Catatonia is a neuropsychiatric syndrome most commonly seen in people with underlying mood disorders such as major depressive disorder, or psychotic disorders such as schizophrenia. People with catatonia exhibit abnormal movement and behaviors that vary from person to person, and which may fluctuate in intensity within a single episode.
People with catatonia appear withdrawn, with limited interaction with the outside world and difficulty processing information. They may be nearly motionless for days on end or perform repetitive, purposeless movements. People may exhibit very different sets of behaviors and still be diagnosed with catatonia. Treatment with benzodiazepines or electroconvulsive therapy is most effective and leads to remission of symptoms in most cases.
There are different subtypes of catatonia, which represent groups of symptoms that commonly occur together. These include stuporous/akinetic catatonia, excited catatonia, malignant catatonia, and periodic catatonia.
Catatonia has historically been related to schizophrenia, but is most often seen in mood disorders. It is now known that catatonic symptoms are nonspecific and may occur in other mental, neurological, and medical conditions. The prognosis of catatonia is typically good, with complete remission in some patients; however, outcomes vary depending on the underlying disorder.
Signs and symptoms To properly diagnose catatonia, both the ICD-11 and DSM-5 require three or more of the symptoms defined in the table below. However, each person can have a different set of symptoms that may worsen, improve, and change in appearance throughout a single episode. Symptoms may develop in varying amounts of time, presenting in hours, days, or even weeks. +SymptomDefinitionStuporA marked lack of psychomotor activity; the individual appears immobile and unresponsiveCatalepsyPassive induction of a posture held against gravityWaxy flexibilitySlight resistance to positioning by the examiner, allowing limbs to remain in imposed positionsMutismLack of verbal response despite apparent alertnessNegativismResistance or no response to external instructions or stimulusPosturingVoluntary assumption of inappropriate or bizarre posturesMannerismOdd, exaggerated movements or behaviorsStereotypyRepetitive, non-goal-directed movements or gesturesAgitationRestlessness or excessive motor activity without external stimulusGrimacingFacial contortions or expressions unrelated to emotional contextEcholaliaMimicking or repeating another person's speechEchopraxiaMimicking or imitating another person's movements Because most patients with catatonia have an underlying psychiatric illness, the majority will present with worsening depression, mania, or psychosis, followed by catatonia symptoms. Even when they are unable to interact, patients presenting with catatonia should not be assumed to be unaware of their surroundings, as some can recall their catatonic state and their actions in detail.
Subtypes There are several subtypes of catatonia recognized: stuporous catatonia, excited catatonia, malignant catatonia, and periodic catatonia. Subtypes are defined by the group of symptoms and associated features that a person is experiencing or displaying. Although catatonia can be divided into subtypes, its presentation is often dynamic, and the same individual may exhibit different subtypes at different times.
Stuporous catatonia is characterized by immobility, mutism, and a lack of response to the world around them. They may appear frozen in one position for long periods of time unable to eat, drink, or speak.
Excited catatonia is characterized by odd mannerisms and gestures, purposeless or inappropriate actions, excessive motor activity, restlessness, stereotypy, impulsivity, agitation, and combativeness. Patients suffering from excited catatonia may have speech and actions that are repetitive or mimic another person's. This state is often characterized by hyperactivity, and the patient may have delusions and hallucinations.
Malignant catatonia is characterized by fever, dramatic and rapid changes in blood pressure, increased heart rate and respiratory rate, and excessive sweating. This condition is life-threatening, and the patient's laboratory tests may come back abnormal.
Periodic catatonia is characterized by a person having recurrent episodes of catatonia. Individuals will experience multiple episodes over time, with no signs of catatonia between episodes. Historically, the Wernicke-Kleist-Leonhard school considered periodic catatonia a distinct form of "non-system schizophrenia", characterized by recurrent acute phases with hyperkinetic and akinetic features and often psychotic symptoms. There is also a residual state between these phases, characterized by low-level catatonic features and abulia of varying severity.
Causes Catatonia develops in the presence of an underlying condition, including psychiatric and neurological disorders, other medical conditions, and substance use.
Neuropsychiatric Mood disorders like bipolar disorder and clinical depression are the most common conditions underlying catatonia. Other psychiatric conditions that can cause catatonia include schizophrenia and other primary psychotic disorders, autism spectrum disorder, ADHD, and post-traumatic stress disorder.
Psychodynamic theorists have historically interpreted catatonia as a psychological defense against the potentially destructive consequences of responsibility, with the passivity of the disorder providing relief.
Other conditions Catatonia is also seen in many medical disorders, including encephalitis, meningitis, autoimmune disorders, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (e.g.,homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia).
Neurological Catatonia can occur due to several neurological conditions. For instance, certain types of encephalitis can cause catatonia. Anti-NMDA receptor encephalitis is a form of autoimmune encephalitis known to cause catatonia, albeit very rarely. Additionally, encephalitic catatonia has been reported in cases of severe HIV and herpes simplex virus infections. A small amount of evidence suggests that catatonia can develop after traumatic brain injury in the absence of a primary psychiatric disorder. Similarly, there are several case reports of catatonia after a stroke, with some having catatonia-associated symptoms that were unexplainable by stroke itself and which improved after treatment with benzodiazepines. Parkinson's disease can cause catatonia for some people by impairing their ability to produce and secrete dopamine, a neurotransmitter which is thought to contribute to motor dysfunction in people with catatonia.
Metabolic and endocrine Abnormal thyroid function may result in the development of catatonia when the thyroid overproduces (hyperthyroidism) or underproduces thyroid hormones (hypothyroidism). This is thought to occur due to the impact of thyroid hormones on metabolism, including in the cells of the nervous system. Abnormal electrolyte levels have also been shown to cause catatonia in rare cases. Most notably, low blood sodium levels can cause catatonia in some people.
Infectious Certain infections are known to cause catatonia, either by directly impairing brain function or by increasing a person's susceptibility to other diseases that can do so. HIV and AIDS can cause catatonia by predisposing one to infections in the brain, including different types of viral encephalitis. Borrelia burgdorferi causes Lyme disease, which has been shown to cause catatonia by infecting the brain and causing encephalitis.
Medications Disulfiram, a drug used to treat alcoholism, can cause catatonia. It is theorized that the medication can cause alterations in dopamine metabolism, as it blocks dopamine beta-hydroxylase. Additionally, phencyclidine, corticosteroids, and antipsychotics, among other drugs, are known to cause catatonia.
Pathogenesis The mechanisms underlying brain catatonia are poorly understood. Currently, there are two main categories of explanations for the brain pathology of catatonia. The first is a disruption of normal neurotransmitter production or release in certain brain areas, preventing normal cognitive function and leading to behavioral and motor symptoms associated with catatonia. The second claims that disruption of communication between different areas of the brain causes catatonia.
Neurotransmitters The neurotransmitters that are most strongly associated with catatonia are GABA, dopamine, and glutamate. GABA is the primary inhibitory neurotransmitter of the brain, meaning it slows down the activity of the systems it acts on. In catatonia, people have low levels of GABA, which causes them to be overly activated, especially in areas of the brain that normally inhibit activity. This is thought to cause the behavioral symptoms associated with catatonia, including withdrawal.Daniels J. Catatonia: Clinical Aspects and Neurobiological Correlates. The Journal of Neuropsychiatry and Clinical Neurosciences 2009;21:371–80. https://doi.org/10.1176/jnp.2009.21.4.371. Dopamine can increase or decrease the activity of the area of the brain it acts on, depending on where in the brain it is. Dopamine is lower than normal in people with catatonia, which is thought to cause many of the motor symptoms, because dopamine is the main neurotransmitter that activates the parts of the brain responsible for movement. Glutamate is an excitatory neurotransmitter, meaning that it increases the activity of the areas of the brain it acts on. Notably, glutamate tells the neuron it acts on to fire by binding to the NMDA receptor. People with anti-NMDA receptor encephalitis can develop catatonia because their antibodies attack the NMDA receptor, reducing the brain's ability to activate different areas through glutamate.
Neurological pathways Several brain pathways have been studied, and they seem to contribute to catatonia when they are not functioning properly. However, these studies were unable to determine if the abnormalities they observed were the cause of catatonia or if the catatonia caused the abnormalities. Furthermore, it has been hypothesized that pathways connecting the basal ganglia with the cortex and thalamus are involved in the development of catatonia.
Diagnosis Catatonia is diagnosed when a person exhibits at least three key symptoms simultaneously.
These can include: Not moving or speaking (stupor or mutism) Unusual body positions Repeating words or actions Sudden restlessness Other, less common symptoms
The DSM-5 and ICD-11, global manuals for mental health conditions, describe catatonia and its various types. Catatonia can occur with other mental illnesses, like depression or schizophrenia. It may also be a reaction to certain drugs or a medical condition. While often linked to psychiatric disorders, about one in five cases of catatonia are due to medical conditions.
There is not a definitive consensus regarding diagnostic criteria. In the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013) and the eleventh edition of the World Health Organization's International Classification of Diseases (ICD-11, 2022), the classification is more homogeneous than in earlier editions. Prominent researchers in the field have other suggestions for diagnostic criteria. Still, diagnosing catatonia can be challenging. Evidence suggests that there is as high as a 15-day average delay to diagnosis for people with catatonia.
DSM-5
The DSM-5 does not classify catatonia as an independent disorder. Instead, it classifies it as:
Catatonia associated with another mental disorder Due to another medical condition