Synopsis
Diagnose catatonia using positive motor and behavioural signs, recognise malignant autonomic deterioration, investigate medical and neurological causes, and use lorazepam and urgent electroconvulsive therapy without worsening the syndrome with dopamine blockade.
- Catatonia is a psychomotor syndrome diagnosed by positive signs such as stupor, mutism, negativism, posturing, waxy flexibility, mannerism, stereotypy, agitation, echolalia and echopraxia.
- It occurs with mood and psychotic disorders but also autoimmune encephalitis, epilepsy, metabolic disease, infection, medicines, substance withdrawal and neurological injury.
- Malignant catatonia adds hyperthermia, autonomic instability, delirium and laboratory consequences of immobility or muscle activity and can progress to death.
- A prodrome of excitement, insomnia, psychosis, mutism, negativism or posturing before fever favours malignant catatonia over classic drug-triggered NMS, although overlap is substantial.
- The Bush-Francis screening items can structure examination and serial response, but scoring never replaces a search for cause or a neurological examination.
- A lorazepam challenge producing marked temporary improvement supports catatonia, yet non-response does not exclude severe or malignant disease.
- Avoid starting or escalating antipsychotics while malignant catatonia or NMS remains possible because dopamine blockade can worsen rigidity and autonomic instability.
- Electroconvulsive therapy is highly effective and time critical for malignant, life-threatening or benzodiazepine-resistant catatonia; referral should begin before prolonged failed drug trials.
- Prevent aspiration, dehydration, pressure injury, contracture and venous thrombosis, and provide nutrition while preserving dignity and avoiding unnecessary restraint.
- Anti-NMDA-receptor encephalitis, non-convulsive status, locked-in syndrome, akinetic mutism and severe Parkinsonism are important neurological mimics requiring targeted tests.
Key red flags
New fever, diaphoresis, tachycardia, labile pressure, delirium and rigidity on a catatonic background signals a life-threatening transition.
Investigation priorities
Document positive signs and create a treatment-response baseline.
Management branches
A patient is mute, immobile, posturing or unusually agitated.
- Assess consciousness, focal neurology, eye movements and cardiorespiratory state, then document mutism, stupor, negativism, posturing, waxy tone and echophenomena.
- Use a structured catatonia scale and obtain collateral history of mood, psychosis, seizure, infection, medicine changes, substances and autoimmune symptoms.
- Stop non-essential dopamine antagonists when malignant catatonia or NMS is possible and involve liaison psychiatry and medical or neurological teams early.
Key medicines
LorazepamA common diagnostic challenge uses 1 to 2 mg orally, intramuscularly or intravenously with reassessment; ongoing dose and interval follow specialist response and monitoring.Monitor airway, respiratory rate, aspiration, falls and paradoxical disinhibition; frailty, lung disease and concurrent sedatives require lower or slower dosing.
Antipsychotic withholdingDo not administer a further dose while malignant catatonia or NMS is unresolved unless a senior specialist documents an overriding indication and monitoring plan.Psychosis still needs humane management with low stimulation and benzodiazepine or ECT pathways; later reintroduction requires recovery, low dose and close observation.