Kendall Bache, M.D., Kanwarjeet Brar, M.D., Steven Lippmann, M.D.

Catatonia has been a condition commonly associated with schizophrenia, but it exists in a number of other psychiatric disorders.  Diagnostic criteria for catatonia involves at least three of these twelve findings: catalepsy, waxy flexibility, posturing, mutism, negativism, mannerism, stereotypy, grimacing, stupor, agitation, echolalia, and/or echopraxia.  However, catatonia can also be a sign of medical or neurological conditions. An expanded understanding of potential etiologies speeds recognition, diagnosis, and treatment.    

Catatonia with a psychiatric etiology is usually recognized when encountering a patient with this clinical presentation.  Psychopathology associated with catatonia includes schizophrenia, bipolar disorder, other psychoses, depression, other mood or anxiety disorders, autism, and Gilles de la Tourette Syndrome.  Pharmacotherapy is the acute conventional treatment; benzodiazepines are often the drug of choice, antipsychotic medications and in some cases ECT can also be helpful.  Then, treat the primary psychopathology in a routine manner.

When evaluating a patient with catatonia that lacks psychiatric indicators, medical conditions should be considered.   Infectious etiologies can incorporate viral, bacterial, or parasitic encephalopathies leading to a catatonic state.  Potential metabolic aberrations include hyponatremia, homocystinuria, hypercalcemia, porphyria, and severe hepatic or renal dysfunction.  Endocrine abnormalities such as hypothyroidism, hyperthyroidism, hyperparathyroidism, and adrenal malignancies can also induce catatonia. It can even emerge with substance intoxications or withdrawal states.  The substances involved with catatonic presentations include alcohol, sedatives, opiates, stimulants, and hallucinogens.  Appropriate evaluation, imaging, and laboratory testing are mandated and followed by treating the specific underlying medical pathology. Symptomatic therapies, on a calmative basis, might be required in addition, if urgently indicated.

Neurological disorders also can present with catatonia and affect various areas of the brain. The basal ganglia, limbic system, frontal, temporal or parietal lobes, third ventricle, thalamus, globus pallidus, caudate, and/or anterior putamen can be the site of the pathology, due to epilepsy, contusion, atrophy, neoplasm, or space-occupying lesion.  After identifying the underlying disorder, instituting appropriate neurological intervention is indicated. Symptomatic sedation may be prescribed adjunctively, in an individualized manner if needed.

Catatonia although most often associated with psychiatric disorders can also be a sign of other underlying etiologies within general medicine or due to neuropathologies.  Physicians should always consider a variety of differential diagnoses when encountering a patient who exhibits catatonia.

Suggested Readings

1.    Diagnostic and Statistical Manual of Mental Disorders: DSM- V. (2013) Washington D.C.: American Psychiatric Association.
2.    Brown M, Freeman S. Clonazepam withdrawal-induced catatonia. Psychosomatics. 2009; 50(3):289-292.
3.    Niraj Ahuja. Organic Catatonia: A Review. Indian Journal of Psychiatry. 2000; 42(4):327-346.
4.    Sadock, V.A., Sadock, B. J., Ruiz, P.(2014). Kaplan and Sadock’s Synopsis of Psychiatry: Behavorial Sciences/Clinical Psychiatry; Philidelpia PA. :Wolters Kluwer.