Catatonia

What is catatonia?

Catatonia is a disorder that disrupts how your brain works, disrupting how a person processes and reacts to the world around them. People with catatonia often don’t react to things happening nearby or may react in ways that seem unusual. Impaired communication, unusual movements or lack of movement, and behavior abnormalities are the most striking features of this condition.

Researchers have studied catatonia since German psychiatrist Karl Kahlbaum named and described it in 1874, but it remains highly underdiagnosed. Part of this is because, until recent decades, catatonia was mistakenly believed to only occur in people with schizophrenia. Further challenges to diagnosis include disagreement within psychiatry on how many criteria and which criteria are required to diagnose catatonia. In addition, some catatonic signs, such as agitation and mutism, overlap with other conditions.

Who does catatonia affect?

Catatonia doesn’t affect any population differently based on race, sex, etc. It’s most common with the following kinds of conditions (more about these conditions is under the Causes and Symptoms section):

• Psychiatric conditions, which specifically affect your mental health.
• Neurological conditions, which specifically affect how your brain works.
• Medical conditions, which affect how one or more systems in your body function.

How common is this condition?

According to available research, catatonia happens in 0.5% to 2.1% of people receiving psychiatric care. That number climbs to around 10% for people who need inpatient mental health treatment.

How does this condition affect my body?

Catatonia disrupts how certain parts of your brain work, causing a person to go into a “catatonic state.” The areas of your brain that are affected are those that control or manage:

• Movement.
• Senses (vision, hearing, smell, touch and taste).
• Memory.
• Thinking and concentration (cognitive) abilities.
• Motivation.
• Emotions.
• Judgment and self-control (executive functions).

Because catatonia can disrupt many different brain areas, it can have many symptoms. That’s one of the reasons that it can happen with so many conditions and why it’s challenging for experts to diagnose.

What are the symptoms of catatonia?

There are 12 officially accepted symptoms of catatonia, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Those are:

• Agitation. This means a person acts upset or irritable. It only counts as a symptom of catatonia if it happens and it 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 that someone else makes.
• Echopraxia (pronounced “eck-oh-prax-ee-ah”). This is when a person mimics or mirrors someone else’s movements.
• 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 could be normal but does them in an unusual or exaggerated way.
• Mutism (pronounced “mew-tizm”). 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 catatonic. 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.

Catatonia activity levels

While most people think of catatonia as a disorder that involves moving very little or not at all, that’s not always the case. Catatonia can also involve sudden and unpredictable behavior changes, including excessive or even constant movement. The activity levels of catatonia are as follows:

• Excited/hyperkinetic. This form usually involves behavior changes, such as pacing, agitation, aggression and violent behavior without any situations causing the behavior change. It can also include acting or speaking strangely, mimicking how others nearby move or talk or even acts of self-harm.
• Withdrawn/hypokinetic. This form of catatonia is often what people think of when they talk or think about this disorder. People with this form are awake but don’t react to what’s happening around them, as if they just aren’t aware of their surroundings. They’re usually silent and have little or no facial expressions. They also might hold themselves in an unusual posture or position and may even resist attempts to move them. They often don’t eat or drink and may have incontinence.
• Mixed. This form combines features of hyperkinetic and hypokinetic catatonia. A person with catatonia can quickly switch between hyperkinetic and hypokinetic behaviors without warning.

Malignant catatonia

In some cases, catatonia can have deadly complications. When this happens, it’s known as malignant catatonia. This condition causes dysautonomia, which is when your autonomic nervous system doesn’t work as it should. Your autonomic nervous system is what controls the automatic body processes you don’t need to think about, such as heartbeat, blood pressure, etc.

The symptoms of malignant catatonia are:

• Dangerously high body temperature and fever (hyperthermia).
• Fast heart rate (tachycardia).
• Sweating (diaphoresis).
• Unstable blood pressure.
• Cyanosis (this is low blood oxygen that causes areas of your skin, especially around your lips and fingernails, to turn blue).

Because malignant catatonia disrupts how your brain runs your body’s automatic processes, it has the potential to cause death. That means it’s a problem that needs immediate medical care.

What causes catatonia?

Despite almost 150 years of study, experts still don’t know exactly why catatonia happens. However, there are several possible explanations, ranging from chemical imbalances in the brain to genetic causes passed from generation to generation.

Without a specific cause, experts can only point to other conditions that may involve catatonia. The mental health conditions that most commonly involve catatonia are:

• Bipolar disorder.
• Schizophrenia.
• Schizoaffective disorder.
• Major depressive disorder.

The neurological and medical conditions that most commonly involve catatonia are:

• Autism spectrum disorder.
• Autoimmune diseases (such as lupus or multiple sclerosis).
• Degenerative brain diseases (such as dementia and Parkinson’s disease).
• Down syndrome.
• Drug-related conditions (this includes prescription and recreational drugs).
• Encephalitis, including anti-NMDA receptor encephalitis.
• Electrolyte imbalance conditions.
• Epilepsy.
• Intellectual disability.
• Normal-pressure hydrocephalus.
• Stroke.
• Tourette syndrome.

Is it contagious?

Catatonia isn’t contagious, and you can’t spread it to or catch it from others.

How is catatonia diagnosed?

Your healthcare provider will diagnose catatonia using a combination of methods. This usually starts with a neurological examination. During that exam, your provider will test your reflexes, reactions and how they respond (or don’t respond) to the world around you.

Your provider will then use a standardized assessment tool, usually the Bush Francis Catatonia Rating Scale, to rate the presence or absence of catatonia and the degree of severity. Once catatonia is identified, healthcare providers must then identify the cause of catatonia, as catatonia is always associated with another psychiatric or medical condition. As catatonia can occur alongside serious or even deadly conditions, ruling out more severe underlying conditions is a priority.

What tests will be done to diagnose this condition?

Diagnosing catatonia and identifying the underlying condition usually involves lab, diagnostic and imaging tests.

• 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, 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 catatonia treated, and is there a cure?

The treatment for catatonia usually depends on the condition(s) with which it happens. If it happens with a medical or a neurological condition, treating that condition — if possible— will often reverse the effects of catatonia. Other treatment approaches have the best chances of success when it happens along with mental health conditions.

What medications or treatments are used?

There are two main ways to treat catatonia: medications and electroconvulsive therapy. There are other possible treatments like transcranial magnetic stimulation, but more research is necessary to understand if these are effective enough for widespread use.

Medications

Benzodiazepines are the primary medication for treating catatonia because they’re safe and very effective. Between 60% and 90% of people with catatonia will improve if treated with benzodiazepines. Lorazepam is the medication of choice, but others like clonazepam, diazepam and zolpidem are also effective. Healthcare providers can give these medications as an infusion through intravenous (IV) lines, an injection or in pill form depending on the particular medication.

Other medications (such as mood stabilizers or antipsychotic drugs) may also help but usually aren’t first-line treatments. These are most helpful for treating other symptoms after the initial catatonia symptoms improve, especially because antipsychotic medications can cause catatonia to become malignant catatonia or neuroleptic malignant syndrome.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) is a treatment that involves running a very mild electrical current through an area of your brain to cause a short seizure. People who undergo ECT do so under general anesthesia, which means they’re in a deep sleep so they don’t feel pain from this treatment.

ECT is also very effective, helping nearly all people with catatonia who receive it. It’s the main treatment for people who have malignant catatonia and is often a life-saving treatment in those cases. It’s also helpful for people whose catatonia isn’t responding to medications.

Complications/side effects of the treatment

The possible complications and side effects of treatments for catatonia can vary depending on which treatment — or combination of treatments — a person receives. A healthcare provider is the best person to explain the side effects or complications that are possible or likely.

How do I take care of myself or manage symptoms?

Catatonia is a difficult condition to diagnose even for trained, experienced healthcare providers. It also can happen because of life-threatening conditions that need immediate medical care. Because of both those factors, you shouldn’t try to self-diagnose or treat it.

How soon after treatment will I feel better, and how long does it take to recover?

With conditions like catatonia, every case is different. Your healthcare provider is the best source of information on the timeline for recovery. That’s because they can consider all the factors that affect a specific case, including the related conditions, a person’s medical history and more.

Benzodiazepines are usually effective quickly. When given intravenously, many people start to improve within 10 to 15 minutes. When a person can take medications by mouth in pills, it can take as little as 20 to 30 minutes for medications to work. However, it can take time to find the right dose, so some people may need several days of treatment before their catatonia improves.

ECT can also be effective quickly. Some people can start to show some improvement within minutes or hours of treatment, while others may need multiple treatments before responding. Most people will receive ECT a few times a week for a few weeks, but some may need daily treatments until symptoms improve.

How can I reduce my risk or prevent this?

Catatonia happens unpredictably and for reasons that experts still don’t fully understand, so it isn’t possible to prevent it or reduce your risk of it happening.

If you have a mental health condition for which you’re prescribed medication, your risk of catatonia may increase if you stop taking your medications.

What can I expect if I have this condition?

Most people who have catatonia are at least somewhat aware of the world around them. They simply can’t react to what’s happening around them as they would normally. It’s also common for people with catatonia to remember some of what happened to them even though they seemed unaware.

Because of how catatonia affects a person’s awareness of the world around them, it’s common that people who have it can’t speak for themselves or make decisions about their medical care. In those cases, healthcare providers will usually talk to a family member or loved one and ask them to make choices about care.

How long does catatonia last?

How long catatonia lasts depends partly on the conditions that it happens along with and the treatments received. Timely treatment is important because the longer that catatonia lasts, the less likely it’ll respond to treatment. Your healthcare provider is the best person to explain how long catatonia will last and what to expect.

What’s the outlook for this condition?

Catatonia usually isn’t life-threatening by itself (except for malignant catatonia, which is deadly without quick treatment). However, it’s associated with an increased risk of death from conditions that happen from not moving much, such as pulmonary embolism and pneumonia. Catatonia is also harder to treat when it lasts longer or when a person has it more than once. Fortunately, benzodiazepines and ECT have very high success rates for this condition, which means it’s very treatable.

People with mood disorders, such as bipolar disorder and major depressive disorder, tend to respond better to treatment than people with schizophrenia. However, this can still vary, and no two cases are alike. Your healthcare provider is the best person to explain the outlook for this condition because they can provide information that’s most relevant and accurate for your situation.

How do I take care of myself?

People with severe catatonia can’t take care of themselves and need care from trained medical professionals. That’s because catatonia increases the risk of complications that happen when a person can’t move or react to the world around them. That means they can’t eat or drink, leading to problems like dehydration and malnutrition. Lack of movement can also lead to pneumonia. They can also have blood clots, which puts them at risk of a stroke or a pulmonary embolism. They’re also at risk for behavior that may cause them to harm themselves or others.

When should I see my healthcare provider, or when should I seek care?

People who show signs of catatonia need medical attention as soon as possible. That’s because the symptoms of this condition are also possible with dangerous conditions that are emergencies and need immediate care. If a loved one shows signs of catatonia, you may need to take them to the hospital or even call 911 (or your local emergency services number).

When should I go to the ER?

People with catatonia, especially with conditions like schizophrenia, 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:

• Suicide and Crisis Lifeline (United States). To call this line, dial 988.
• 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.

A note from Cleveland Clinic

Catatonia is a disorder that can disrupt how a person’s brain works, affecting how they respond to the world around them. People with catatonia sometimes respond very little or not at all to what’s happening around them. Others may behave in ways that are unpredictable or dangerous to themselves or others. Catatonia can happen with many conditions, ranging from mental health disorders to medical conditions. It’s usually not acutely life-threatening, though there’s potential for serious complications and progression to malignant catatonia, which is a life-threatening emergency.

People with this disorder also often can’t care for themselves, so they need medical care from trained healthcare personnel. Fortunately, catatonia is very treatable, and most people respond to medication. Those who don’t respond to medication usually respond to electroconvulsive therapy. With timely, effective treatment, the effects of catatonia are often reversible, offering the chance for the treatment of or recovery from underlying conditions associated with catatonia.