The diagnosis and treatment of catatonia

Scope and purpose

This concise guidance highlights some of the key recommendations of the Evidence-based consensus guidelines for the management of catatonia: recommendations from the British Association for Psychopharmacology, published in April 2023.⁵ In this article, we emphasis points from the guidelines that are of relevance to general physicians.

Differential diagnosis of catatonia

When considering the diagnosis of a patient with possible catatonia, there are two key questions:

• What conditions could account for this patient's presentation if it is not catatonia? Examples of such disorders and how to distinguish them are provided in Table 1.

• If it is catatonia, what medical or psychiatric disorder might be underlying it? Catatonia occurring de novo, on its own, is rare. The list of disorders associated with catatonia is very long, but some important examples are provided in Box 2. Importantly, underlying medical disorders are at least as common as psychiatric disorders in acute medical and surgical settings.⁷

Work-up

Given that catatonia is associated with intense anxiety, the approach to a patient is crucial. Despite appearances to the contrary, there is evidence that many patients with catatonia are aware of, and recall, their experiences⁸; thus, clinicians should interact with the person as they would with someone who understands what is happening. History from the patient is often limited; therefore, obtaining a thorough collateral history is essential. As well as ascertaining the course of the current illness, such a collateral should establish the presence of prior psychiatric or neurological disorders, any recent changes in medications and any recreational drug use.

Physical examination should involve attempts to elicit catatonic signs, such as catalepsy, echopraxia and abnormalities of muscle tone. Videos illustrating how to do this are available from https://bfcrs.urmc.edu. Equally important is an examination aimed at establishing volume status, focal neurological signs, evidence of pressure sores and evidence of deep venous thrombosis. Cardiovascular and respiratory examination are important in advance of treatment with high-dose benzodiazepines or electroconvulsive therapy (ECT).

In terms of investigations, the approach depends on the clinical situation and the index of suspicion for particular diagnoses (Box 3). Where it is unclear whether a presentation represents catatonia, a lorazepam challenge can be particularly useful. A baseline assessment of catatonic signs is conducted before 1–2 mg of lorazepam is administered. After an interval of 5 min (for intravenous (IV) lorazepam), 15 min (intramuscular; IM) or 30 min (oral), a reduction in catatonic signs of 50% supports a diagnosis of catatonia.

Treatment considerations

Treatment should usually be directed at the underlying condition at the same time as giving specific treatments for catatonia. Treatment of the underlying condition might be psychiatric or medical, such as immunosuppression in NMDAR encephalitis. There is some evidence suggesting that treatment response is better if given sooner. Prevention and management of medical complications can include thromboprophylaxis, pressure mattresses, intravenous fluids and nasogastric feeding.⁹

The mainstay of specific catatonia management is benzodiazepines and/or ECT. Antipsychotic medications, although possibly helpful in some cases where the underlying diagnosis is schizophrenia, should be used with caution, because catatonia is a strong risk factor for neuroleptic malignant syndrome.³ If clozapine has recently been discontinued for reasons other than for severe adverse effects, prompt reinstatement should be considered.

Benzodiazepines

The response to benzodiazepines in acute catatonia can be dramatic and rapid, sometimes within minutes. Although all benzodiazepines are probably effective, lorazepam has been most studied and, thus, is the preferred option. Routes of administration include oral, sublingual, IM and IV, depending on the clinical setting and availability.

Although many patients with catatonia might respond to doses of lorazepam licensed for other conditions, some require titration over several days to much higher doses. Titration should not be considered complete until catatonia is fully treated, sedation occurs or dose reaches at least 16 mg/day (in divided doses). Benzodiazepines should be gradually titrated down, although occasionally patients require longer-term benzodiazepine treatment.

Electroconvulsive therapy

ECT is usually highly effective in catatonia and National Institute for Health and Care Excellence (NICE) also recognises catatonia as an indication.¹⁰ Legal requirements for the administration of ECT depend on different jurisdictions. Box 4 summarises the recommendations for ECT.

Other treatments

Numerous other treatments have been suggested for catatonia, mostly based on case reports and case series. The evidence is a little stronger for the NMDAR antagonists amantadine and memantine, which are recommended after benzodiazepines and ECT. After NMDAR antagonists, there is a wide range of options with a low degree of evidence, namely levodopa, a dopamine agonist, carbamazepine, valproate, topiramate and a second-generation antipsychotic. However, antipsychotics should be avoided in the absence of a psychotic disorder and, even where a primary psychosis is present, should be used with caution.

Special groups

Treatment of catatonia in children and adolescents, older adults, women in the perinatal period, individuals with autism spectrum disorder and certain medical conditions is summarised in Table 2.

Limitations

The main limitation of these guidelines is the low quality of the evidence underlying them. Although a few randomised clinical trials have been conducted, they have tended to have been at high risk of bias, poorly reported or poorly applicable to most patients or modern treatments. Therefore, most of the evidence comprises small observational studies, often without a control group, although effects are sometimes dramatic. It should also be noted that most treatments for catatonia are outside the licence of the product; thus, relevant guidance, including providing information to the patient where possible and documenting the need for an unlicensed medication, should be followed.¹¹

Implications for implementation

Fortunately, benzodiazepines are cheap and widely available. However, access to ECT is patchy, which can delay care. Liaison between local services will be necessary to facilitate this. Multidisciplinary working more generally, particularly between psychiatrists and physicians, is important, because there are few clinicians who have expertise in the entire range of diagnoses detailed in Table 1 and Box 2.

Conflicts of interest

JPR, MSZ and ASD were members of the BAP Guideline Development Group. JPR is supported by the Wellcome Trust. MSZ declares honoraria for one lecture each for each of the four mentioned in the last 3 years: Norwegian Neurological Society; Copenhagen Neuropsychological Society, Rigshospitalet; and Cygnet Healthcare. MSZ declares travel and hotel support for a stay in Florence from the European Association of Neurology (EAN) for an EAN meeting on autoimmune encephalitis in April 2022. MSZ represents neurology in the UK for the Association of British Neurologists for matters related to Covid in meetings with NHS England and Royal College of Physicians.