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

Studies suggest that 1.8% of adult hospitalized patients and 8.9% of elderly hospitalized patients for whom psychiatry was consulted exhibited signs and symptoms of catatonia. Among ventilated patients, 31% met the criteria for both delirium and catatonia and 3% for catatonia alone.
While depression, schizophrenia, and bipolar disorder are common psychiatric comorbidities, patients can develop catatonia from several medical etiologies, even when no preexisting psychiatric disorder is present.
The proposed physiology involves dopamine and GABA hypoactivity, and glutamate hyperactivity. Hence, dopamine antagonists like haloperidol or metoclopramide can exacerbate these physiologic perturbations, as can the abrupt withdrawal of benzodiazepines.

Clinical characteristics.
Rigidity, posturing, stupor, immobility, and mutism are the most common features. Catatonia is characterized by three or more or the following symptoms:
- abnormal behaviors
- catalepsy; abnormal posturing or maintenance of an abnormal position with repositioning
- grimacing; exaggerated facial expressions
- limited activity
- mannerism; unusual purposeful actions or behaviors (e.g., ambulating on one foot)
- mutism; decreased speech production or volume (not necessarily fully mute)
- negativism; opposition or no response to instructions or passive movements
- paroxysmal hyperactivity; short episodes of agitation, excited motor movements, echolalia (mimicking of examiner’s speech), and/or echopraxia (mimicking movements)
- stereotypy; repetitive, frequent, non-goal directed movements
- stupor; minimal responsiveness, muscles and posture often appear rigid
- unusual positioning
- waxy flexibility; slight but even resistance to positioning by examiner

Although features can fluctuate in severity and range from hypoactivity to hyperactivity, without prompt identification, and especially receiving concurrent antipsychotic medication, catatonia can progress to a condition called “malignant catatonia,” involving fevers, autonomic instability, and unstable vital signs.

Diagnosis. 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.

Management.
- Psychiatry consultation is recommended.
- Discontinue precipitating agents, such as neuroleptics.
- Benzodiazepines are first-line catatonia treatments.
- If fever and autonomic instability occur in a patient with catatonia, ICU transfer and/or psychiatry consult may be necessary, electroconvulsive therapy and/or dopaminergic medications are often required.

Case series suggest that lorazepam remission rates are about 75-80% for patients with catatonia. Malignant catatonia is associated with a mortality rate of 20% and worse response rates to lorazepam.

See reference for more information.

Adapted from Weinberg R, Fishman D, Azzam P. Catatonia. Palliative Care Network of Wisconsin. Fast facts and concepts #349. Internet. Accessed on May 4, 2018.