Catatonia in General
What is Catatonia?
“Catatonia is a behavior syndrome of movement and mood, classically marked by stupor, mutism, posturing, rigidity and repetitive speech and acts. Usually acute in onset, its signs are recognizable, and when recognized, it can be successfully treated.”
Fink, M, Shorter, E (2018). The Madness of Fear: A History of Catatonia. Oxford University Press.
"Catatonia is a severe neuropsychiatric disorder affecting movement, speech and complex behavior often involving disturbances in automatic [involuntary] functions or affect [moods, feeling and attitudes]. It has been associated with excess morbidity and, sometime, mortality compared to other serious mental illnesses." Rogers, JP et al. (2023) Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology
Unfortunately, recognition by healthcare professionals is often poor and knowledge about Catatonia and it's treatments is often limited among providers. The mission of The Catatonia Foundation is to raise awareness and educate healthcare providers and the public about Catatonia including identification, diagnosis and effective treatment options.
Catatonia typically comes on suddenly with behaviors and/or activity that are out of character compared to the person's baseline. It may take family members some time to realize how significant the changes are. In many cases, family members may not realize the changes to baseline are not volitional as the person may appear to be belligerent, stubborn, depressed, anxious or just acting strange. Patients with catatonia are frequently overwhelmed by fear, dread and anxiety.
Catatonia is NOT Schizophrenia
While Catatonia used to be associated with schizophrenia, it is now more commonly known that Catatonia is NOT schizophrenia.
The DSM-5-TR no longer puts catatonia with the subtype of schizophrenia. It creates a category for catatonia under Schizophrenia Spectrum and other Psychotic Disorders section. Within the category of catatonia, the DSM-5-TR splits catatonia into (1) catatonia due to general medical condition, (2) catatonia due to another mental disorder, and (3) catatonia not otherwise specified.
ICD-11 codes for catatonia in the following ways: (1) catatonia, unspecified, (2) catatonia induced by substances or medications, (3)catatonia associated with another mental disorder, and (4) secondary catatonia syndrome.
Signs and Symptoms of Catatonia
There may be overlap between the signs and symptoms of other diagnoses and catatonia, including delirium, cognitive decline, suicidal ideation, delusion of poverty, self-stimulatory behavior, echolalia, impulsivity, belligerence, or aggression. The lorazepam challenge and an evaluation using a Catatonia rating scale (described below) may help to make a proper diagnosis of Catatonia.
Catatonia is typically diagnosed by observing specific signs that may indicate the presence of Catatonia. Many signs have been identified as significant and they fall within several categories - focal motor activity, generalized motor activity, speech, affect, complex behavior and autonomic activity.
Focal motor activity includes catalepsy (spontaneous maintenance of postures including mundane - sitting or standing for long periods without reacting), mannerisms (odd purposeful movements - hopping or walking tiptoe, saluting passers by or exaggerated caricatures of mundane movements), stereotypy (repetitive non-goal-directed motor activity - finger-play, repeated touching, patting or rubbing self), grimacing (odd facial expressions) and echopraxia (mimicking movements).
Generalized motor activity includes stupor (extreme hypoactivity, immobile and minimally responsive to stimuli) and agitation (extreme hyperactivity, constant motor unrest which is apparently non-purposeful).
Speech includes mutism (verbally unresponsive or minimally unresponsive), verbigeration (repetition of phrases or sentences - like a scratched record) and echolalia (mimicking speech).
Affect includes affective blunting, anxiety and ambivalence.
Complex behavior includes negativism (refusal to comply with requests, expectations or suggestions), reduced oral intake and withdrawal.
Autonomic activity includes tachycardia and hypertension.
A diagnosis of Catatonia does not require that all of the symptoms are exhibited by the patient. In fact, a diagnosis is typically made if three or more diagnostic symptoms are identified. The symptoms may wax and wane making a diagnosis difficult.
Click here for a description of the symptoms of Catatonia and how to diagnose it.
“Catatonia is more than a movement disorder. It entails negativistic behavior [refusal to comply with requests] and psychotic ideation [perceiving or interpreting things differently from reality] as well as rigidity, immobility, posturing [spontaneous adoption of positions that are held for an abnormal length of time], muscle tension, stupor, agitation, tics, echolalia [repeating other's words], echopraxia [imitating other's movements] and mannerisms [exaggerated example of normal action.]” (Fink and Shorter, 2018, page 2)
Expressions
It's important to recognize that Catatonia has many expressions with certain symptoms commonly associated with each expression. Stuporous or Akinetic Catatonia involves immobility and stupor. Excited Catatonia involves delirium, disorientation and confusion. Agitated Catatonia (a form of excited catatonia) is typically seen in patients with autism or developmental disorders and may involve self-injurious or unprovoked aggressive behavior.
Click here for a description of the different expressions of Catatonia.
Catatonia typically responds to the benzodiazepine Lorazepam (Ativan) and electroconvulsive therapy (ECT). It is important to note that the symptoms of patients with Catatonia who are treated with antipsychotic medication may worsen.
Click here for more information about treatment options.
Catatonia and Fear
Catatonia's cause is not well understood. The focus of healthcare professionals has been on diagnostic criteria based on the observation of a variety of movements and behaviors. Fear is a theme that comes up as a possible cause and it appears that suffering and distress seems to be prominent in patients with Catatonia.
Karl Kahlbaum, the German psychiatrist who formulated the syndrome of Catatonia in 1874, noticed that these patients conveyed impressions of profound mental anguish, or an immobility induced by severe mental shock. This was addressed in a 2004 article "Scared Stiff". Catatonia as an evolutionary-based Fear Response.
Dr. Max Fink has expressed the idea that Catatonia is based in fear in his book, The Madness of Fear: The History of Catatonia and in the 2017 article by Dr. Max Fink and Professor Edward Shorter, Does persisting fear sustain catatonia? which states “While it may seem that patients with Catatonia have either withdrawn into themselves or are caught in a web of delusion, there appears to be a preoccupation with heightened distress and active fears that fully occupy their consciousness.”
Patients have described their experience after their recovery as intense emotions like fear and heightened anxiety that may be associated with a perceived impending danger, concerns about death and dying, missing close family and yearning to be with them, and a preoccupation with feeling trapped, embarrassed, rejected, or intense loneliness. Sometimes patients were not aware of how sick they were and what their symptoms were. This was described in a 2022 qualitative study on the psychological and subjective experience of catatonia.
It has also been postulated that there is a correlation between Catatonia and intense fear associated with trauma. Several case studies have described the association of Catatonia with PTSD. In one case study, a 12-year old female patient had two life-threatening experiences. She presented with four of the 12 specified criteria for Catatonia in the DSM-5 prior to treatment with ECT and was discharged with complete improvement. Of note, there has been some discussion of whether refugees who have fled war torn countries and are diagnosed with resignation syndrome may have Catatonia.
Fear in patients with Catatonia and autism has also been mentioned in the literature. While no empirical studies have been done, it has been noted that sometimes Catatonia develops after severe psychological trauma or stressful events. It has been postulated that Catatonia may be an extreme motor reaction to fear in the autistic population and that they may be particularly vulnerable to Catatonia due to social, cognitive, and sensory deficits.
What’s the prevalence of Catatonia?
Based on reviews of the literature, statistics regarding the prevalence of Catatonia are highly variable. It is difficult to determine prevalence because of the lack of awareness and education of how to diagnose Catatonia.
A Dutch study found that clinicians identified Catatonia in only 2% of 139 patients, whereas a research team identified Catatonia in 18%.
This study looked at the number of patients in a specific group who were identified as having Catatonia by clinicians versus the number of patients in the same group who were identified as having Catatonia by a research team educated on the diagnostic criteria for making a diagnosis of Catatonia. In this study, clinicians identified Catatonia in only 2% of 139 patients, whereas an educated research team identified Catatonia in 18% of the same 139 patients.
We believe it’s important to try to accurately identify the prevalence of Catatonia as best as possible to address the commonly held belief that Catatonia is rare and therefore, not worthy of consideration as a possible diagnosis.
"14% of patients in the general hospital setting had signs of Catatonia."
- Dr. Max Fink
Prevalence
Note: There may be variations in statistical prevalence due to lack of awareness and education about Catatonia.