Catatonia is a syndrome of abnormal movement and behavior that affects roughly 10% of people with schizophrenia. It can look like complete physical shutdown, with a person unable to move, speak, or respond, or it can swing in the opposite direction with agitated, purposeless movement. Once considered a defining feature of schizophrenia, catatonia is now recognized as a condition that can appear alongside many psychiatric and medical illnesses.
How Catatonia Was Reclassified
Until 2013, “catatonic schizophrenia” was an official subtype of schizophrenia in the diagnostic manual used by psychiatrists. The DSM-5 eliminated all schizophrenia subtypes, including the catatonic, paranoid, and disorganized forms, because they had poor diagnostic reliability and didn’t predict how someone would respond to treatment or how their illness would progress over time. Catatonia is now listed as a “specifier,” meaning it can be noted alongside schizophrenia, bipolar disorder, depression, or a separate medical condition. This change reflected what clinicians had long observed: catatonia isn’t unique to schizophrenia.
What Catatonia Looks and Feels Like
Catatonia involves at least two of a wide range of motor and behavioral symptoms. These tend to cluster into two broad patterns.
The more recognized pattern is one of withdrawal and immobility. A person may sit or lie completely still for hours, appearing unaware of the world around them. Their face may become mask-like and expressionless, their eyes fixed at a distance. They may stop speaking entirely (mutism) or resist any attempt to be moved or repositioned (negativism). One of the most distinctive signs is waxy flexibility: if someone lifts the person’s arm into an awkward position, they hold it there indefinitely, as if their limbs were made of wax.
The opposite pattern, sometimes called excited catatonia, involves constant purposeless motion, impulsive actions, and agitation that can escalate to the point of physical danger. A person in this state may strike out at others, repeat the same words or phrases endlessly (verbigeration), or mimic someone else’s movements or speech (echopraxia and echolalia). These two patterns can even alternate in the same person.
Other common features include stereotypy (repetitive movements with no clear goal), grimacing, automatic obedience (carrying out any instruction without question), and withdrawal from eating or drinking.
What Happens in the Brain
Catatonia doesn’t come from damage to a single brain area. Instead, it involves disrupted signaling across several regions, including the frontal lobes, basal ganglia, parietal lobe, and cerebellum. The leading theory centers on a neurotransmitter called GABA, the brain’s primary calming signal. Brain imaging studies have found that people in catatonic states have significantly reduced GABA receptor activity in the right orbitofrontal cortex, a region involved in decision-making and motor planning. Blood flow to the right parietal cortex is also decreased.
This GABA dysfunction appears to set off a chain reaction. The orbitofrontal cortex connects to deeper brain structures through loops that run from the cortex to the striatum, then to the thalamus, and back again. When GABA signaling drops in the cortex, dopamine regulation in these loops goes haywire, which helps explain why movement is so profoundly affected. Excess glutamate (the brain’s primary excitatory signal) may also play a role by further suppressing GABA function, creating a feedback loop that locks the motor system in place or sends it into overdrive.
How Catatonia Is Identified
Because people in catatonic states often can’t describe what they’re experiencing, diagnosis relies on direct observation. The most widely used tool is the Bush-Francis Catatonia Rating Scale, which scores 23 specific signs on a scale from 0 to 3. These range from immobility, mutism, and staring to rigidity, combativeness, and autonomic abnormalities like unstable heart rate or blood pressure. A screening version uses the first 14 items; if two or more are present, the full assessment is completed.
A quick diagnostic test involves giving a dose of a benzodiazepine and watching for improvement. In catatonia, this often produces a dramatic and rapid response, with a previously mute, immobile person beginning to speak and move within minutes. This response both confirms the diagnosis and begins treatment.
Treatment and Recovery
Benzodiazepines are the first-line treatment and work in 66% to 100% of cases. Treatment typically starts at a low dose, and if the person doesn’t respond, the dose is gradually increased every 24 to 48 hours. If benzodiazepines fail, electroconvulsive therapy (ECT) is the next step. ECT has strong evidence behind it: in the largest study to date, 89% of 63 patients with catatonia responded to bilateral ECT. Across multiple studies, response rates typically range from 59% to 93%, with several showing rates above 85%. Even among people who didn’t respond to benzodiazepines, roughly 89% improved with ECT.
For people with schizophrenia specifically, treatment requires a careful balance. Certain antipsychotic medications, particularly older ones, can actually worsen catatonia or trigger a dangerous condition called neuroleptic malignant syndrome, which closely resembles malignant catatonia. This is one reason accurate diagnosis matters so much.
Physical Risks of Prolonged Catatonia
When catatonia goes unrecognized or untreated, the prolonged immobility creates serious medical dangers. People who cannot move for days or weeks are at risk for blood clots, particularly pulmonary embolism, which can be fatal. Pressure ulcers develop on skin compressed against a bed or chair. Muscles can waste and permanently shorten into contractures. Breakdown of muscle tissue (rhabdomyolysis) can lead to kidney failure. People who stop eating and drinking face dehydration, malnutrition, and aspiration pneumonia if they inhale food or liquid into their lungs.
These complications are a major reason catatonia carries increased morbidity and mortality. They are largely preventable with prompt recognition and treatment.
Malignant Catatonia
The most dangerous form is malignant catatonia, which involves the breakdown of the body’s automatic regulatory systems. Signs include dangerously high body temperature, rapid heart rate, heavy sweating, unstable blood pressure, and bluish discoloration of the skin around the lips and fingernails from low blood oxygen. Because the brain loses control of the body’s automatic processes, malignant catatonia is fatal without emergency treatment. It requires immediate medical intervention and is treated as a psychiatric emergency distinct from ordinary catatonia.