Synopsis
Identify catatonia through positive motor, behavioural and speech signs, support nutrition and complication prevention, investigate psychiatric, neurological and medical causes, and use a measured lorazepam trial and timely electroconvulsive therapy without harmful diagnostic delay.
- Catatonia is a psychomotor syndrome identified by clusters of signs such as stupor, mutism, posturing, negativism, waxy flexibility, echophenomena, stereotypy, mannerism, grimacing or purposeless excitement.
- Look for positive signs and demonstrate them carefully; immobility or silence alone can reflect coma, delirium, severe depression, neurological disease, sedation or deliberate non-participation.
- Use a structured bedside scale to record the same signs before and after treatment and across shifts rather than describing the patient merely as withdrawn.
- Assess hydration, nutrition, swallowing, skin, bladder and bowel, venous thrombosis, infection, contracture and aspiration from the first encounter.
- Investigate mood disorder, psychosis, medicines and withdrawal, seizures, encephalitis, metabolic disturbance and systemic illness according to the clinical phenotype.
- A lorazepam challenge for catatonia is specialist-led and off-label; use the BAP guideline as the dosing authority and the current lorazepam SmPC for formulation safety, while recognising that a negative or partial response does not exclude severe disease.
- Electroconvulsive therapy is time critical for malignant, life-threatening or benzodiazepine-resistant catatonia and referral should begin while supportive care continues.
- Avoid reflexive antipsychotic initiation until catatonia, malignant catatonia and neuroleptic malignant syndrome have been assessed by an experienced specialist.
Key red flags
Fever, labile blood pressure, tachycardia, delirium or rising creatine kinase with catatonic signs indicates malignant physiology and potential organ failure.
New seizure, dyskinesia, focal neurology, memory loss or autonomic fluctuation raises autoimmune encephalitis or another neurological disorder.
Absent intake, urinary retention, immobility, pressure injury, hypoxia or suspected thrombosis requires active medical prevention and treatment.
Recent dopamine blockade with hyperthermia and rigidity creates overlap with neuroleptic malignant syndrome and makes further antipsychotic dosing hazardous.
Excited, impulsive or repetitive motor behaviour can cause exhaustion and accidental injury even when the person is not stuporous.
Investigation priorities
Record defined motor, speech, behavioural and response signs at baseline and serially.
Management branches
Mutism, immobility, posturing, negativism, echophenomena or unexplained motor excitement is present.
- Use a structured bedside examination to document positive signs and assess awareness, physiology, intake, swallowing, injury and immediate complications.
- Review mood, psychosis, medicines, withdrawal, substances, infection and neurological features and obtain targeted blood, ECG, imaging, EEG or fluid tests.
- Begin hydration, nutrition, pressure, mobility and thrombosis care and involve liaison psychiatry and medical teams without waiting for diagnostic certainty.