Catatonic Schizophrenia

What is catatonic schizophrenia?

“Catatonic schizophrenia” is a subtype of schizophrenia that includes catatonia as a key feature. Experts no longer recognize it as a diagnosis, making this name obsolete. Today, experts recognize schizophrenia as a specific disease and a spectrum of disorders. Healthcare providers regard catatonia as an important syndrome to consider and treat, especially when it happens with schizophrenia.

The American Psychiatric Association removed catatonic schizophrenia from its list of official diagnoses when updating to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013. The World Health Organization (WHO) removed “catatonic schizophrenia” from the International Classification of Diseases when updating to the 11th edition (ICD-11) in 2019.

What is catatonia?

Catatonia is a syndrome — a collection of signs and symptoms — where your brain doesn’t manage muscle movement signals as it should and you behave abnormally. It happens with many other conditions, but schizophrenia is frequently associated with catatonia. Once thought to be the only condition associated with catatonia, it’s now known that bipolar disorder is more commonly associated with catatonia and that catatonia occurs alongside a number of medical and mental health conditions.

There are three main forms of catatonia: excited, withdrawn and mixed.

• Excited/hyperkinetic: This form involves increased movement (such as in the form of pacing), agitated behavior, unusual or exaggerated movements, repetitive movements or speaking, or mimicking someone speaking or moving near them.
• Withdrawn/hypokinetic: This form of catatonia is often easier to spot because people with this form of catatonia have very limited responses — or no response at all — to what’s happening around them. They may be mute, show no emotions or facial expressions, hold completely still or stare or stay in an unusual position for an extended period.
• Mixed: This form combines features of hyperkinetic and hypokinetic catatonia.

What is the difference between catatonic schizophrenia and paranoid schizophrenia?

Like “catatonic schizophrenia,” “paranoid schizophrenia” is an obsolete term for a diagnosis that no longer exists. Paranoid schizophrenia was the name for schizophrenia where experts regarded paranoia, delusions and hallucinations as key symptoms. Catatonic schizophrenia is the term for schizophrenia where catatonia is the most dominant feature.

Who does it affect?

Schizophrenia tends to happen earlier, between ages 15 and 25, for men and people assigned male at birth. It usually happens between ages 25 and 35 for women and people assigned female at birth. It happens at the same rates regardless of sex. Children can develop schizophrenia in rare cases, and their cases are usually more severe than those that appear in adults. In contrast to adults, catatonia in childhood is most commonly associated with schizophrenia.

How common is this condition?

Schizophrenia is a widely known condition, but it isn’t very common. About 85 people out of every 10,000 will develop it during their lifetime. Worldwide, healthcare providers diagnose about 2.77 million people per year with this condition.

Catatonia happens in a small — but still noteworthy — percentage of people with schizophrenia. Researchers estimate it happens in between 10% and 25% of people with schizophrenia.

How does this condition affect my body?

Schizophrenia is a condition that disrupts how your brain works, especially the processes related to your thinking and focusing ability, memories, key senses and more. Schizophrenia that involves catatonia often stands out because it involves extremely high levels of movement or no movement at all, though most people have more subtle presentations in between these extremes.

What are the symptoms?

Schizophrenia typically happens in three stages and has five key symptoms. The active stage of schizophrenia is when symptoms are at their worst. The key symptoms of schizophrenia can happen regardless of whether or not catatonia is also present. Those five symptoms are:

• Delusions.
• Hallucinations.
• Disorganized or incoherent speaking.
• Disorganized or unusual movements.
• Negative symptoms (in this context, negative means “diminished” or “reduced” instead of bad).

See our main Schizophrenia article for more about these symptoms and the stages during which they happen.

Symptoms of catatonia

Historically, experts have recognized up to 40 different symptoms that can happen with catatonia. The DSM-5 narrows that list to 12 symptoms.

• Agitation. This means a person acts upset or irritable for no clear reason. It only counts as a symptom of catatonia if it happens and isn’t a response to something around the person having it.
• Catalepsy (pronounced “cat-ah-lep-see”). This is when a person holds a position in which someone places them (you can still move them around to make them take on a new pose).
• Echolalia (pronounced “eck-oh-la-lee-ah”). This is when a person echoes sounds or words that someone else makes.
• Echopraxia (pronounced “eck-oh-prax-ee-ah”). This is when a person mimics or mirrors someone else’s movements or behaviors.
• Grimacing. This is holding the same facial expression, usually with stiff or tense facial muscles. Sometimes, it can take the form of smiling in inappropriate contexts.
• Mannerism. This is when a person acts out motions or movements that are usually seen as normal, but does them in an unusual and exaggerated way.
• Mutism (pronounced “mew-tism”). This is when a person is either very or totally quiet (this is only a symptom if the person doesn’t have another condition, such as aphasia, to explain why they aren’t speaking).
• Negativism (pronounced “neg-uh-tiv-ism”). This means a person doesn’t react to something happening around them or actively resists what’s happening around them for no rational reason.
• Posturing. This is when a person holds a specific position, which would often be uncomfortable to people who aren’t experiencing catatonia. In contrast to catalepsy, this doesn’t involve being placed in the position by another person.
• Stereotypy (pronounced “stair-ee-oh-type-ee”). These are repetitive movements that don’t seem to have a purpose. They can include finger-play and patting/rubbing one’s body.
• Stupor (pronounced “stoop-er”). This is when a person is awake but doesn’t respond to what’s happening around them. People with catatonia often don’t respond to painful stimuli such as being pinched.
• Waxy flexibility. This is when a person puts up some slight, even push-back or resistance to any attempt to change their position. Then their muscles slowly release and their limbs bend like a warm candle.

While people who show signs of catatonia may not react to what’s happening around them, many of them are aware of what’s happening. Research shows that people who had catatonia symptoms often remember what happened to and around them, even though they showed little or no reaction to their surroundings.

Shifts in activity level

While schizophrenia happens in phases, the involvement of catatonia often changes how the condition progresses. Most cases of schizophrenia with catatonia develop and get worse quickly.

Catatonia can also involve different levels of activity. Some people with catatonia will stay nonresponsive to the world around them for a time, but then, will shift to a much higher level of activity. In some cases, these shifts in activity level include behavior that’s impulsive or even dangerous to the person themselves or to those around them.

What causes the condition?

Experts haven’t yet uncovered a confirmed cause of schizophrenia, but they suspect there are many factors that can play a role or contribute.

• Chemical imbalances in your brain. These are chemicals your brain uses for brain cell-to-brain cell communication.
• Congenital brain problems. These are problems that happen as your brain develops in the womb before you’re born.
• Communication disruptions between areas of your brain. There are networks of connected brain cells (neurons) that communicate across different areas. These networks of neurons link different parts of your brain so they can work together. Researchers suspect that when these connections miss, schizophrenia can be the result.

Experts believe there are several risk factors that can increase the chances that you’ll develop schizophrenia. Some examples of these include mutations you inherit from one or both parents, exposure to certain chemicals or substances, stress or complications that happened as you developed in your mother’s uterus and recreational drug use. None of these are confirmed causes, however.

Is it contagious?

Schizophrenia isn’t contagious and it doesn’t spread from person to person. Catatonia also isn’t contagious, but infectious diseases can sometimes cause it.

How is it diagnosed?

Your healthcare provider diagnoses schizophrenia using a combination of methods and approaches. These include a physical examination, neurological examination, lab tests, imaging scans and more. There’s no one lab test, diagnostic test or imaging scan that can diagnose any form of schizophrenia. However, tests and imaging scans can still help your provider rule out other dangerous or life-threatening conditions.

A diagnosis of schizophrenia requires that a person show at least two of that condition’s main symptoms. In addition, a person must also have at least three of the 12 catatonia signs for their provider to diagnose that as part of their schizophrenia.

What tests will be done to diagnose this condition?

The tests that can happen when your healthcare provider suspects schizophrenia include:

• Imaging tests. These can include computerized tomography (CT) scans, magnetic resonance imaging (MRI) scans and other imaging tests.
• Blood, urine and cerebrospinal fluid (spinal tap) tests. These tests look for chemical changes in bodily fluids, as well as heavy metal poisoning, infections and more.
• Brain activity testing. An electroencephalogram (EEG) analyzes and records the electrical activity in your brain, which can rule out seizures or epilepsy.

How is it treated, and is there a cure?

Schizophrenia is usually treatable, though not curable. Medications are usually the main form of treatment for schizophrenia. However, when this condition also involves catatonia, different treatments are required.

There are two main ways to treat schizophrenia that’s currently causing catatonia:

• Medications. A specific class of medication is usually the first line of treatment for schizophrenia with catatonia. Benzodiazepines (pronounced “ben-zoh-die-az-ep-eens”), which can also treat severe anxiety and panic or seizures, are often very effective at reversing the effects of catatonia. Antipsychotics, which are the mainstay of treatment for schizophrenia, are typically avoided in people with acute catatonia due to their potential to worsen catatonia.
• Electroconvulsive therapy (ECT). This treatment involves sending a mild electrical current through your skin and skull and into a part of your brain. This current causes a brief seizure and changes in brain activity. Unlike how some movies and TV shows portray it, this treatment happens while a person is under anesthesia, so it’s painless. This treatment is both safe and very effective for treating catatonia symptoms. It’s usually a second-line treatment except in very severe cases (or with malignant catatonia, described below under “What’s the outlook for this condition?”).

Complications/side effects of the treatment

The complications and side effects that are possible with treatments for schizophrenia depend on several factors, including the medications you take, any other health conditions you might have and more. Your healthcare provider is the best person to tell you what side effects are possible or likely because they can consider your specific case and tailor the information to your needs.

How do I take care of myself or manage the symptoms?

You should never try to diagnose schizophrenia in yourself or a loved one because it takes training and experience to diagnose it accurately. This condition also involves symptoms that can happen with other conditions or substance use. Lastly, the medications necessary to treat schizophrenia require a prescription from your healthcare provider. Because of all these factors, your healthcare provider should be the one to diagnose this condition and recommend treatments.

How soon after treatment will I feel better?

Your healthcare provider is the best source of information on when you should start to feel better and notice the effects of treatment. They can consider your specific case and all its details, providing you with information that’s the most accurate for your situation.

How can I reduce my risk or prevent this condition?

Schizophrenia is a condition that happens unpredictably. That means it’s impossible to prevent it or reduce your risk of developing it.

What can I expect if I have this condition?

Schizophrenia is a condition that’s well-known partly because of how it disrupts a person’s ability to think and understand the world around them. Because it’s a condition that causes psychosis, which means a disconnection from reality, people who have this condition struggle to tell what’s real and what isn’t. They also may not recognize that they have a condition because their brain can’t process that fact.

People who have catatonic schizophrenia may not respond to what’s happening around them, but they might be aware of it all the same. They may also cycle between not responding and periods of high activity, where they could act violently and pose a threat to themselves or others.

When schizophrenia goes untreated, this condition can cause severe disruptions in a person’s life. They may struggle to hold a job, maintain friendships and relationships and more. Many try — consciously or unconsciously — to self-medicate, which can lead to alcohol and substance use disorders.

With treatment, schizophrenia is often manageable. Many people who receive treatment find ways to manage their condition and follow the treatment plan can live happy, fulfilling lives.

How long does schizophrenia last?

Schizophrenia is a permanent condition. Some cases can go into remission, which means a person’s symptoms go away and don’t return. However, because the symptoms can return unpredictably, experts still consider this a lifelong condition.

What’s the outlook for this condition?

Schizophrenia with catatonia isn’t usually fatal on its own. However, it’s associated with increased risk of death from conditions that happen from not moving much, such as pulmonary embolism and pneumonia. There’s also one type of catatonia, malignant catatonia, that can be severe and even deadly. Malignant catatonia is dangerous because it can cause a very high fever and disrupt a person’s autonomic nervous system, which runs body systems without you thinking about them (such as breathing, blood pressure, etc.). Because malignant catatonia is potentially dangerous, ECT is usually a first-line treatment instead of medication.

In general, schizophrenia with catatonia is a condition that responds well to treatment. The outcomes are usually fair to good, especially with faster diagnosis and treatment. However, catatonic schizophrenia is often more difficult to treat than catatonia occurring alongside other mental health conditions.

How do I take care of myself?

It’s possible to manage schizophrenia and take care of yourself, even if you have a history of catatonia symptoms. Some steps you can take include:

• Take your medication(s) as prescribed (and don’t stop taking them without first talking to your healthcare provider).
• See your provider as recommended (these visits can help with adjusting medication or treatment plans to help you best).
• Don’t ignore or avoid your symptoms.
• Avoid alcohol and recreational drug use (these can worsen your symptoms or cause other problems).
• Consider seeking support.
• Build relationships with people you trust — especially loved ones and your healthcare provider — and don’t isolate yourself from them.

When should I see my healthcare provider or seek care?

Your healthcare provider will schedule appointments for you regularly, and it’s important for you to go to them. You should also see them if you notice a change in your symptoms or the effectiveness of your medication(s).

When should I go to the ER?

People who have schizophrenia symptoms now or who’ve had it in the past have an increased risk of self-harm and suicide. You should go to the ER or call 911 (or your local emergency services number) if you have thoughts about harming yourself, including thoughts of suicide, or about harming others. If you have thoughts like this, you can call any of the following:

• National Suicide Prevention Lifeline (United States). To call this line, dial 1.800.273.TALK (1.800.273.8255).
• Local crisis lines. Mental health organizations and centers in your area may offer resources and help through crisis lines.
• 911 (or your local emergency services number): You should call 911 (or the local emergency services number) if you feel like you’re in immediate danger of harming yourself. Operators and dispatchers for 911 lines can often help people in immediate danger because of a severe mental crisis and send first responders to assist.

What can I do if a loved one shows signs of schizophrenia or a similar condition?

Because people with schizophrenia frequently can’t recognize their symptoms or condition, they often don’t believe they need medical care or treatment. That can be frustrating or frightening for both the person with the symptoms and those who care about them.

Schizophrenia with catatonia can also cause you to feel worried or frightened if you have it, or if you have a loved one who has it. If you notice a loved one showing signs of schizophrenia, especially with symptoms like catatonia, it’s important to seek medical treatment for them. That’s because people with catatonia and schizophrenia may develop malignant catatonia, and are prone to agitation or dangerous behavior and other complications in some cases.

How to help a loved one who has schizophrenia

If you notice a loved one showing signs of schizophrenia or a related condition, you can try to help them by doing the following:

• Ask how you can help. Listening and offering your help keeps a line of communication open and helps them feel connected to others.
• Encourage them to see someone who can help. Treatment for schizophrenia, especially medication, can improve a person’s symptoms. In many cases, that’s enough to help them recognize that they have a medical condition that needs care.
• Don’t judge or argue. People with schizophrenia have trouble recognizing what’s real and what isn’t. Avoid judging them or trying to convince them that they’re experiencing hallucinations or delusions. That may cause them to lose trust or fuel feelings of paranoia.
• Stay calm. Anger and frustration can negatively affect your relationship with a loved one who has schizophrenia. It’s also easy for them to feel overwhelmed in noisy or hectic environments. Try to pick quiet and calming environments, and do what you can so they feel as safe and comfortable as possible.
• Get help in emergencies. If someone with schizophrenia talks about harming themselves or others, or if they show severe paranoia, agitation or act violently, you should call your local emergency services immediately.

A note from Cleveland Clinic

“Catatonic schizophrenia” is an obsolete term for a subtype of schizophrenia. While experts don’t use this diagnosis any longer, catatonia is still a feature that happens commonly with schizophrenia. It’s also a symptom that stands out because it affects a person’s movements, behavior and ability to communicate. In some cases, catatonia can also turn into a deadly issue, so people with catatonia should receive medical care as quickly as possible. Fortunately, there are ways to treat catatonia and schizophrenia, and people who have schizophrenia can often manage their condition and live fulfilling, enjoyable lives.