An 82 year-old female presents to the ED with her daughter due to altered mental status. On EMS arrival to the patient’s home, she is somnolent and unable to speak. She is activated as a Code Stroke and brought immediately to CT scan upon arrival. After returning from the CT scan, you go in to perform a comprehensive neurologic exam. The patient is lying in bed with her eyes closed, she does not arouse to voice. She does grimace with painful stimulation such as sternal rub. She groans and mumbles words but does not make coherent sentences. She does not follow commands. Her extremities do localize to painful stimulation. Despite her concerning neurologic exam, she is maintaining O2 saturations at 98% on room air and a respiratory rate of 14 with full deep breaths. While performing her neurologic exam, you lift her arm into the air and she holds it there indefinitely until you move the arm again. The radiologist calls to inform you of her normal non-contrast CT and CTA of the brain and neck. All laboratory work returns reassuring. On re-examination, she continues leave her limbs in the exact position you place them in until re-positioned. This reminds you of a condition that you learned about in medical school… catatonia!
Catatonia is a syndrome characterized by psychomotor abnormalities and often associated with a variety of psychiatric and neurologic conditions, classically schizophrenia. The syndrome can present with a variety of psychomotor symptoms and often decreased mental state. Although it was originally thought to be associated solely with schizophrenia, it has now been found to be associated with any psychiatric condition including PTSD, bipolar disorder, depression as well as neurologic conditions such as encephalitis, stroke, malignancy, or dementia. Catatonia can be a difficult diagnosis to make due to a variety of presentations. Some of the classic features of catatonia are listed below.
In the DSM-V definition of catatonia, the patient must present with at least three of the following:
Stupor – overall decreased activity or decreased interaction with the environment
Catalepsy – muscular rigidity, i.e. a limb stays where it is positioned
Waxy flexibility – resistance to positioning, like a feeling of bending a candle
Mutism – no verbal response
Negativism – no response to external stimuli
Posturing – maintaining a specific position for prolonged periods of time
Mannerisms – odd movements
Stereotypy – repetitive movements
Echolalia – mimicking speech
Echopraxia – mimicking movements
The diagnosis of catatonia is based on recognition of these classic clinical findings. Appropriate medical workup to exclude organic etiology is also very important. For example, common mimics could include acute intracranial processes such as ischemic or hemorrhagic stroke, meningitis/encephalitis, electrolyte derangement, neuroleptic malignant syndrome, serotonin syndrome, delirium, and many other causes. Consideration to medical workup to exclude these causes is of utmost importance to make the diagnosis and not miss a life-threatening process. Detailed history and physical exam should be performed, including specific attention to complete neurologic exam, evaluation of reflexes, and any signs of autonomic instability. Additional testing should include broad laboratory work, brain imaging including CT or MRI, and consideration of CSF studies.
Once a diagnosis of catatonia is suspected, the treatment should be initiated as soon as possible. The simplest treatment for an ED physician to perform is termed the “benzodiazepine challenge.” This can help with diagnostic uncertainty and rapidly improve symptoms in a majority of patients. Lorazepam is most often cited as the agent of choice due to its evaluation in the literature and the ease of use for ED physicians. It is estimated that about 60-80% of patients will achieve remission with benzodiazepine monotherapy. In a patient with suspect catatonia, the ED physician can give 2 mg IV lorazepam and observe the patient. Rapid improvement can be seen in their symptoms within a few minutes. After approximately 20-30 minutes, the patient may have recurrence of their catatonia symptoms and regress. Additional IV lorazepam can be given as needed. Besides IV benzodiazepines, the alternative treatment of choice is ECT. This should be started as soon as feasible, ideally within 24 to 48 hours of diagnosis. Antipsychotic drugs should be avoided in patients with catatonia, even for aggression or agitated patients. If not properly and promptly treated catatonia can proceed to malignant catatonia which carriers an associated mortality of up to 20%.
All patients with suspected diagnosis of catatonia should be admitted to the hospital for aggressive management of catatonia as well as the underlying psychiatric or medical disorder. Patients who have autonomic instability or hyperthermia should be admitted to the intensive care unit for close supportive care. Long term catatonia carriers a favorable prognosis.
Our patient was given a single dose of 1 mg IV lorazepam and soon after, began to speak and interact with her daughter, who had accompanied to the ED. Within one hour, she had return of mutism and cataplexy so an additional dose of IV lorazepam was given with rapid improvement of her symptoms. She was admitted to internal medicine with psychiatry consulting and was transitioned to an oral lorazepam regimen. She ultimately had good recovery and was discharged back to home with her daughter after an inpatient stay.
Catatonia is a purely clinical diagnosis that can be made in the ED
Recognize the characteristic clinical findings to keep this syndrome on your differential diagnosis of patients with mental changes
The treatment of catatonia should be initiated in the ED with IV lorazepam and rapid clinical improvement can help confirm your diagnosis
Faculty Reviewer: Dr. Kristina McAteer
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013
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Sharma, Puja, et al. "Catatonia in patients with dementia admitted to a geriatric psychiatry ward." Journal of neurosciences in rural practice 8.Suppl 1 (2017): S103.
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