Symptoms & Diagnosis
What are the general symptoms of Catatonia?
A patient with Catatonia can have a sudden onset of a variety of symptoms that are both confusing and scary. It may be difficult for a patient’s family member or caregiver to describe all of the symptoms to a healthcare provider because it is so out of character for the patient and overwhelming for the caregiver. Understanding the possible symptoms of Catatonia will be helpful in getting an accurate diagnosis and access to highly curative treatment.
What are the ways to diagnose Catatonia?
There are a variety of ways a diagnosis of Catatonia can be made, including evaluating symptoms, determining responses to specific medication or ECT, as well as specific tests or scans.
Dr. Max Fink explains the Bush-Francis Catatonia Rating Scale and the Lorazepam Challenge.
The following are some of the more common ways Catatonia may be diagnosed.
1
Bush-Francis Catatonia Rating Scale
The Bush-Francis Catatonia Rating Scale is the most commonly used rating scale for making a diagnosis of Catatonia. It is preferred for routine use because of its validity and reliability and its ease of administration.

NOTE: In the experience of the founding members of the Board of Directors of The Catatonia Foundation, caregivers can provide valuable information when evaluating a patient using this rating scale. Caregivers have spent a great deal of time with the patient and the symptoms of Catatonia are not static whereas a physician who evaluates a patient at a particular moment in time in an office or hospital setting may not have an opportunity to observe all of the relevant symptoms.
In addition, medication the patient may be taking may temporarily mask symptoms or create other symptoms or side effects. Caregivers can provide valuable information with respect to these symptoms.
2
Lorazepam Challenge
A type of medication called benzodiazepines (and more specifically, Lorazepam or Ativan) may be helpful in determining whether a patient has Catatonia. Following a specific protocol for administering lorazepam, either intravenously or orally, a reduction in the symptoms of Catatonia may occur. This is known as the Lorazepam (or Ativan) Challenge.
It may be helpful to assess the patient using the Bush-Francis Catatonia Rating Scale before performing the Lorazepam Challenge and then reassess the patient with the same rating scale after an adequate amount of Lorazepam has been given to reduce symptoms.
NOTE - The Lorazepam Challenge should be performed under the supervision of a healthcare provider.
An excellent explanation of the Lorazepam Challenge by medical professionals with expertise in the challenge can be accessed here.
3
Lab Test of CSF or Blood Serum for Anti-NMDA Receptor Encephalitis
The diagnosis of anti-NMDA encephalitis is confirmed by the presence of NMDA antibodies in the cerebrospinal fluid (CSF) or blood serum. This test will be useful in determining treatment options.
4
DSM-5
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a reference book on mental health and brain-related conditions and disorders written by the American Psychiatric Association. The DSM, 5th Edition, includes Catatonia under “Schizophrenia and Other Psychotic Disorders.”
The manual recognizes a) catatonia associated with another mental disorder (i.e., a neurodevelopmental, psychotic disorder, a bipolar disorder, a depressive disorder, or other mental disorder), b) catatonic disorder due to another medical condition, and c) unspecified catatonia.
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5
Post ECT Success
When electroconvulsive therapy (ECT) successfully treats a patient with the symptoms of Catatonia, it is considered evidence of an accurate diagnosis of Catatonia.
Bush-Francis Catatonia Rating Scale
The symptoms typically evaluated when determining whether Catatonia is a possible diagnosis are set forth in the Bush-Francis Catatonia Rating Scale. The rating scale provides a method to determine whether a diagnosis of Catatonia can be made as well as the severity of the illness. Download Bush-Francis Catatonia Rating Scale here.
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In addition to the symptoms described in the rating scale below, the patient may exhibit psychotic (disconnected from reality) and delusional (holding false beliefs or judgments about external reality that are held despite incontrovertible evidence to the contrary) symptoms.
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In patients with a diagnosis of autism, the patient may exhibit self-injurious behavior and unprovoked severe aggression.
Evaluating Symptoms using the Bush-Francis Catatonia Rating Scale
According to the Bush-Francis Catatonia Rating Scale, If a person exhibits at least three of the following 14 symptoms, a diagnosis of Catatonia may be made.
1. Immobility/Stupor
Extreme hypoactivity (or slowed movements), immobile, minimally or not responsive to stimuli.
2. Mutism
Verbally unresponsive or minimally responsive.
3. Staring
Fixed gaze, little or no visual scanning of environment, decreased blinking.
4. Posturing/Catalepsy
Spontaneous maintenance of posture(s), including mundane postures (e.g. sitting or standing for long periods without reacting).
5. Grimacing
Maintenance of odd facial expressions.
6. Echopraxia/Echolalia
Mimicking of another person’s movement or speech.
7. Stereotypy
Repetitive, non-goal-directed motor activity (e.g. finger-play, repeatedly touching, patting or rubbing self); abnormality is not inherent in its act but in its frequency.
8. Mannerisms
Odd, purposeful movement (e.g. hopping or walking tiptoe, saluting passers-by, or exaggerated caricatures of mundane movements); abnormality is inherent in the act itself.
9. Stereotyped and Meaningless Repetition of Words and Phrases
(Verbigeration)
Repetition of phrases or sentences (like a scratched record).
10. Rigidity
Maintenance of a rigid position despite efforts to be moved. Does not include cogwheeling (jerky when moving or rotating limb or joint) or tremor.
11. Negativism
Apparently motiveless resistance to instructions or attempts to move/examine patient. Contrary behavior; does exact opposite of instruction.
12. Waxy flexibility
During repositioning of patient, patient offers initial resistance before allowing themself to be repositioned, similar to that of a bending candle (also defined as slow resistance to movement as the patient allows the examiner to place their extremities in unusual positions. The limb may remain in the position in which it is placed or not).
13. Withdrawal
Refusal to eat, drink, and/or make eye contact.
14. Excitement
Extreme hyperactivity, constant motor unrest which is apparently non-purposeful. Not to be attributed to akathisia (caused by medication) or goal-directed agitation.
The severity of Catatonia is determined by looking at the severity of the symptoms described in 1 through 14 above as well as the severity of the symptoms described below in 15 through 23 below.
15. Impulsivity
Patient suddenly engages in inappropriate behavior (e.g. runs down hallway, starts screaming or takes off clothes) without provocation. Afterward can give no or only a facile
(superficial) explanation.
16. Automatic obedience
Exaggerated cooperation with examiner’s request or spontaneous continuation of movement requested.
17. Passive obedience
Patient raises arm in response to light pressure of finger, despite instructions to the contrary.
18. Muscle resistance (Gegenhalten)
Involuntary resistance to passive movement of a limb to a new position. Resistance increases with the speed of the movement.
19. Motorically stuck (Ambitendency)
Patient appears stuck in indecisive hesitant motor movements.
20. Grasp reflex
Striking the patient's open palm with two extended fingers of the examiners hand results in automatic closure of patients hand.
21. Perseveration
Repeatedly returns to same topic or persists with the same movements.
22. Combativeness
Belligerence or aggression. Usually in an undirected manner, without explanation.
23. Autonomic abnormality
Abnormality of body temperature (e.g. fever), blood pressure, pulse, respiratory rate, inappropriate sweating/flushing.
Complications that may arise if someone has Catatonia
In addition to symptoms of the condition itself, Catatonia can also cause the following complications:
Aspiration
Pneumonia
Dehydration
Muscle Contraction
Pressure Ulcers
Nutritional Deficiencies
Severe Weight Loss
Thiamine Deficiency
Electrolyte Disturbances
Urinary tract Infections
Deep Vein Thrombosis
Pulmonary Embolism
Penis Thromboembolism
Why might it be challenging to get a diagnosis of Catatonia?
1
Lack of awareness or education by healthcare professionals (including psychiatry) about Catatonia and how to diagnose it.
2
Patients often are seen by specialists other than psychiatry who have not been educated about Catatonia, its diagnostic treatment or highly curative treatment options.
3
Crossover of the symptoms of Catatonia with other diagnoses.
4
Difficulty of evaluating a patient using Catatonia Rating Scales in a brief appointment.
5
Symptoms of Catatonia may wax and wane.
6
Patient caregivers are not familiar with the diagnostic symptoms and are unable to provide relevant input to the provider.
7
Providers may not recognize the importance of input from the family regarding symptoms they are seeing at home.
8
Caregivers are overwhelmed with the sudden onset of bizarre symptoms and are not able to communicate clearly.