Recognition
Catatonia is a transdiagnostic psychomotor syndrome (mood disorders > psychotic disorders; also medical/neurological and autoimmune causes) — not a schizophrenia subtype (that historical classification is obsolete). Two poles: retarded/stuporous (mutism, stupor, negativism, posturing, waxy flexibility/catalepsy, staring) and excited (purposeless agitation). Also: echolalia, echopraxia, stereotypies, automatic obedience, ambitendency. Screen with the Bush‑Francis Catatonia Rating Scale.
Why it's an emergency 🚩
Complications of prolonged immobility/reduced intake: dehydration, malnutrition, VTE, pressure injury, aspiration, rhabdomyolysis. Malignant catatonia (hyperthermia + autonomic instability) overlaps clinically with NMS and can be fatal.
Management
- Lorazepam challenge (e.g., 1–2 mg) is both diagnostic and therapeutic — a positive response supports catatonia; titrate as first‑line.
- ECT for severe, malignant, or benzodiazepine‑refractory catatonia (definitive treatment).
- Caution with antipsychotics — D2 blockade can worsen catatonia and precipitate NMS, especially in malignant catatonia; treat the catatonia first.
- Investigate the underlying cause in parallel (affective, psychotic, organic/autoimmune).
Discriminators
- Depressive retardation vs catatonia: catatonia has the specific motor sign cluster (waxy flexibility, negativism, posturing), not just slowing.
- Malignant catatonia vs NMS: overlapping; the safe move is to stop dopamine blockers and support/treat with benzodiazepines/ECT.
Pitfalls
- Interpreting mutism/immobility as "uncooperative" and missing the syndrome.
- Reaching for an antipsychotic in a catatonic patient and precipitating deterioration.
Pearls
- 🎯 *Lorazepam is diagnostic and therapeutic* in catatonia.
- 🩺 A mute, immobile patient is a clinical finding, not a character trait — screen every stuporous patient for catatonia.
Next → From psychosis and neuropsychiatry to the mood disorders — depression from first principles (Part 3).