Catatonia is a severe neuropsychiatric syndrome defined by profound disturbances in movement and behavior, representing a collection of symptoms rather than a standalone diagnosis. While the public often associates catatonia with a single image of immobility, the condition encompasses a wide spectrum of psychomotor abnormalities, ranging from near-complete lack of movement to extreme agitation. The syndrome is a manifestation of an underlying medical or psychiatric illness affecting brain function. Understanding its diverse presentations is key to recognizing the intense internal experience of those affected.
The Subjective Internal Experience
Contrary to the common visual impression of a person frozen or withdrawn, individuals experiencing catatonia are often fully conscious and painfully aware of their surroundings. This awareness transforms the catatonic state into a terrifying experience of feeling profoundly “trapped” within one’s own body. The internal world is dominated by intense fear and anxiety, often likened to an extreme “freeze” response to perceived danger.
For those in the immobile or stuporous state, the struggle is an internal battle to initiate movement that fails to translate into physical action. They may try to speak or move a limb, but the motor command is blocked in the brain’s circuitry, leading to feelings of powerlessness and depersonalization.
In the excited form of catatonia, the internal feeling is one of being driven by an uncontrollable motor force. The patient may feel compelled to engage in purposeless, chaotic, or aggressive movements, or to mimic the speech and actions of others, without the ability to stop. This state is often accompanied by an internal sense of extreme agitation and a loss of control over thoughts and emotions. Retrospective accounts highlight that the most disturbing part of the episode was the cognitive and emotional alterations, such as overwhelming ambivalence or intense anxiety.
Observable Signs and Motor Disturbances
The diagnosis of catatonia relies on observing a cluster of specific psychomotor signs reflecting the disruption of motor control systems. One recognizable sign is stupor, a state of profound unresponsiveness where the individual is motionless and appears unaware of the environment, despite being awake. This is often accompanied by mutism, the absence of speech.
Catatonia is characterized by several distinct motor disturbances. A diagnosis requires the presence of at least three of these features to distinguish it from other conditions:
- Waxy flexibility (cerea flexibilitas), where a limb, once passively moved, retains the new posture for an extended period.
- Posturing, where the patient spontaneously maintains an unusual or inappropriate body position against gravity.
- Negativism, an apparent motiveless opposition or lack of response to instructions.
- Mannerisms, odd, exaggerated caricatures of normal actions.
- Echolalia, the repetition of another person’s spoken words.
- Echopraxia, the repetitive imitation of another person’s movements.
Underlying Conditions That Trigger Catatonia
Catatonia is virtually always secondary to another medical or psychiatric illness, representing a common pathway for various insults to the brain’s regulatory circuits. The underlying causes are broadly grouped into two primary categories.
The first and most frequent category is psychiatric conditions, with mood disorders being the most common trigger. Severe episodes of bipolar disorder, particularly during mania or severe depression, account for a large percentage of cases, often more than schizophrenia. Catatonia also occurs in other psychiatric disorders, including psychotic disorders and autism spectrum disorder.
The second category involves medical and neurological conditions, which require immediate identification as they can be life-threatening. These causes include autoimmune disorders, infections, specific metabolic imbalances like electrolyte disturbances, and neurological issues such as nonconvulsive status epilepticus. Identifying and treating the primary cause is necessary for long-term recovery.
Immediate Medical Intervention
Catatonia is considered a medical emergency because prolonged immobility or severe agitation can lead to life-threatening complications, including dehydration, blood clots, and muscle breakdown (rhabdomyolysis). Stabilization must begin immediately, even while the underlying cause is still being investigated. The standard first-line intervention is the administration of benzodiazepines, specifically lorazepam.
The Lorazepam Challenge involves giving 1 to 2 mg of lorazepam intravenously or intramuscularly; a rapid, noticeable improvement in symptoms is both diagnostic and therapeutic. Benzodiazepines modulate the GABA-A receptor system, and the response rate is typically 70% to 80%. If catatonia does not respond adequately to a trial of lorazepam, or if the patient’s condition is rapidly deteriorating, Electroconvulsive Therapy (ECT) is the definitive second-line treatment.
ECT is highly effective and safe, often leading to a rapid and complete resolution of symptoms when medication has failed. In cases of malignant catatonia, characterized by autonomic instability, fever, and blood pressure changes, ECT may be initiated immediately as the treatment of choice due to the urgency.