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.
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.
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.
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.