Catatonia in schizophrenia: recognising it, treating it

Catatonia is one of the most striking syndromes in psychiatry — and one of the most underdiagnosed. A person who was talking yesterday may today sit motionless for hours, fix their gaze on the wall, refuse to eat, hold strange postures, or repeat the same phrase in a flat tone. To family members, it can look like the worst possible deterioration. To clinicians who recognise it, it is almost always highly treatable, often within days. Understanding what catatonia is — and isn't — can change outcomes dramatically.

A brief history

The German psychiatrist Karl Kahlbaum first described catatonia in 1874 as its own syndrome. Later, Emil Kraepelin folded it into what would become schizophrenia, and for most of the 20th century "catatonic schizophrenia" was a recognised subtype. The DSM-5 (2013) removed the catatonic subtype but added catatonia as a "specifier" that can be applied to schizophrenia, mood disorders, and a wide range of medical conditions. The change reflected the recognition that catatonia is not specific to schizophrenia — in fact, it is more commonly associated with mood disorders.

What catatonia looks like

Catatonia is diagnosed when a person shows at least three of the following clinical features (DSM-5 criteria):

• Stupor — no psychomotor activity, no active engagement with the environment
• Catalepsy — passive maintenance of a posture against gravity
• Waxy flexibility — slight, even resistance to repositioning by an examiner; the limb stays where placed
• Mutism — little or no verbal response (when not due to known aphasia)
• Negativism — opposing or not responding to instructions or external stimuli
• Posturing — spontaneous and active maintenance of a posture against gravity
• Mannerisms — odd, exaggerated normal actions
• Stereotypies — repetitive, non-goal-directed movements
• Agitation — not influenced by external stimuli
• Grimacing
• Echolalia — repeating another's speech
• Echopraxia — mimicking another's movements

The presentation can be predominantly retarded (slow, immobile, mute) or excited (agitated, hyperactive, sometimes purposeless). Both forms can dangerously progress.

Why it gets missed

Catatonia in someone with known schizophrenia is sometimes misread as worsening of negative symptoms, severe depression, intoxication, or simple non-cooperation. A person who hasn't spoken or eaten in two days may be assumed to be "not engaging with care" rather than catatonic. The Bush-Francis Catatonia Rating Scale, a well-validated screening tool, takes about five minutes to administer and dramatically increases recognition. Many psychiatric units now use it routinely on admission.

Malignant catatonia: a true emergency

Causes beyond schizophrenia

Catatonia can be a feature of:

• Mood disorders (most common — bipolar mania, severe depression)
• Schizophrenia spectrum disorders
• Autism spectrum conditions, particularly in adolescence
• Autoimmune encephalitis (e.g., anti-NMDA receptor encephalitis)
• Infections, electrolyte disturbances, thyroid disease
• Drug intoxication or withdrawal
• Adverse effects of antipsychotics (overlap with neuroleptic malignant syndrome)

Workup typically includes blood tests, an EEG, and sometimes brain imaging or lumbar puncture, especially in a first presentation.

Treatment

Benzodiazepines, especially lorazepam

The first-line treatment for catatonia is a benzodiazepine, almost always lorazepam. A test dose is given (typically 1–2 mg IM or IV), and a clear improvement within an hour or two is both diagnostic and therapeutic. Dosing is then titrated, sometimes to surprisingly high totals over the day. The response is often dramatic — patients who were mute and motionless can be talking and eating within hours.

Electroconvulsive therapy (ECT)

For catatonia that doesn't respond to benzodiazepines, or for malignant catatonia, ECT is highly effective. Modern ECT is delivered under general anaesthesia and is one of the most reliable treatments in psychiatry for this indication. The NICE guidance on ECT includes catatonia as an accepted indication.

Cautious use of antipsychotics

Antipsychotics — especially high-potency typical agents like haloperidol — can paradoxically worsen catatonia and may precipitate neuroleptic malignant syndrome in someone who is catatonic. Most experts recommend pausing or reducing antipsychotics until the catatonia is treated, then reintroducing carefully, often using a second-generation agent.

Supportive care

Catatonic patients can develop dehydration, malnutrition, pressure sores, deep vein thrombosis, and aspiration pneumonia. Inpatient supportive care — IV fluids, repositioning, DVT prophylaxis — is critical alongside specific treatment.

Recovery

With prompt treatment, most catatonic episodes resolve within days. Some people experience repeated episodes over the course of their illness; for them, ongoing benzodiazepine maintenance or knowledge of "what worked last time" can prevent severe recurrences. Family members who have witnessed an episode often find it helpful to know that despite the alarming presentation, catatonia generally has one of the most favourable treatment responses in serious psychiatric care.

For families

If a person with schizophrenia stops moving, stops speaking, holds odd postures, or refuses to eat, do not assume it's stubbornness or worsening negative symptoms. Call the treating clinician or, if severe, an emergency department, and use the word catatonia. Many clinicians outside psychiatry do not consider it as a possibility until prompted, and earlier treatment leads to faster recovery.

This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.