Catatonia

Catatonia is a transdiagnostic neuropsychiatric syndrome of marked, and often internally contradictory, disturbances of movement, volition, speech, and behavior that arises across psychiatric, neurologic, and general medical illness. This review covers the phenotype and diagnostic criteria, the psychiatric disorders in which catatonia arises, the clinical and paraclinical features that distinguish catatonia due to a medical or neurologic condition (CMC) from catatonia associated with a psychiatric disorder (CPD), the expanding role of autoimmune disease, and the differential diagnosis of catatonic and catatonia-mimicking states. It concentrates on adults, with pediatric data noted where distinctive; treatment is summarized only insofar as it informs diagnosis and etiologic classification.

For the closely related hyperthermic emergency, see our reference on neuroleptic malignant syndrome. For the broader first-presentation workup, see the medical workup of first-episode psychosis and the psychosis triage protocol.

Among primary psychiatric illnesses, mood disorders account for the majority of catatonia cases, with up to 20% of patients in an acute manic episode exhibiting classic catatonic signs. Catatonia also complicates major depressive disorder and occurs in up to roughly 35% of individuals with schizophrenia, and it is increasingly recognized in autism spectrum disorder and other neurodevelopmental disorders.

The essential feature is a marked psychomotor disturbance ranging from severe hypokinesis (stupor, mutism, negativism) to excited, agitated, and stereotyped hyperactivity, with the same patient sometimes oscillating between the two poles. Because teaching overemphasizes rare, dramatic signs such as waxy flexibility, milder presentations, elective mutism, ambitendency, staring, and negativism, are frequently missed. Psychiatric episodes tend to run a more prolonged course of weeks to months, recur in about a quarter of patients, and carry less autonomic instability than medical catatonia.

Two-thirds of catatonia attributed to non-psychiatric medical illness is due to primary neurologic conditions such as encephalitis, structural CNS lesions, and seizures, making the medical-versus-psychiatric distinction a priority in every first-episode workup. The largest direct comparison, 249 patients with 58 medical and 191 psychiatric cases, found medical catatonia is more severe and less benzodiazepine-responsive. A LASSO-derived model discriminated medical catatonia with an AUC of 0.87 using six predictors.

EEG is the single most useful paraclinical test for etiology. A meta-analysis of 707 patients found abnormal EEG had 82% sensitivity and 66% specificity for medical catatonia (AUC 0.83), with limbic-encephalitic patterns, epileptiform discharges, focal abnormalities, and status epilepticus being highly specific, while generalized slowing was only moderately specific and also occurred in 23% of psychiatric cases. Extreme delta brush is pathognomonic for anti-NMDAR encephalitis but rare. MRI is preferred over CT for structural causes, though over 75% of catatonia patients have nonspecific imaging abnormalities and one case-control study found no radiologic difference from other psychiatric inpatients after adjustment. Functional imaging suggests acute psychiatric catatonia is associated with prefrontal and SMA hyperactivity whereas NMDAR-encephalitis catatonia shows prefrontal hypoactivity.

The catatonia-delirium comorbidity is itself a robust marker of a medical etiology: about one-third of critically ill and delirious medical inpatients also meet catatonia criteria, and greater catatonia burden strongly predicts delirium, with 3 or more features conferring 27.8-fold odds.