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Catatonia

Key sources
The following summarized guidelines for the evaluation and management of catatonia are prepared by our editorial team based on guidelines from the British Association for Psychopharmacology (BAP 2023), the United States Department of Defense (DoD/VA 2022), and the American Psychiatric Association (APA 2010).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria
Include catatonia in the differential diagnosis of patients presenting with a substantially altered level of activity or abnormal behavior, especially where it is grossly inappropriate to the context.
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Diagnose catatonia based on the presence of ≥ 3 catatonic signs according to the DSM-5-TR or the ICD-11.
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2.Diagnostic investigations

History and physical examination: elicit a history to identify possible medical and psychiatric disorders underlying catatonia and prior response to treatment in history. Elicit a collateral history wherever possible.
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  • Laboratory tests

  • EEG

  • Neuroimaging

  • Lorazepam challenge test

3.Diagnostic procedures

Lumbar puncture: consider performing lumbar puncture based on history and examination findings, taking into account the possible diagnoses likely to mimic catatonia and the possible underlying etiology of the catatonia.
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4.Medical management

General principles: obtain initial assessment and initiate treatment of catatonia in secondary care.
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  • Benzodiazepines

  • Antipsychotics

  • NMDA receptor antagonists

  • Other agents

5.Therapeutic procedures

Electroconvulsive therapy: offer electroconvulsive therapy as a first-line treatment option in patients with catatonia.
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  • Transcranial magnetic stimulation

6.Specific circumstances

Pediatric patients: recognize that catatonia is known to occur in pediatric patients as young as 5 years. Screen for catatonia whenever clinically suspected.
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  • Elderly patients

  • Pregnant patients (during pregnancy)

  • Pregnant patients (breastfeeding)

  • Pregnant patients (postnatal period)

  • Patients with comorbidities

  • Patients with depression

  • Patients with autism spectrum disorder

  • Patients with periodic catatonia

  • Patients with malignant catatonia

  • Patients with neuroleptic malignant syndrome

  • Patients with antipsychotic-induced catatonia

7.Follow-up and surveillance

Assessment of treatment response: use a validated instrument, such as the Bush-Francis Catatonia Rating Scale or the Northoff Catatonia Rating Scale, for the assessment of treatment response.
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