other medical conditions (encephalitis, neuroleptic malignant syndrome, traumatic brain injury, stroke, developmental disorders, Parkinson’s-related akinesia, and status epilepticus).
Several clinical features can indicate clinicians the presence of catatonia or delirium.
Catatonia: posturing; increased motor tone, mutism, negativism, echolalia or echopraxia, repetitive movements, symptoms worsen from neuroleptics.
Delirium: disorientation; inability to attend; disorganized thinking; hallucinations; impaired short-term memory; altered sleep-wake cycle; symptoms may improve with neuroleptics.

Treatment.
- Psychiatry consultation.
- Discontinuation of precipitating agents (neuroleptics) and restart recently withdrawn GABAergic medications (benzodiazepines).
- Benzodiazepines (lorazepam) are first-line catatonia treatments.
- Electroconvulsive therapy and/or dopaminergic medications (e.g., amantadine, bromocriptine) are often required.

See reference for more information.

Adapted from Weinberg R, Fishman D, Azzam P. Catatonia. Palliative Care Network of Wisconsin. Fast facts # 349. Internet. Accessed on November 15, 2021. Available at https://www.mypcnow.org/fast-fact/catatonia/