Clinical Pearls & Morning Reports

Posted by Carla Rothaus, MD

Published November 9, 2023


What is an effective treatment for acute catatonia?

There are numerous clinical presentations and underlying disorders associated with catatonia. Read the NEJM Review Article here.

Clinical Pearls

Q: Is catatonia easily diagnosed?

A: Many physicians incorrectly believe that catatonia is a rare form of schizophrenia, with bizarre abnormalities of motor behavior. Consequently, the diagnosis is often missed, and a person with catatonia may be inappropriately treated. One of the reasons that catatonia is often not recognized is that its severity ranges from subtle behavioral abnormalities, lasting only hours, to malignant, at times lethal, forms.

Q: What are some of the clinical signs associated with catatonia?

A: Among the many signs of catatonia, 12 are recognized as diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), text revision. Any 3 of the 12 signs are sufficient for the DSM diagnosis of catatonia. Some signs are found in most patients: staring, stupor, mutism, and posturing. Other signs, some considered almost pathognomonic, are found in less than 20% of patients: echophenomena (imitation of words or actions), waxy flexibility (slight and even resistance to positioning), and catalepsy (passive induction of a posture that is then held by the patient against gravity).

Morning Report Questions

Q: Describe an approach to the evaluation of suspected catatonia in patients hospitalized in a medical unit or in those with a history of psychiatric illness.

A: Catatonia in a patient in a medical unit requires extensive diagnostic efforts because otherwise unusual underlying causes are common in such patients. First, anti–N-methyl-D-aspartate receptor encephalitis may cause acute catatonia before progressing to encephalopathy or seizures. Second, several metabolic disorders and focal cerebral lesions may be manifested as catatonia. Third, catatonia may be due to prescribed or illicitly used drugs, especially in patients withdrawing from benzodiazepines, alcohol, or opioids. Fourth, in critically ill patients, catatonia may linger in the shadow of delirium because the psychomotor signs of catatonia are often not recognized in a delirious patient with fluctuating levels of attention and cognition. In addition, certain conditions confer a predisposition to an acute episode of catatonia (e.g., postpartum psychosis in the perinatal period and urinary tract infections in older patients). Catatonia in psychiatric patients may be due to a medical condition rather than an underlying psychiatric disorder. For this reason, an assessment for medical causes should be performed not only during the initial presentation but also after years of psychiatric illness.

Q: What is an effective treatment for acute catatonia?

A: Most forms of acute catatonia remit promptly with appropriate treatment. The lorazepam challenge test for catatonia has been found to be an effective treatment, and remission with the challenge validates the diagnosis. Within minutes after intravenous administration of 1 to 2 mg of lorazepam, previously mute patients start talking, and immobile patients move and resume oral intake. Typically, these effects wear off quickly but can be reinstated with repeated administration. Intramuscular or oral administration is also effective, albeit with a slower onset of action. Lorazepam is effective in up to 90% of acute catatonia cases.

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