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Assess and treat catatonia using this systematic approach
Catatonia is a neuropsychiatric condition with varying presentations that involve behavioral, motoric, cognitive, affective, and, occasionally, autonomic disturbances. Underlying causes of the syndrome include:
- mood disorders
- psychotic disorders
- neurologic disease
- general medical conditions
- metabolic abnormalities
- drug intoxication or withdrawal.
- deep vein thrombosis and pulmonary embolism
- pressure sores or ulcers
- muscle contractures
- nutritional deficiencies and dehydration from decreased oral intake.1
Prompt recognition, assessment, and treatment are vital.
We recommend the following systematic approach to evaluate and treat catatonia (Table).
Assess
Appropriate assessment of catatonia requires recognition of the array of potential underlying causes of the syndrome.
Obtain a complete history, including:
- recent changes in behavior
- past psychiatric illness and hospitalization
- past or current neurologic or medical disease
- prescription and illicit drug use.
Collateral informants, such as family members and caregivers, could provide valuable information. This history could reveal causative factors and identify appropriate targets for treatment.
Physical and mental status examinations can help characterize the type and severity of motoric and behavioral symptoms, such as rigidity, waxy flexibility, negativism, automatic obedience, ambitendency, and perseveration. Monitoring vital signs is crucial because of the risk of medical complications and malignant catatonia, which can be lethal if not treated.
Laboratory testing and imaging might be indicated to rule out medical causes, such as infection, metabolic disturbances, drug intoxication and withdrawal, and acute neurologic etiologies.
Rate
Identify and rate symptom severity. After determining that a patient has catatonia, consider using a standardized instrument, such as the Bush Francis Catatonia Rating Scale (BFCRS),2 to assess the patient’s type of symptoms and degree of impairment. Scores obtained on such instruments can be tracked as the patient receives treatment. Although the BFCRS is imperfect because of ambiguous symptom descriptions and because symptoms can remain after effective treatment, it is the most widely researched catatonia scale.
Treat and monitor
Although there are no published data from large-scale, randomized, controlled trials, clinical experience shows that the mainstays of treatment still are benzodiazepines and electroconvulsive therapy (ECT). A benzodiazepine challenge of IV lorazepam, 2 mg, can lead to rapid, substantial symptomatic relief with relatively low risk of harm. An estimated 50% to 70% of patients with catatonia respond within 5 days to IV lorazepam, 2 mg, every 3 to 8 hours.3
When patients do not respond to benzodiazepines, consider ECT. For patients with medical, neurologic, and toxic metabolic causes of catatonia, treat the underlying disturbance first.
1. Clinebell K, Azzam PN, Gopalan P, et al. Guidelines for preventing common medical complications of catatonia: case report and literature review. J Clin Psychiatry. 2014;75(6):644-651.
2. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2):129-136.
3. Fink M. Catatonia: syndrome or schizophrenia subtype? Recognition and treatment. J Neural Transmission (Vienna). 2001;108(6):637-644.
Catatonia is a neuropsychiatric condition with varying presentations that involve behavioral, motoric, cognitive, affective, and, occasionally, autonomic disturbances. Underlying causes of the syndrome include:
- mood disorders
- psychotic disorders
- neurologic disease
- general medical conditions
- metabolic abnormalities
- drug intoxication or withdrawal.
- deep vein thrombosis and pulmonary embolism
- pressure sores or ulcers
- muscle contractures
- nutritional deficiencies and dehydration from decreased oral intake.1
Prompt recognition, assessment, and treatment are vital.
We recommend the following systematic approach to evaluate and treat catatonia (Table).
Assess
Appropriate assessment of catatonia requires recognition of the array of potential underlying causes of the syndrome.
Obtain a complete history, including:
- recent changes in behavior
- past psychiatric illness and hospitalization
- past or current neurologic or medical disease
- prescription and illicit drug use.
Collateral informants, such as family members and caregivers, could provide valuable information. This history could reveal causative factors and identify appropriate targets for treatment.
Physical and mental status examinations can help characterize the type and severity of motoric and behavioral symptoms, such as rigidity, waxy flexibility, negativism, automatic obedience, ambitendency, and perseveration. Monitoring vital signs is crucial because of the risk of medical complications and malignant catatonia, which can be lethal if not treated.
Laboratory testing and imaging might be indicated to rule out medical causes, such as infection, metabolic disturbances, drug intoxication and withdrawal, and acute neurologic etiologies.
Rate
Identify and rate symptom severity. After determining that a patient has catatonia, consider using a standardized instrument, such as the Bush Francis Catatonia Rating Scale (BFCRS),2 to assess the patient’s type of symptoms and degree of impairment. Scores obtained on such instruments can be tracked as the patient receives treatment. Although the BFCRS is imperfect because of ambiguous symptom descriptions and because symptoms can remain after effective treatment, it is the most widely researched catatonia scale.
Treat and monitor
Although there are no published data from large-scale, randomized, controlled trials, clinical experience shows that the mainstays of treatment still are benzodiazepines and electroconvulsive therapy (ECT). A benzodiazepine challenge of IV lorazepam, 2 mg, can lead to rapid, substantial symptomatic relief with relatively low risk of harm. An estimated 50% to 70% of patients with catatonia respond within 5 days to IV lorazepam, 2 mg, every 3 to 8 hours.3
When patients do not respond to benzodiazepines, consider ECT. For patients with medical, neurologic, and toxic metabolic causes of catatonia, treat the underlying disturbance first.
Catatonia is a neuropsychiatric condition with varying presentations that involve behavioral, motoric, cognitive, affective, and, occasionally, autonomic disturbances. Underlying causes of the syndrome include:
- mood disorders
- psychotic disorders
- neurologic disease
- general medical conditions
- metabolic abnormalities
- drug intoxication or withdrawal.
- deep vein thrombosis and pulmonary embolism
- pressure sores or ulcers
- muscle contractures
- nutritional deficiencies and dehydration from decreased oral intake.1
Prompt recognition, assessment, and treatment are vital.
We recommend the following systematic approach to evaluate and treat catatonia (Table).
Assess
Appropriate assessment of catatonia requires recognition of the array of potential underlying causes of the syndrome.
Obtain a complete history, including:
- recent changes in behavior
- past psychiatric illness and hospitalization
- past or current neurologic or medical disease
- prescription and illicit drug use.
Collateral informants, such as family members and caregivers, could provide valuable information. This history could reveal causative factors and identify appropriate targets for treatment.
Physical and mental status examinations can help characterize the type and severity of motoric and behavioral symptoms, such as rigidity, waxy flexibility, negativism, automatic obedience, ambitendency, and perseveration. Monitoring vital signs is crucial because of the risk of medical complications and malignant catatonia, which can be lethal if not treated.
Laboratory testing and imaging might be indicated to rule out medical causes, such as infection, metabolic disturbances, drug intoxication and withdrawal, and acute neurologic etiologies.
Rate
Identify and rate symptom severity. After determining that a patient has catatonia, consider using a standardized instrument, such as the Bush Francis Catatonia Rating Scale (BFCRS),2 to assess the patient’s type of symptoms and degree of impairment. Scores obtained on such instruments can be tracked as the patient receives treatment. Although the BFCRS is imperfect because of ambiguous symptom descriptions and because symptoms can remain after effective treatment, it is the most widely researched catatonia scale.
Treat and monitor
Although there are no published data from large-scale, randomized, controlled trials, clinical experience shows that the mainstays of treatment still are benzodiazepines and electroconvulsive therapy (ECT). A benzodiazepine challenge of IV lorazepam, 2 mg, can lead to rapid, substantial symptomatic relief with relatively low risk of harm. An estimated 50% to 70% of patients with catatonia respond within 5 days to IV lorazepam, 2 mg, every 3 to 8 hours.3
When patients do not respond to benzodiazepines, consider ECT. For patients with medical, neurologic, and toxic metabolic causes of catatonia, treat the underlying disturbance first.
1. Clinebell K, Azzam PN, Gopalan P, et al. Guidelines for preventing common medical complications of catatonia: case report and literature review. J Clin Psychiatry. 2014;75(6):644-651.
2. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2):129-136.
3. Fink M. Catatonia: syndrome or schizophrenia subtype? Recognition and treatment. J Neural Transmission (Vienna). 2001;108(6):637-644.
1. Clinebell K, Azzam PN, Gopalan P, et al. Guidelines for preventing common medical complications of catatonia: case report and literature review. J Clin Psychiatry. 2014;75(6):644-651.
2. Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2):129-136.
3. Fink M. Catatonia: syndrome or schizophrenia subtype? Recognition and treatment. J Neural Transmission (Vienna). 2001;108(6):637-644.