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Catatonia

What's new

Added 2023 BAP guidelines for the diagnosis and management of catatonia.

Guidelines

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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Screening and diagnosis

Diagnostic criteria
As per BAP 2023 guidelines:
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.
B
Diagnose catatonia based on the presence of ≥ 3 catatonic signs according to the DSM-5-TR or the ICD-11.
B
DSM-5 diagnostic criteria for catatonia
Stupor (no psychomotor activity; not actively relating to environment)
Catalepsy (passive induction of a posture held against gravity)
Waxy flexibility (slight, even resistance to positioning by examiner)
Mutism (no, or very little, verbal response; exclude if known aphasia)
Negativism (opposition or no response to instructions or external stimuli)
Posturing (spontaneous and active maintenance of a posture against gravity)
Mannerism (odd, circumstantial caricature of normal actions)
Stereotypy (repetitive, abnormally frequent, non-goal-directed movements)
Agitation (not influenced by external stimuli)
Grimacing
Echolalia (mimicking another's speech)
Echopraxia (mimicking another's movements)
Diagnostic criteria not met
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Diagnostic investigations

History and physical examination: as per BAP 2023 guidelines, 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.
B
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Bush-Francis Catatonia Rating Scale (BFCRS)
1. Excitement (extreme hyperactivity, constant motor unrest apparently non-purposeful; not attributed to akathisia or goal-directed agitation)
Absent
Excessive motion, intermittent
Constant motion, hyperkinetic without rest periods
Full-blown catatonic excitement, endless frenzied motor activity
2. Immobility/stupor (extreme hypoactivity, immobile, minimally responsive to stimuli)
Absent
Sits abnormally still, may interact briefly
Virtually no interaction with external world
Stuporous, non-reactive to painful stimuli
3. Mutism (verbally unresponsive or minimally responsive)
Absent
Verbally unresponsive to majority of questions, incomprehensible whisper
Speaks < 20 words/5 min
No speech
4. Staring (fixed gaze, little or no visual scanning of environment, decreased blinking)
Absent
Poor eye contact, repeatedly gazes < 20 sec between shifting of attention, decreased blinking
Gaze held > 20 sec, occasionally shifts attention
Fixed gaze, non-reactive
5. Posturing/catalepsy (spontaneous maintenance of posture, including mundane, such as sitting or standing for long periods without reacting)
Absent
< 1 min
> 1 min to < 15 min
Bizarre posture, or mundane > 15 min
6. Grimacing (maintenance of odd facial expressions)
Absent
< 10 sec
< 1 min
Bizarre expression, or maintained > 1 min
7. Echopraxia/echolalia (mimicking of examiner's movements/speech)
Absent
Occasional
Frequent
Constant
8. Stereotypy (repetitive, non-goal-directed motor activity, such as finger-play, repeatedly touching, patting, or rubbing self; abnormality not inherent in act but in its frequency)
Absent
Occasional
Frequent
Constant
9. Mannerisms (odd, purposeful movements, such as hopping or walking tiptoe, saluting passers-by, or exaggerated caricatures of mundane movements; abnormality inherent in act itself)
Absent
Occasional
Frequent
Constant
10. Verbigeration (repetition of phrases or sentences, like a scratched record)
Absent
Occasional
Frequent, difficult to interrupt
Constant
11. Rigidity (maintenance of a rigid position despite efforts to be moved; exclude if cogwheeling or tremor is present)
Absent
Mild resistance
Moderate
Severe, cannot be repostured
12. Negativism (apparently motiveless resistance to instructions or attempts to move/examine patient; contrary behavior, does exact opposite of instruction)
Absent
Mild resistance and/or occasionally contrary
Moderate resistance and/or frequently contrary
Severe resistance and/or continually contrary
13. Waxy flexibility (during reposturing of patient, patient offers initial resistance before allowing themselves to be repositioned, similar to that of a bending candle)
Absent
Present
14. Withdrawal (refusal to eat, drink, and/or make eye contact)
Absent
Minimal oral intake/interaction for < 1 day
Minimal oral intake/interaction for > 1 day
No oral intake/interaction for ≥ 1 day
15. Impulsivity (patient suddenly engages in inappropriate behavior, such as runs down hallway, starts screaming, or takes off clothes, without provocation; afterwards can give no, or only a facile explanation)
Absent
Occasional
Frequent
Constant or not redirectable
16. Automatic obedience (exaggerated cooperation with examiner's request or spontaneous continuation of movement requested)
Absent
Occasional
Frequent
Constant
17. Mitgehen ("Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary)
Absent
Present
18. Gegenhalten (resistance to passive movement proportional to strength of the stimulus; appears automatic rather than willful)
Absent
Present
19. Ambitendency ([atient appears motorically "stuck" in indecisive, hesitant movement)
Absent
Present
20. Grasp reflex (per neurological examination)
Absent
Present
21. Perseveration (repeatedly returns to same topic or persists with movement)
Absent
Present
22. Combativeness (usually in an undirected manner, with no, or only a facile explanation afterwards)
Absent
Occasionally strikes out, low potential for injury
Frequently strikes out, moderate potential for injury
Serious danger to others
23. Autonomic abnormality (temperature, BP, pulse, respiratory rate, diaphoresis)
Normal
Abnormality of 1 parameter (excluding preexisting hypertension)
Abnormality of 2 parameters
Abnormality of ≥ 3 parameters
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More topics in this section

  • Laboratory tests

  • EEG

  • Neuroimaging

  • Lorazepam challenge test

Diagnostic procedures

Lumbar puncture: as per BAP 2023 guidelines, 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.
C

Medical management

General principles: as per BAP 2023 guidelines, obtain initial assessment and initiate treatment of catatonia in secondary care.
B
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More topics in this section

  • Benzodiazepines

  • Antipsychotics

  • NMDA receptor antagonists

  • Other agents

Therapeutic procedures

Electroconvulsive therapy: as per BAP 2023 guidelines, offer electroconvulsive therapy as a first-line treatment option in patients with catatonia.
B
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More topics in this section

  • Transcranial magnetic stimulation

Specific circumstances

Pediatric patients: as per BAP 2023 guidelines, recognize that catatonia is known to occur in pediatric patients as young as 5 years. Screen for catatonia whenever clinically suspected.
B
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More topics in this section

  • 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

Follow-up and surveillance

Assessment of treatment response: as per BAP 2023 guidelines, use a validated instrument, such as the Bush-Francis Catatonia Rating Scale or the Northoff Catatonia Rating Scale, for the assessment of treatment response.
B