Catatonia

Catatonia is a state in which someone is awake but does not seem to respond to other people and their environment. Catatonia can affect someone’s movement, speech and behaviour in many different ways. Catatonia can have a number of different causes. However, the exact reason that someone develops catatonia is not clear and more research is needed in this area.

Catatonia can come on suddenly or slowly. In the past, people with catatonia were said to sit in strange positions for days on end. We now know people with catatonia can also experience a number of other symptoms.

If someone has three or more of these symptoms, they may have catatonia:

• Sitting very still and staring into space.
• Holding unusual postures which would normally be uncomfortable.
• Keeping their arms or legs in whatever position someone else moves them into.
• Repeating the same movements for a long time.
• Repeating the same movements as another person (known as ‘echopraxia’).
• Repeating phrases or words that they hear (known as ‘echolalia’).
• Holding strange faces.
• Not speaking, eating or drinking.
• Doing as they are told or directed without question.
• Not doing something, or resisting doing something (known as ‘negativism’).
• Becoming suddenly very agitated or restless. This is called ‘excited catatonia’.

These symptoms may come and go and may become more or less intense. The symptoms of catatonia can vary between individuals. While some people might move very little, other people might seem very agitated.

It is important to seek help if you notice three or more of these symptoms in yourself or someone else. Help is available from your GP, mental health team or by calling NHS 111.

Catatonia can occur in many conditions. These include:

Psychiatric conditions such as:

• schizophrenia
• mood disorders (including bipolar disorder and depression)
• obsessive-compulsive disorder (OCD)
• post-traumatic stress disorder (PTSD) or experiences of past trauma
• psychosis
• dissociative disorders

Physical conditions such as:

• infections
• brain injury
• drug and alcohol use
• metabolic disorders, e.g. diabetes – these are where the body uses too much or too little of the essential chemicals that keep you healthy.
• autoimmune disorders – these are where the body’s immune system, which normally fights off illness, attacks healthy cells by mistake.

If someone has catatonia, their medical team should always investigate whether there is a physical cause.

Although these illnesses can cause catatonia, the way in which they do this is unclear.

Not everyone who has these psychiatric and physical conditions will get catatonia, and we do not know exactly why this is.

Research suggests that brain chemicals such as GABA, glutamate and dopamine may be involved. These chemicals affect how the brain works, and having too much or not enough of these chemicals is thought to be involved in someone developing catatonia.

Catatonia can also affect people with autism spectrum disorders (ASD). You can find out more about this on the National Autistic Society’s website.

There are different tests a doctor might do to find out if someone has catatonia and what is causing it. Finding out what might have caused catatonia can help a doctor to treat the catatonia itself.

If it is thought you might have catatonia, your doctor will consider the following things:

• History - The doctor will talk to you or the person caring for you to find out about your history. They will also want to know how you have been feeling recently. You or the person caring for you should let them know about any drugs you are taking, any head injuries you might have had and any other health problems.
• Observation - The doctor might observe your behaviour during an appointment or when you are on a hospital ward.
• Examination - The doctor might choose to examine you to make sure that your body is working properly. This should be a full physical examination of your heart, lungs, abdomen and nervous system.
• Blood tests - The doctor might take some blood tests. These will look to see if you have any infections or any problems with how your body is working.
• Brain scan - After doing an examination and taking blood tests, the doctor might do a brain scan if they need more information. The scan will let your doctor see your brain in more detail.
• Electroencephalogram (EEG) - This test monitors the electrical activity in your brain. It can be used to see if you have a neurological condition. EEGs are performed by attaching small sensors to your head and using a machine to pick up the electrical signals produced by your brain. You can find out more about EEGs on the NHS website.

Catatonia can be treated, and people with the condition can make a good recovery. If catatonia is diagnosed early, it can sometimes be treated at home. However, someone with catatonia will often need more intensive treatment or support. This might mean they need to go into hospital.

Treating an underlying condition

Sometimes, treating the underlying cause of catatonia will be enough to treat the catatonia too. For example, if someone has bipolar disorder, treating their bipolar disorder might treat their catatonia at the same time. However, most people will also need specific treatment for catatonia.

Lorazepam

Catatonia is often treated with a medication called lorazepam. Lorazepam is a benzodiazepine, which is a type of sedative medication. This means that it helps to slow down the body and brain and relax the muscles. It is also used to treat epileptic fits, and in the short term it can be used to treat anxiety, insomnia and panic attacks.

Sometimes, doctors will think someone has catatonia but may not be sure. When this happens, before starting full treatment, the doctor might give the person a single dose of lorazepam. This is called a ‘challenge’.

If the person’s symptoms improve after one dose, this can help a doctor confirm the diagnosis of catatonia.

If you have catatonia, lorazepam can be given to you in one of two ways:

• If you can swallow, you can take lorazepam as a tablet.
• If you can’t swallow, you can have it as an injection into a muscle or a vein.

The body breaks down lorazepam in a few hours. Therefore, once catatonia is confirmed and diagnosed, most people will need to take lorazepam more than once a day on a regular schedule. High doses may be needed to treat the catatonia effectively.

Electroconvulsive therapy (ECT)

When catatonia symptoms are more severe or they do not get better with lorazepam, a different treatment option may be considered.

If someone can’t move, eat or drink, they might become very physically unwell. If this happens, they might be offered ECT. This is a treatment where a person’s brain is stimulated with short electric pulses while they are under general anaesthetic and asleep. A person may be prescribed a course of ECT over several weeks to help relieve their symptoms.

ECT is very effective in treating catatonia. You can find out more about ECT by reading the College’s ECT resource.

Monitoring nutrition

When someone with catatonia is being treated, their nutrition might need to be monitored to keep them well. To do this, doctors and nurses may check their blood tests, urine and general physical health.

If someone with catatonia does not get treatment, they can become very unwell. Untreated catatonia can have the following effects:

• dehydration
• malnutrition
• pressure ulcers
• infections
• blood clots
  

If catatonia is left untreated, these effects can sometimes lead to the person dying.

If you think that your friend, family member or someone you are caring for might have catatonia, speak to their doctor or nurse or contact NHS 111.

• Providing information – A person with catatonia can struggle to provide helpful information. As a result, you might need to answer questions from their doctors and nurses. This will help the person with catatonia to get the right diagnosis and treatment.
• Explaining what is happening – Some people with catatonia are aware that they are in a catatonic state, and this can be confusing and frightening for them. You can support them by explaining what is happening.
• Explaining what happened – Some people with catatonia can’t remember how they felt while they were in a catatonic state. When the person you know is no longer in a catatonic state, they might find it useful and reassuring for you to explain what happened.
• Visiting – If you are visiting someone with catatonia, try to stay calm. People with catatonia can often hear people around them talking, even if they are not talking themselves, so it can help to talk to the person you are visiting.
• Eating – If a person with catatonia is not eating, try bringing them food that you know they like and are comfortable with. 

If you have catatonia, your doctor or nurse will answer any questions you may have and can provide you with further details.

You can find more information about catatonia here:

• University College London – this web page has information on catatonia for clinicians, patients and carers.
• National Autistic Society – this information looks at how catatonia can affect people with autism. It includes guides for adults with autism, parents and carers, and professionals.

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert authors: Dr Emma Salter, Dr Husam Khalil, Dr Nabeel Helal

Full references for this resource are available on request.