Catatonia: A Care Staff Guide to Recognition and Escalation

Catatonia is a syndrome of disordered movement and behaviour that is easily missed. A person may stop speaking, hold a fixed posture, stare, refuse food and drink, or, less often, become agitated and overactive. In care settings it is regularly mistaken for depression, dementia, stubbornness or "refusing care". Yet it is a treatable and sometimes life-threatening condition. This guide explains how to recognise it and what care staff should do. It builds on our guides to psychosis and schizophrenia, where catatonia can occur.

What catatonia is

A clinical review published in PubMed Central describes catatonia as a movement and motivation dysregulation syndrome with multiple medical and psychiatric causes. It has two main presentations: a withdrawn form, with reduced responsiveness, and an excited form, with increased motor activity.

Signs to look for

The Bush-Francis Catatonia Rating Scale, widely used by clinicians, includes features such as:

• immobility, mutism and staring;
• posturing and waxy flexibility, where limbs stay in the position they are placed;
• stereotyped movements and mannerisms;
• echophenomena, which means copying another person's words or actions;
• negativism, which means resisting or doing the opposite of what is asked, and withdrawal.

Crouse and Moran, writing in Current Psychiatry in 2018, also name the Northoff Catatonia Scale as an assessment tool. Care staff do not score these scales, but accurate descriptions of what you see are what lead clinicians to use them.

How common is it?

Estimates differ by setting. The PubMed Central review says catatonia likely reaches up to 18% of patients with psychiatric disorders, while Crouse and Moran say it may be present in 10% to 20% of psychiatric inpatients. It is not confined to mental health wards: it can occur in general hospitals and care settings, particularly in people who are acutely unwell.

Why it is missed

The withdrawn form can look very like depression, dementia or delirium: the person is quiet, still, not eating and not engaging. In a busy care setting it is easy to describe this as low mood, refusal or "settling in". The clues that should prompt a second look are an abrupt change, unusual postures, repeated or purposeless movements, copying of words or actions, and a person who seems awake but does not respond. Clear notes about timing and behaviour help the clinical team tell these conditions apart.

Causes

Catatonia is not a diagnosis in itself so much as a syndrome with several possible causes. The PubMed Central review lists:

• psychiatric causes such as depression, mania and psychotic disorders;
• medical and neurological causes such as epilepsy, brain tumours and infections affecting the brain;
• medication-related causes, including antipsychotics, and withdrawal from medicines that act on dopamine or GABA.

This is why a physical assessment is part of the work-up. A person with new stillness, mutism or reduced intake should also be screened for delirium, which can look similar but needs different treatment.

Why it is dangerous

The review warns that untreated catatonia risks deep vein thrombosis, pulmonary embolism, pressure ulcers and death. Crouse and Moran add that malignant catatonia features fever, a fast heart rate, raised blood pressure and unstable autonomic function, which can be life-threatening, and that it must be distinguished from neuroleptic malignant syndrome. Someone who is not eating or drinking is also at risk of dehydration. A person who is stuporous, feverish or has an unstable pulse or blood pressure needs urgent medical assessment, not observation alone. Our guide to pressure ulcer prevention is relevant to anyone who cannot change position.

Treatment

Treatment is decided by doctors. The sources we reviewed describe benzodiazepines such as lorazepam as first-line, with the PubMed Central review reporting response rates of 70% to 85%. Crouse and Moran describe a lorazepam challenge in a case report, with a 2 mg intramuscular dose and a response within about an hour. Electroconvulsive therapy (ECT) is described as the most effective treatment, particularly in malignant presentations. The PubMed Central review cautions that antipsychotics can worsen catatonia and may trigger malignant catatonia or neuroleptic malignant syndrome. If a person on an antipsychotic becomes rigid, mute or feverish, escalate immediately and do not give further doses until a prescriber has reviewed them.

What care staff should do

1. Describe what you see in plain words: what the person is doing or not doing, since when, and what has changed.
2. Take and record observations, including temperature, pulse, blood pressure and fluid and food intake.
3. Escalate the same day to a GP or the mental health team, and urgently if there is fever, a fast pulse or very poor intake.
4. Provide care that protects the person: help with fluids, nutrition, hygiene, skin care and repositioning, and follow any clinical advice on preventing blood clots.
5. Speak calmly, explain what you are doing and avoid forcing the person to move or respond.

Our CPD courses for health and care staff support teams developing their mental health knowledge.

Working with the clinical team

Ask the prescriber or mental health team what to monitor, how often, and what should trigger an urgent call. Share your observation charts and any recent medicine changes, including new antipsychotics or recently stopped medicines, because these can be relevant to the cause. Keep the family informed in plain language, and record what you tell them. After recovery, a debrief with the person about what the experience was like can help rebuild trust and shape their care plan.

Frequently asked questions

Is catatonia the same as being stubborn or refusing care? No. It is a medical syndrome, and the person may be unable to respond even though they appear alert.

Can it be treated? Yes. The sources describe good response rates to benzodiazepines and to ECT, but treatment must be directed by a doctor.