Catatonia - Treatment and Prognosis - UpToDate

6/3/2018 Catatonia: Treatment and prognosis - UpToDate
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Catatonia: Treatment and prognosis
Author: M Justin Coffey, MD

Section Editors: Peter P Roy-Byrne, MD, Stephen Marder, MD
Deputy Editor: David Solomon, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2018. | This topic last updated: Nov 22, 2017.
INTRODUCTION — Catatonia is a behavioral syndrome marked by an inability to move normally, which can occur in the context of
many psychiatric and general medical disorders [1]. Prompt treatment of catatonia with benzodiazepines or electroconvulsive therapy
(ECT), as well as treatment of the underlying cause, generally leads to remission of catatonia. However, failure to recognize and
properly treat catatonia can lead to poor outcomes; malignant catatonia in particular can be fatal.
This topic reviews the treatment and prognosis of catatonia. The epidemiology, clinical features, assessment, underlying disorders,
diagnosis, and differential diagnosis are discussed separately. (See "Catatonia in adults: Epidemiology, clinical features, assessment,
and diagnosis".)
DEFINITION OF CATATONIA — Catatonia is a behavioral syndrome marked by an inability to move normally, and can occur in patients
with underlying psychiatric (eg, autism spectrum disorder, bipolar disorders, psychotic disorders, and unipolar major depression) and
general medical disorders. The syndrome is marked by heterogeneous signs that are observed or elicited (table 1 and table 2); the most
common are immobility, rigidity, mutism, posturing, excessive motor activity, stupor, negativism, staring, and echolalia [1-3].
Subtypes of catatonia are based upon the specific nature of the movement disturbance and other associated features [1]. The three
principal forms in order of incidence are:
● Retarded – Mutism, inhibited movement, posturing, rigidity, negativism, and staring
● Malignant – Fever, autonomic instability (labile or elevated blood pressure, tachycardia, tachypnea, and diaphoresis), delirium, and
rigidity
● Excited – Excessive and purposeless motor activity, restlessness, stereotypy, impulsivity, frenzy, agitation, and combativeness
Additional information about the clinical features, subtypes, assessment, underlying disorders, diagnosis, and differential diagnosis of
catatonia is discussed separately. (See "Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis".)
TREATMENT
Setting and management — The presence of catatonia reflects that the patient is severely ill with an underlying psychiatric or general
medical disorder [4,5]. Patients are commonly hospitalized to treat the catatonic syndrome and underlying disorder, as well as to prevent
and manage complications of catatonia such as aspiration pneumonia, venous thromboembolism (deep vein thrombosis and pulmonary
embolism), constipation with impaction, and urinary retention [2].
Malignant catatonia in particular is life-threatening and generally warrants admission to an intensive care unit to monitor and treat [6]:
● Hyperthermia – Management of hyperthermia requires ensuring adequate airway protection, breathing, and circulation; initiation of
rapid cooling; and treatment of complications. (See "Severe nonexertional hyperthermia (classic heat stroke) in adults", section on
'Management'.)
● Hypertension – Oral or parenteral medication may be necessary for severe hypertension. (See "Drugs used for the treatment of
hypertensive emergencies".)
● Cardiopulmonary instability – Arrhythmias may occur from electrolyte imbalance.
For all patients with catatonia, clinicians should try to prevent and manage [7]:
● Dehydration and malnutrition – Patients who refuse to eat or drink should be monitored for input and output and may require enteral
or parenteral fluids and feeding. (See "Nutrition support in critically ill patients: An overview".)
● Deep vein thrombosis and pulmonary embolism – Deep vein thrombosis may occur in more than 25 percent of patients with
catatonia; the retarded subtype of catatonia presents the highest risk [8]. Prevention and treatment of venous thromboembolism
includes graduated compression stockings, intermittent pneumatic compression, and anticoagulants. (See "Prevention of venous
thromboembolic disease in acutely ill hospitalized medical adults".)
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● Contractures – Studies of patients with structural neurologic damage suggest that stretching and passive range of motion may
prevent and treat contractures, but the results are inconsistent.
● Pressure ulcers – Pressure relief is the most important factor in preventing pressure (decubitus) ulcers and can be accomplished
with proper patient positioning and appropriate use of pressure-reducing devices. Positioning of bed-bound individuals includes a
regular turning and repositioning schedule (eg, every two hours), with attention to vulnerable tissue covering bony prominences
such as the sacrum. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury" and
"Prevention of pressure-induced skin and soft tissue injury" and "Clinical staging and management of pressure-induced skin and
soft tissue injury".)
● Excitement and impulsivity – Catatonic excitement and impulsivity are most safely treated with a benzodiazepine such as
lorazepam, although seclusion and physical restraints are occasionally required as well. Antipsychotic drugs should be avoided.
(See 'Benzodiazepine safety and administration' below and "Assessment and emergency management of the acutely agitated or
violent adult", section on 'Physical restraints'.)
Underlying disorder — Management of catatonia includes treating the underlying cause as soon as it is identified, which may improve
outcomes [9]. On acute inpatient psychiatric units, catatonia is most likely to occur in bipolar disorder with psychotic features and
psychotic depression [10-13]. Catatonia is also associated with psychotic disorders (eg, schizophrenia) and autism spectrum disorder
[5]. Many general medical conditions can progress to catatonia, including infectious, metabolic, and neurologic disorders [1,5,14].
Treatment of the general medical condition may need to be prioritized over catatonia. (See "Catatonia in adults: Epidemiology, clinical
features, assessment, and diagnosis", section on 'Underlying disorders'.)
Avoid dopamine blocking drugs — Clinicians should try to avoid antipsychotics and other dopamine blocking drugs (eg, antiemetic
agents) in patients with catatonia, including patients who are psychotic, impulsive, or aggressive [1]. First-generation antipsychotics do
not appear to provide any benefit for treating catatonia [15]. Although there are reports that second-generation antipsychotics may treat
catatonia [2,16-19], all antipsychotics can precipitate and worsen catatonia [3,11,20]. In addition, treating catatonia with an antipsychotic
is a risk factor for the neuroleptic malignant syndrome (NMS) [12,21-25]; the risk may be particularly elevated in patients who are
dehydrated, receive the antipsychotic parenterally or at rapidly escalating doses, or have a prior history of catatonia [26]. Antipsychotics
are contraindicated in malignant catatonia. (See "Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Malignant catatonia'.)
After catatonia has resolved and the patient is autonomically stable, eating and drinking normally, and moving as expected, clinicians
may consider resuming an antipsychotic drug to treat an underlying psychotic disorder [12]. However, reintroducing antipsychotics
should be done cautiously, with patients examined regularly for autonomic instability and recurrence of catatonic signs. If a
benzodiazepine resolved the catatonic episode, it should be maintained during treatment with an antipsychotic [13]. Although high-
potency, first-generation antipsychotics carry the highest risk of NMS, all second-generation antipsychotics can also cause NMS [24,27];
one case report described NMS in a patient who was treated with low-dose clozapine soon after recovering from catatonia [28].
NMS is discussed separately. (See "Neuroleptic malignant syndrome".)
Treatment algorithm — First-line treatment for catatonia is a benzodiazepine or electroconvulsive therapy (ECT), depending upon the
subtype of catatonia, clinical urgency, and availability of treatments (algorithm 1) [1,15,29-33]:
● For patients with malignant catatonia, we recommend a benzodiazepine plus immediate preparation to administer ECT as soon as
possible. If the benzodiazepine provides a substantive response during the first 24 to 48 hours, it can be continued in lieu of ECT.
● For patients with nonmalignant catatonia, whether the behavioral phenotype (motor disturbance) is retarded or excited, we
recommend treatment with a benzodiazepine (lorazepam is used most often).
The goal of treatment is full remission.
Few randomized trials have evaluated benzodiazepines [34] or ECT [35] for acute catatonia, and these are limited to patients with
nonaffective disorders. Multiple prospective open-label studies, cases series, and retrospective studies suggest that benzodiazepines
alone, ECT alone, or benzodiazepines followed by ECT, lead to recovery in approximately 60 to 80 percent of patients [1,15,26,36-39].
Treatment guidelines from the American Psychiatric Association, United Kingdom National Institute for Health and Clinical Excellence,
and World Federation of Societies of Biological Psychiatry recommend treating catatonia with either a benzodiazepine or ECT,
depending upon the clinical urgency [29-33].
Multiple reviews of open-label studies, case series, and case reports have found that treatment of catatonia is the same regardless of
the underlying disorder [14,39,40].
In children and adolescents, the approach to treatment is the same. In a prospective observational study of youth (n = 66, ages 9 to 19
years) who were hospitalized for catatonia, 51 patients received benzodiazepines, which were effective in 65 percent of cases [40]. The
benzodiazepine used most often was lorazepam (mean dose 5 mg per day); the large majority received concomitant medications such
as antipsychotics. A course of bilateral ECT was administered as first-line treatment in three patients, including two with malignant
catatonia, and as second-line treatment in eight other patients.
Studies suggest that catatonia may respond to the combination of benzodiazepines plus ECT [41]. Although this is not our standard
practice, when the combination is employed, an agent such as flumazenil is administered prior to ECT in order to reverse the
anticonvulsant properties of benzodiazepines. (See "Overview of electroconvulsive therapy (ECT) for adults", section on 'Psychotropic
drugs'.)
Malignant catatonia — ECT is first-line treatment for patients with malignant catatonia (algorithm 1) [1,15,29-33]:
[1,3,15,26]. We recommend that clinicians concurrently start a benzodiazepine and the process of obtaining informed consent and
medical consultation for ECT. If the patient does not measurably respond to a benzodiazepine within the first day or two, ECT should
commence and the benzodiazepine should be discontinued. Reviews of case reports have found that mortality for progressive malignant
catatonia increases if ECT does not begin within five days of symptom onset [26,42]. Another review of case reports found that in
patients with malignant catatonia, response to ECT occurred in 9 of 11 patients (89 percent), whereas response to a benzodiazepine
occurred in 2 of 5 patients (40 percent) [15].
For malignant catatonia that does not respond fully to initial treatment with ECT, we suggest continuing ECT until full remission is
achieved. If improvement does not occur or plateaus at partial remission, we recommend continuing ECT and restarting the same
benzodiazepine (eg, lorazepam) that was used while preparations were made to initiate ECT. If there is no further incremental
improvement after additional ECT (eg, three more treatments), clinicians should evaluate the quality of the ECT (eg, electrode
placement and stimulus) and re-evaluate the patient to determine whether the diagnosis is malignant catatonia. If ECT has been
administered properly and the diagnosis of malignant catatonia is confirmed, we suggest that treatment focus upon the underlying
disorder (see 'Underlying disorder' above). As an example:
● Catatonia may be due to the neuroleptic malignant syndrome, which occurred in the context of administering a depot neuroleptic.
Treatment consists of supportive care and watchful waiting while the neuroleptic is metabolized.
● Alternatively, catatonia may be secondary to mania; aggressive treatment of the manic syndrome should be pursued.
The safety and administration of benzodiazepines and ECT are discussed elsewhere in this topic. (See 'Benzodiazepine safety and
administration' below and 'Electroconvulsive therapy safety and administration' below.)
Nonmalignant catatonia — Based upon prospective open-label studies and case series, we recommend initial treatment with a
benzodiazepine for patients with nonmalignant catatonia, whether the behavioral phenotype (motor disturbance) is retarded or excited
(algorithm 1) [1,15,29-33]:
[1,15]. Lorazepam has been studied most frequently [1,12,15,36,43,44], but case reports also describe successful treatment with
diazepam, clonazepam, clorazepate, midazolam, and alprazolam [45-54]. In a review of case reports of 104 catatonic episodes that
were treated with benzodiazepine monotherapy, 70 percent remitted; among the 72 episodes treated with lorazepam, 79 percent
remitted [15]. Other reviews estimate that 60 to 80 percent of patients with catatonia respond to lorazepam monotherapy [3,45,55].
Although amobarbital was significantly more effective than placebo in a randomized trial [56], most authorities consider benzodiazepines
as first-line pharmacotherapy because they are generally effective and safer than barbiturates [1-3]. In addition, benzodiazepines have
been studied more often, are familiar to clinicians, and an antagonist (flumazenil) is available. (See 'Benzodiazepine safety and
administration' below.)
Clinical factors may be associated with response to a benzodiazepine. Successful benzodiazepine treatment may be more likely in
patients with a significant reduction of catatonic signs after the first dose of lorazepam or other benzodiazepine (positive lorazepam
challenge test) [42]. Acutely catatonic patients with an underlying bipolar or depressive disorder may respond more favorably to a
benzodiazepine than schizophrenic patients [13,57]. In addition, benzodiazepines at low doses do not appear to benefit chronic
catatonia in schizophrenic patients. A randomized trial compared adjunctive lorazepam with placebo for treating slow-onset, long-
standing (≥4 years) catatonic signs in severely disabled and treatment-resistant chronic schizophrenic patients; lorazepam 6 mg daily
provided no benefit [34]. It is not clear whether a longer duration of catatonia prior to treatment is associated with a poorer response to
treatment, due to contradictory study results [13,36]. Age, sex, and the number and pattern of catatonic signs do not appear to be
associated with response to a benzodiazepine [3,11,26,36]. The lorazepam challenge test is discussed separately. (See "Catatonia in
adults: Epidemiology, clinical features, assessment, and diagnosis", section on 'Lorazepam challenge'.)
Based upon clinical experience, retarded or excited catatonia generally responds to a benzodiazepine within one week. For patients who
do not respond to a benzodiazepine within one week, ECT is the treatment of choice [1,3,26,36]. In addition, if the underlying cause of
catatonia is a bipolar or depressive disorder, or for patients requiring a rapid treatment response, ECT is the most effective treatment
option. Evidence supporting the use of ECT includes a small, three-week trial that enrolled inpatients (n = 14) with nonaffective catatonia
who did not respond to lorazepam (6 to 8 mg/day) within five days; patients were randomly assigned to real ECT (bilateral) plus pill
placebo or to sham ECT plus risperidone (4 to 6 mg/day) [35]. Improvement of catatonia was greater with real ECT than risperidone.
Based upon open-label studies, case series, and retrospective studies, it is estimated that approximately 60 percent or more of catatonic
patients achieve remission with ECT, including patients unresponsive to a benzodiazepine [3,29,36,37,43,58-60]. As an example, a
review of case reports of 55 catatonic episodes that were treated with ECT alone found that 85 percent remitted [15]. A subsequent
chart review of 27 catatonic patients treated with ECT found that 59 percent improved [37]. For patients with a bipolar or depressive
disorder or acute psychosis, ECT can relieve both the catatonic syndrome and the underlying psychopathology [3,26]. (See
'Electroconvulsive therapy safety and administration' below.)
There are no established predictors of response to ECT for patients with catatonia [2]. However, acutely catatonic patients with an
underlying bipolar or depressive disorder may respond more favorably to ECT than schizophrenic patients [57], and ECT does not
appear to benefit chronic catatonia in schizophrenic patients [61].
For retarded or excited catatonia that does not respond fully to initial treatment with a benzodiazepine and subsequent treatment with
ECT, we suggest continuing ECT and restarting the same benzodiazepine (eg, lorazepam) that was used initially. If there is no further
incremental improvement after additional ECT (eg, three more treatments), clinicians should evaluate the quality of the ECT (eg,
electrode placement and stimulus) and re-evaluate the patient to determine whether the diagnosis is retarded or excited catatonia. If
ECT has been administered properly and the diagnosis of catatonia is confirmed, we suggest that treatment focus upon the underlying
disorder (see 'Underlying disorder' above). In addition, it is reasonable to use other treatments that are described below. (See 'Other
treatments' below.)
Benzodiazepine safety and administration — Benzodiazepines are generally safe and well tolerated in this setting. At doses used for
treating catatonia, benzodiazepines are not associated with respiratory depression in otherwise healthy adults. However, clinicians
should be cognizant of concomitant drugs (eg, opioids) that can cause sedation or respiratory depression. In addition, benzodiazepines
cause varying degrees of motor incoordination and increase the risk of falls [12].
Benzodiazepines can be administered intravenously, intramuscularly, or orally (lorazepam is available in all three formulations) [3,36].
Intravenous administration is preferred to assure adherence and rapid, complete absorption (intravenous access also permits
administration of fluids for dehydration). Intravenous benzodiazepines should be injected or infused slowly. As patients improve, they
should be switched to oral medication.
Lorazepam has been studied most often, and is typically initiated at 1 to 2 mg three times per day. For patients who are already
receiving lorazepam for another indication when they present with catatonia, the starting dose of lorazepam for catatonia (eg, 1 mg three
times per day) is added to the existing dose of lorazepam (eg, 1 mg each night for insomnia). Close observation for a clinical response
can substantiate the diagnosis of catatonia. (See "Catatonia in adults: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Lorazepam challenge'.)
Subsequently, the dose is increased by 3 mg per day every one to two days, depending upon patient response, tolerability, and clinical
urgency. A dose of 6 to 21 mg daily is effective for most patients, but a dose of 30 mg per day is occasionally necessary [1]. For patients
with excited catatonia, lorazepam 1 to 2 mg is given at more frequent intervals until the patient is calm but awake.
A more cautious approach is suggested for patients at risk of cardiorespiratory compromise or oversedation, including patients with:
● Cardiovascular or respiratory disease
● Older age
● Obesity
● Volume depletion
● Prescriptions for opioid analgesics
For patients with these risk factors, the initial dose may be reduced to 0.5 mg three times per day and closer monitoring provided
[12,43].
The duration of treatment required to achieve remission of catatonia with a benzodiazepine is typically 4 to 10 days [42]. The
benzodiazepine is usually continued at the effective dose for three to six months to maintain recovery and is then slowly tapered and
discontinued, although longer maintenance treatment may be necessary [62].
Drug information topics are available for specific benzodiazepines.
Electroconvulsive therapy safety and administration — ECT is generally safe, even in patients whose general medical status is
compromised [63], as well as patients who are pregnant [64] or elderly [65]. However, the success of ECT depends upon an appropriate
pre-ECT evaluation, the goals of which are to optimize treatment efficacy and minimize the risk of cognitive and other side effects
associated with ECT. ECT is typically administered with the same technique used for other indications. (See "Medical consultation for
electroconvulsive therapy" and "Technique for performing electroconvulsive therapy (ECT) in adults".)
There are no absolute contraindications to ECT [66-70]. Underlying general medical conditions may increase the risk of adverse effects
of ECT or general anesthesia, but modern ECT technique and preprocedure consultation to optimize the patient’s general medical status
reduce these risks. As an example, catatonic patients with motor immobility and muscle damage are at increased risk for transient
hyperkalemia associated with the muscle relaxant succinylcholine [2,14]. This increased risk is eliminated by using a nondepolarizing
muscle relaxant (eg, rocuronium) [71].
Electrode placement and other aspects of ECT technique for treating catatonia have not been standardized [14]. However, bitemporal
electrode placement and brief pulse current are generally preferred [1]. ECT is generally given three times per week on alternating days.
However, for patients with malignant catatonia, we suggest daily treatments until the patient is physiologically stable, which often occurs
within two to five treatments [1,72]. At least six treatments are given regardless of the catatonia subtype to reduce the risk of sudden
relapse. Most patients receiving ECT regardless of the indication remit with 6 to 12 treatments, but some patients may require 20 or
more [63]. ECT is usually terminated after the acute catatonic episode has remitted, but one case report described maintenance ECT for
a patient with recurrent catatonia [73]. Additional information about ECT is discussed separately. (See "Overview of electroconvulsive
therapy (ECT) for adults" and "Technique for performing electroconvulsive therapy (ECT) in adults".)
Case reports describe catatonic patients who responded to ECT plus lorazepam [69,70]. The decision to continue a benzodiazepine
during ECT is determined by the patient’s initial response to the medication and the modifications in ECT technique that are required.
For patients with a partial but incomplete response to lorazepam, the drug may be continued during ECT to maintain the drug’s
therapeutic benefit. However, the benzodiazepine should be discontinued if it interferes with ECT (increases seizure threshold and
shortens seizure duration) despite adjustments in the ECT technique. (See "Overview of electroconvulsive therapy (ECT) for adults",
section on 'Concurrent medications'.)
Other treatments — Alternative treatments may be available for patients with catatonia who do not respond to benzodiazepines and
decline ECT or do not respond to ECT or have access to it [3]. Case reports describe other treatments that were added to an existing
pharmacotherapy regimen and may possibly be beneficial. These other treatments include carbamazepine [74], topiramate [75],
valproate [76,77], zolpidem [3,78,79], memantine [80-83], and bromocriptine [84]. Amantadine has also been used, but has dopamine
agonist activity that can potentially worsen an underlying psychosis [83]. Additional case reports describe treatment of catatonia with
repeated transcranial magnetic stimulation [14].
LONG-TERM PROGNOSIS — Although the long-term outcome of catatonia has not been rigorously studied, catatonia appears to have
a generally favorable prognosis, especially the retarded and excited subtypes [3,85]. Long-term prognosis appears to be linked to the
nature and severity of the underlying psychiatric or general medical disorder [2,26]. Retarded or excited catatonia in patients with an
underlying bipolar or depressive disorder or toxic-metabolic disorder usually resolves with treatment of the catatonic syndrome plus the
underlying condition [26]. However, catatonia may persist for years, particularly in patients with schizophrenia [34]. In addition, patients
with malignant catatonia may be left with permanent morbidity (eg, cognitive deficits, apathy syndromes, and limb strictures), and death
rates of up to 20 percent have been reported [42].
Case reports describe recurrent catatonic episodes [15,73]. One case series of five patients reported that the mean interval between
consecutive episodes was 11 months (range 5 to 20 months) [86]. The motor signs were generally consistent across each patient’s two
episodes. For cases with complete information, the same treatment worked in the two episodes.
SUMMARY AND RECOMMENDATIONS
● Catatonia is a behavioral syndrome marked by an inability to move normally that is associated with many psychiatric, neurologic,
and general medical disorders. Signs of catatonia are listed in the tables (table 1 and table 2). The three primary subtypes of
catatonia are retarded, excited, and malignant. (See 'Definition of catatonia' above and "Catatonia in adults: Epidemiology, clinical
features, assessment, and diagnosis".)
● Treatment of acute catatonia generally occurs in hospital settings where the patient’s general medical health can be monitored and
optimized. Malignant catatonia in particular is life-threatening and generally warrants admission to an intensive care unit. (See
'Setting and management' above.)
● Concurrently treating the underlying psychiatric or general medical disorder along with the catatonia may improve outcomes.
Clinicians should avoid using dopamine blocking drugs, even if patients are psychotic, impulsive, or aggressive. Treating catatonia
with an antipsychotic is a risk factor for the neuroleptic malignant syndrome (NMS). Antipsychotics are contraindicated in malignant
catatonia. (See 'Underlying disorder' above and 'Avoid dopamine blocking drugs' above.)
● Mortality in malignant catatonia may increase if electroconvulsive therapy (ECT) does not begin within five days of symptom onset.
For patients with malignant catatonia, we recommend ECT rather than a benzodiazepine (algorithm 1) (Grade 1C). A
benzodiazepine should be administered during preparations for ECT; if malignant catatonia improves significantly with the
benzodiazepine during the first 24 to 48 hours, it can be continued in lieu of ECT. (See 'Treatment algorithm' above and 'Malignant
catatonia' above.)
● For patients with nonmalignant catatonia, whether the behavioral phenotype (motor disturbance) is retarded or excited, we
recommend a benzodiazepine rather than ECT (Grade 1C). For retarded or excited catatonia that does not respond to a
benzodiazepine, we suggest ECT rather than other medications (Grade 2C). (See 'Treatment algorithm' above and 'Nonmalignant
catatonia' above.)
● The benzodiazepine used most often is intravenous lorazepam 1 to 2 mg three times per day, which is increased by 3 mg per day
every one to two days. A dose of 6 to 21 mg daily is effective for most patients, but a dose of 30 mg per day is occasionally
necessary. The benzodiazepine is usually continued orally at the effective dose for three to six months and then tapered and
discontinued. Following remission of catatonia, the benzodiazepine should be continued if an antipsychotic drug is used to treat the
underlying disorder. (See 'Benzodiazepine safety and administration' above.)
● There are no absolute contraindications to ECT. For catatonic patients with motor immobility and muscle damage, a nondepolarizing
muscle relaxant is used in order to eliminate the risk of transient hyperkalemia associated with the use of the succinylcholine. ECT
is generally given three times per week on alternating days, but malignant catatonia may initially require daily treatments. ECT is
typically administered at least six times with bilateral electrode placement and brief pulse current. (See 'Electroconvulsive therapy
safety and administration' above.)
● Retarded and excited catatonia both appear to have a generally favorable prognosis, especially in patients with an underlying
bipolar or depressive disorder or toxic-metabolic disorder. By contrast, malignant catatonia may result in permanent morbidity, and
death rates of up to 20 percent have been reported. (See 'Long-term prognosis' above.)
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Topic 15869 Version 16.0
GRAPHICS
Observed signs of catatonia
Feature Description and examples
Immobility Hypokinetic or akinetic behavior that is not influenced by external stimuli.
Stupor Decreased alertness, hypoactivity, and diminished responses to voice and painful stimuli.
Excitement Impulsive, frantic, and stereotypic behavior that may include sudden outbursts of talking, singing, dancing, and tearing of
clothes. Patients may be irritable and damage objects or injure themselves or others. Excitement may suddenly alternate with
stupor.
Mutism Patients are awake but verbally unresponsive. Mutism is not always associated with immobility and may appear elective. Less
severe forms of mutism include lack of spontaneous speech, sluggish responses to questions with automatic answers such as "I
don't know" (speech-prompt), and speaking with progressively less volume until speech is an inaudible mumble (prosectic
speech).
Posturing Voluntarily maintaining a position of the body or a body part for a long time; eg, standing or lying down in the same position, an
(catalepsy) exaggerated pucker, lying in bed with the head elevated and unsupported as if on a pillow, holding arms above the head or
raised in a prayer-like manner, and holding fingers and hands in odd positions.
Echophenomena Echolalia (senseless repetition of another person's utterances) and echopraxia (senseless repetition of another person's
movements).
Speech Robotic speech, feigned foreign accent, palilalia or verbigeration (involuntary repetition of words or phrases).
mannerisms
Behavioral Odd, purposeful movements, such as holding hands as if they were handguns or saluting passersby, or exaggerated or stilted
mannerisms caricatures of mundane movements.
Stereotypy Non-goal-directed, repetitive movements that often are awkward or stiff; examples include grimacing, teeth/tongue clicking,
rocking, sniffing, biting, or automatically touching or tapping.
Staring Fixed gaze with little or no scanning of the environment and decreased blinking.
Adapted from:
1. Fink M, Taylor MA. The catatonia syndrome: Forgotten but not gone. Arch Gen Psychiatry 2009; 66:1173.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000.
3. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand 1996; 93:129.
4. Greenhalgh J, Knight C, Hind D, et al. Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia
and mania: systematic reviews and economic modelling studies. Health Technol Assess 2005; 9:1.
Graphic 53391 Version 3.0
Elicited signs of catatonia
Feature Description and examples
Ambitendency The patient appears "stuck" in an indecisive, hesitant movement when the examiner verbally contradicts his or her own nonverbal
signal. As an example, the examiner offers his hand as if to shake hands while stating, "Do not shake my hand."
Waxy The rigid patient's initial resistance to the examiner's manipulations is gradually overcome, allowing re-positioning (as in bending a
flexibility candle).
Automatic The patient moves with the examiner's light pressure into a new position despite instructions to the contrary. The new position may
obedience then be maintained despite instructions to the contrary. Test bilaterally as this sign may result from contralateral brain lesions.
Negativism The patient resists the examiner's manipulations with strength equal to that applied (rigidity); social negativism may include
sleeping under the bed, turning away when addressed, refusing to open the eyes, and closing the mouth when offered food or
liquids.
Stimulus- The patient's behavior is tied to certain stimuli. As an example, the examiner states, "When I touch my nose, you touch your
bound chest," and the patient touches his nose in a mirrored behavior despite understanding the instruction.
behavior
Adapted from:
1. Fink M, Taylor MA. The catatonia syndrome: Forgotten but not gone. Arch Gen Psychiatry 2009; 66:1173.
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000.
3. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand 1996; 93:129.
4. Greenhalgh J, Knight C, Hind D, et al. Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia
and mania: systematic reviews and economic modelling studies. Health Technol Assess 2005; 9:1.
Algorithm for acute treatment of catatonia
ECT: electroconvulsive therapy.

* Malignant catatonia is life-threatening and is characterized by fever, autonomic instability, delirium, and rigidity. Catatonia occurs in the context of many
mental disorders (eg, unipolar major depression, bipolar disorder, and psychotic disorders) and general medical disorders. Refer to UpToDate content that
discusses the clinical features of catatonia.
¶ The initial choice for pharmacotherapy is typically a benzodiazepine, such as lorazepam 1 to 2 mg intravenously three times per day. For patients who are
already receiving lorazepam for another indication when they present with catatonia, the starting dose of lorazepam for catatonia (eg, 1 mg three times per
day) is added to the existing dose of lorazepam (eg, 1 mg each night for insomnia). Refer to UpToDate content that discusses treatment of catatonia.
Δ Pharmacotherapy is used while preparations are made to administer ECT. The medication is discontinued when ECT commences, unless the patient responds
to drug therapy. Refer to the ¶ footnote definition above and UpToDate content that discusses treatment of catatonia.
◊ The goal of treatment is full remission.
§ The same medication regimen continues while preparations are made to administer ECT. Pharmacotherapy is discontinued when ECT commences. Refer to
UpToDate content that discusses treatment of catatonia and provides an overview of ECT.
¥ Use the same drug from the initial course of pharmacotherapy. Refer to UpToDate content that discusses treatment of catatonia.
‡ Resume same drug from the initial course of pharmacotherapy used during preparations for ECT.
Contributor Disclosures
M Justin Coffey, MD Nothing to disclose Peter P Roy-Byrne, MD Employment: Mass Medical Society (journal Watch); Wiley Lliss
(Depression and Anxiety) [Editor in Chief]. Stock Options: Valant Medical Solutions [behavioral health (EMR)]. Stephen Marder,
MD Grant/Research/Clinical Trial Support: Forum; Neurocrine [schizophrenia and tardive dyskinesia]. Consultant/Advisory Boards:
Takeda, Gideon Richter, Boeringer-Ingleheim, Otsuka; Allergan; Teva [schizophrenia (brexpiprazole, cariprazine)]. David Solomon,
MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through
a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
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Catatonia: Treatment and prognosis

Author: M Justin Coffey, MD

● Retarded – Mutism, inhibited movement, posturing, rigidity, negativism, and staring

● Cardiopulmonary instability – Arrhythmias may occur from electrolyte imbalance.

NMS is discussed separately. (See "Neuroleptic malignant syndrome".)

The goal of treatment is full remission.

● Cardiovascular or respiratory disease

● Prescriptions for opioid analgesics

Drug information topics are available for specific benzodiazepines.

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 15869 Version 16.0

Observed signs of catatonia

Feature Description and examples

Immobility Hypokinetic or akinetic behavior that is not influenced by external stimuli.

Graphic 53391 Version 3.0

Elicited signs of catatonia

Feature Description and examples

Graphic 66229 Version 2.0

Algorithm for acute treatment of catatonia

ECT: electroconvulsive therapy.

Graphic 111223 Version 1.0

Conflict of interest policy

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