Patients with catatonia usually cannot provide any history. So the history is usually obtained from the family or caregiver and may include the following:

• Any recent infection, trauma, exposure to toxins or use of drugs
• Prior history of catatonia
• Use of antipsychotics
• Comorbid disorders like mood disorders, schizophrenia, and pregnancy

In an emergency setting one must always rule out:

• Acute psychotic episode
• Encephalitis
• Neuroleptic malignant syndrome
• Status epilepticus

Catatonia is a syndrome associated with many clinical features, most of which are nonspecific these include:

• Ambitendency 
• Automatic obedience 
• Aversion 
• Catalepsy 
• Echolalia 
• Echopraxia 
• Excitement 
• Forced grasping 
• Gegenhalten 
• Grimacing 
• Immobility 
• Mannerisms 
• Mitgehen 
• Mitmachen 
• Mutism 
• Negativism Obstruction 
• Perseveration 
• Posturing 
• Psychological pillow 
• Rigidity 
• Speech may reveal logorrhea, echolalia
• Staring
• Stereotypical motions
• Stupor which is the most classic feature of the disorder. It often presents with mutism and immobility
• Verbigeration 
• Waxy flexibility

Physical exam

• May be hyperexcitable to completely immobile
• Automatic obedience
• Echolalia and echopraxia
• Inappropriate use of words
• Repetitive and inappropriate motions
• Muscle rigidity with continued grasp reflex 
• Cog wheeling
• Other features may include
• Hyperthermia
• Hypertension
• Tachycardia

Other signs include:

• Hyperpyrexia
• Autonomic instability
• Clouding of consciousness

Several rating scales to help make a diagnosis of catatonia developed. Determine comorbid conditions like, schizophrenia, mood disorders or any medical disorder. Headache, fever, and a nuchal rigidity in an acutely ill patient are suggestive of encephalitis. The presence of severe muscle rigidity, hyperthermia and autonomic dysregulation, suggests neuroleptic malignant syndrome. Acute psychosis may present with delusions, paranoia, hallucinations, or threatening behaviors.

• Fever

  RESULTS: The most common symptoms in patients with neuroleptic malignant syndrome were fever (87.7 %), rigor (85.9 %), laboratory evidence of muscle injury (70.5 %), and tachycardia (62.1 %) and in patients with catatonia were mutism (78.0 %), rigor [ncbi.nlm.nih.gov]

  Besides supportive care like hydration and control of fever, the two basic treatments are use of medications and electroconvulsive therapy (ECT). [symptoma.com]

  In all cases, the administration of antipsychotics has been suspended as soon as fever and autonomic disturbances occurred. [doi.org]

• Acutely Ill Patient

  Headache, fever, and a nuchal rigidity in an acutely ill patient are suggestive of encephalitis. The presence of severe muscle rigidity, hyperthermia and autonomic dysregulation, suggests neuroleptic malignant syndrome. [symptoma.com]

• Swelling

  This helps to rule out a brain tumor or swelling. How Is Catatonia Treated? Medications Medications are usually the first approach to treating catatonia. [healthline.com]

• Fecal Incontinence

  After this, he became bedridden, would refuse feeds and resist to be fed, developed stiffness of the body, would refuse being lifted, had urinary and fecal incontinence, became almost mute or would have echolalia for few minutes, had posturing, and weight [jgmh.org]

  An overview of associated conditions of catatonia in children and adolescents is provided in Table 1. 7-22 The frequencies of the most common catatonic symptoms in children and adolescents are shown in Table 2. 8 Rates for urinary and fecal incontinence [primarypsychiatry.com]

• Hypertension

  Causes[edit] Stupor is associated with infectious diseases, complicated toxic states (e.g. heavy metals), severe hypothermia, mental illnesses (e.g. schizophrenia, severe clinical depression), epilepsy, vascular illnesses (e.g. hypertensive encephalopathy [en.wikipedia.org]

  Malignant catatonia has a much poorer prognosis and is associated with rapid onset, fever, hypertension, and without the distinguishing features of involuntary movements, which is similar to neuroleptic malignant syndrome. [medlink.com]

  There is also an excited-delirious variety of catatonia with extreme hyperactivity (constant motor unrest or non-purposeful repetitive motor activity).[2] Patients may develop hyperthermia, tachycardia, and hypertension and be in danger of collapse from [patient.info]

  The patient also presented with mild hypertension and tachycardia. Past medical history. The patient had been treated for ADHD at age 12 with atomoxetine for three months. [innovationscns.com]

• Negativism

  During week three of hospitalization, she was given olanzapine with subsequent improvement in her negativism. [ncbi.nlm.nih.gov]

  History of the concept In 1874, Kahlbaum1,2 was the first to propose a syndrome of motor dysfunction characterized by mutism, immobility, staring gaze, negativism, stereotyped behavior, waxy flexibility, and verbal stereotypies that he called catatonia [mdedge.com]

  Svensk definition En neuropsykisk störning kännetecknad av ett eller flera av följande drag: orörlighet, mutism, negativism (vägringsattityd), tillgjordhet, stereotypi, gestikulerande, grimaserande, upphetsning, ekolal i (efterhärmning av ord), ekopraxi [mesh.kib.ki.se]

• Hunger

  We’d been doing the band for such a long time we thought we might all focus on something else for a while, to see if we still have the drive and the hunger to do Katatonia. As it turned out, we all missed it very much. [sonyhall.com]

• Stupor

  In catatonic stupor, i.e. immobility and stupor, the first-line therapy is electrotherapy, preferably at an earliest possible stage. In mania, catatonia may become manifest also as psychomotor excitement. [ncbi.nlm.nih.gov]

  Catatonia Other names Catatonic syndrome A patient in catatonic stupor Specialty Psychiatry Catatonia is a state of psycho-motor immobility and behavioral abnormality manifested by stupor. [en.wikipedia.org]

  In terms of symptoms, catatonia can be stuporous and excited. The characteristics of stuporous catatonia are immobility, stupor, mutism, and stereotypy. The characteristics of excited catatonia are bizarre, hyperactivity, and impulsivity. [youtube.com]

  […] to excited,14,15 and from benign to malignant.13 Examples of these ranges of presentation include5,12,13,15-19: Stuporous/retarded catatonia (Kahlbaum syndrome) is a primarily negative syndrome in which stupor, mutism, negativism, obsessional slowness [mdedge.com]

• Altered Mental Status

  When the patient's altered mental status could not otherwise be explained, benzodiazepine withdrawal-induced catatonia was considered. [ncbi.nlm.nih.gov]

  A 16-year-old boy with a history of attention deficit hyperactivity disorder (ADHD) and a mild learning disability diagnosed at age 12 presented to our emergency department with altered mental status. [innovationscns.com]

  Catatonia vis-à-vis delirium: The significance of recognizing catatonia in altered mental status. Gen. Hosp. Psychiatry 2015, 37, 554–559. [ Google Scholar ] [ CrossRef ] [ PubMed ] Grover, S.; Ghosh, A.; Ghormode, D. [mdpi.com]

• Apathy

  […] en at least two of: temperature > 38 °C or < 36,5 °C or temperature instability, tachycardia or bradycardia, apnoea, extended capillary refilling time (CRT), metabolic acidosis, hyperglycaemia, other sign of BSI such as apathy bg в Белгия- Registre [bg.glosbe.com]

  Over the years, his symptoms progressed further and in addition to psychotic symptoms, he developed apathy, incontinence, and his forgetfulness increased. [jgmh.org]

• Comprehensive physical exam with emphasis on neurological deficits and mental status.
• Differentiate between functional or organic cause.
• Needs medical admission or a psychiatric assessment.

Investigations:

• Complete blood count
• Electrolytes
• Renal and liver function
• Thyroid function
• Blood glucose
• Creatine phosphokinase
• Urine drug screen

Other investigations depend on physical findings: 

• Electrocardiogram (ECG)
• CT or MRI brain
• Electroencephalogram (EEG) 
• Blood and urine culture
• Heavy metal screen
• Serology for sexually transmitted diseases
• Lumbar puncture

Catatonia is managed by a multidisciplinary team including a neurologist, ophthalmologist, hematologist, psychiatrist and an internist [7] [8]. Hospital admission is required as most patients refuse to eat, are unable to care for themselves and have autonomic instability. Because of fever, dehydration many require IV hydration. It is vital to treat catatonia as early as possible. The longer the treatment is delayed the less responsive are the symptoms.

Besides supportive care like hydration and control of fever, the two basic treatments are use of medications and electroconvulsive therapy (ECT). The most important thing is to diagnose and treat the malignant catatonia like NMS, acute psychosis, encephalitis and non-convulsive status epilepticus immediately. These are neurological emergencies that are best managed in the ICU. Patients who cannot eat may require TPN or a feeding tube. Some patients may need admission to the psychiatric ward to prevent harm to themselves or others.

Pharmacologic therapy

There are many medications which have been used to treat catatonia but the benzodiazepines are the drugs of choice.[9] Others include:

• Sedatives like amobarbital, zolpidem 
• Anticonvulsants like carbamazepine 
• Tricyclic antidepressants 
• Muscle relaxants 
• Reserpine 
• Thyroid hormone 
• Lithium carbonate
• Dopamine agonists such as bromocriptine 
• NMDA antagonists like amantadine, memantine
• Antipsychotics 

Once the symptoms subside, the drug can be gradually withdrawn. In some cases, low dose maintenance treatment with drugs may be required. After drug treatment, improvement is seen within 48 hours.

Electroconvulsive treatment (ECT)

ECT is indicated for patients who fail to respond to medical therapy or those who have NMS or malignant catatonia or catatonic schizophrenia. The response is often immediate but patients may require several treatments over several weeks. Unfortunately, relapses do occur after a 12 month period and repeat treatments are required. After ECT treatment, patient can be discharged when the symptoms improve.[10]

The prognosis for catatonia depends on the cause. It has been observed that idiopathic cases do spontaneously recover in 10-40% of cases, regardless of treatment. When benzodiazepines are used, the response rates are much better. Failure to institute treatment early, generally has a poor prognosis. Children with cationic schizophrenia generally have a poor prognosis compared to children with other forms of schizophrenia. Many patients with mental disorders and catatonia need inpatient psychiatric treatment. Because of immobility, patients with catatonia are also at a high risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall about 70% of patients have a good response to treatment. But cognitive impairment and deficits in daily living activities are reported. After ECT high rate of relapse occurs within 12 months.

Complications

• Dehydration
• Malnutrition
• Immobility
• Pulmonary embolism
• Significant harm to self and others
• After a first episode of catatonia, repeat episodes are very common.

Catatonia has many causes but the most common include the following:

• Mood disorder (depression) and schizophrenia
• Postpartum depression
• Temporal lobe epilepsy
• When clozapine is discontinued, catatonia is a potential adverse reaction
• Use of ecstasy and cocaine
• Medications like ciprofloxacin
• Hyponatremia
• Wilson disease
• Prior brain injury
• Physical illness
• Rheumatic fever
• Hysteria

The exact incidence of catatonia is unknown but the rates are down from previous decades. Few reports from psychiatric in patients have been published on the prevalence but it is felt that these numbers are not valid because they do not reflect the patients on other medical wards or the general population. Further the difficulty in making the diagnosis and different diagnostic criteria used have led to confusion in the literature. In psychiatry wards, catatonia prevalence has been reported to be from 7-17%. The disorder is rare in children and often presents in adults. A slightly higher prevalence has been observed in female schizophrenics.

The exact cause of catatonia is unknown but several hypotheses exist based on abnormal neurotransmitter levels. It is believed that there is a deficiency in the inhibitory neurotransmitter GABA. This may also explain why the benzodiazepines, which increase GABAergic activity, have a therapeutic response. Similarly the excitatory neurotransmitter, glutamate, has been suggested as an underlying cause of catatonia.

Others believe that catatonia may be due to sudden and massive blockade of dopamine receptors and this may explain why antipsychotics are not always beneficial or may precipitate worsening of the disorder.[6]

Since the cause of catatonia is not known there is no preventive method. However, patients who have medical disorders like schizophrenia, depression, bipolar disorder should follow up closely with their healthcare provider. For healthcare professionals it is important to be aware of the signs and symptoms of the disorder, because the earlier catatonia is treated, the better is the prognosis.

Catatonia is a physical state of partial/complete indifference to external stimuli in an individual who is apparently awake. Catatonia is an important medical disorder with dramatic presentation. The disorder is underdiagnosed and not well recognized. The prevalence of catatonia has declined but is not miniscule.

Catatonia can occur in people of all ages and is associated with a range of comorbid disorders. The typical signs and symptoms range from complete immobility, mutism, movement disorders and impairment of voluntary expression of thoughts. The behavior can range from echolalia, automatism, or agitation. Catatonia has been classified in several ways but the most common classification as per DSM-5 is as follows:

• Catatonia associated with a mental disorder (eg. schizophrenia or mood disorder)
• Catatonic disorder due to another medical disorder
• Unspecified catatonia

Another classification includes dividing catatonia as follows:

• Systemic catatonia that is usually not genetically determined, has a higher prevalence and occurs early age and is more frequent in males. It is often associated with mid gestational infections
• Periodic catatonia has no difference in age of onset or prevalence, but has a genetic origin and often seen in schizophrenia [1] [2] [3] [4] [5].

Catatonia can often be mistaken for other disorders like neuroleptic malignant syndrome (NMS), nonconvulsive status epilepticus, acute psychosis, conversion disorder, malingering, and psychogenic movement disorders. There is a vast differential for catatonia but it is important to rule out life threatening malignant catatonia due to NMS or serotonin syndrome.

Diagnostic criteria (DSM-5)

DSM-5 criteria for diagnosis of catatonia require presence of at least 3 of the following features:

• Agitation
• Catalepsy
• Echolalia
• Echopraxia
• Grimacing
• Mannerism
• Mutism
• Negativism
• Posturing
• Stupor
• Stereotypy
• Waxy flexibility

Even though catatonia is often associated with schizophrenia, the majority of cases are associated with mood disorders (depression and bipolar disorder).

Catatonia is a complex disorder where the individual suddenly becomes unresponsive to external stimuli. The patient is awake but indifferent to what is going on in the environment. There are many causes of catatonia and it is often seen in patients with manic disorder, depression and schizophrenia. The disorder can occur in both genders and in all ages. The signs and symptoms are quite variable but the individual may become stiff, tends to repeat words, is unable to swallow, walk and have fever. Once the diagnosis is made, patients are admitted. Fluids are usually given. The treatment is either medications or electroconvulsive therapy. The outcome in most patients is good but recurrences are common.

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2. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the treatment of catatonia. Front Psychiatry. 2014 Dec 9;5:181.
3. Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry. 2014 Nov 19.
4. Padhy SK, Parakh P, Sridhar M. The catatonia conundrum: controversies and contradictions. Asian J Psychiatr. 2014 Feb;7(1):6-9.
5. Gonzales N, Quinn DK, Rayburn W. Perinatal catatonia: a case report and literature review. Psychosomatics. 2014 Nov-Dec;55(6):708-14.
6. Dhossche DM, Sienaert P, van der Heijden FM. [Mechanisms of catatonia]. Tijdschr Psychiatr. 2015;57(2):99-103
7. Hidasi Z, Salacz P, Csibri E. [Movement disorders is psychiatric diseases]. Neuropsychopharmacol Hung. 2014 Dec;16(4):205-11.
8. Clinebell K, Azzam PN, Gopalan P, Haskett R. Guidelines for preventing common medical complications of catatonia: case report and literature review. J Clin Psychiatry. 2014 Jun;75(6):644-51.
9. Pot AL, Lejoyeux M. [Catatonia]. Encephale. 2015 Jun;41(3):274-9.
10. Luchini F, Medda P, Mariani MG, Mauri M, Toni C, Perugi G. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry. 2015 Jun 22;5(2):182-92.