Catatonia – new tools for an old challenge

Dr Ewan Mahony and Dr Cormac Maguire explore the challenges of diagnosing catatonia and introduce new practical tools to support clinicians.

Despite being first accurately described by Kahlbaum in 1847, catatonia has retained a feeling of mystery. It is often seen as being something bizarre, and seems to appear as ‘query catatonia’ more often than not.

It is notable that it has taken until ICD-11 to finally liberate catatonia from being only coded as a qualifier of Schizophrenia specifically. There have been strides forward, in particular the hugely useful 2023 BAP Catatonia Guidelines, and then 2025 American Psychiatric Association’s resource document on catatonia.

However, these materials are extensive and discuss the research base at length, making them harder to quickly apply to the patient in front of you. For this reason we have created and are keen to share:

The Catatonia Bundle and Guideline

• The NHS Lothian Catatonia Bundle – a four-page tool which walks you through from diagnosis, to investigation, to treatment and how to consider the patient’s broader needs
• The NHS Lothian Catatonia Guideline

Why is it so hard?

As referred to in our article in the Spring issue of ‘The Registrar’ magazine (page 10), in many ways catatonia acts like a mystery shopper to our services. It can present atypically, symptoms can fluctuate, there are physical health ramifications/concerns/causes... in other words there is a lot of room for delayed diagnosis and iatrogenic harm. It is easy for these patients to fall through the gaps. Especially in stretched services and stressed wards, withdrawn catatonic patients may lose out on care and attention to patients who are higher profile and more visibly demonstrate their needs. Over-active presentations, which often may feature odd or unusual signs, may result in liberal use of the term ‘behavioural’ and delays to effective treatment.

We have also found this to be a syndrome which often causes disagreement. Questions may be asked about if the patient is actually unwell, if something else is going on, or if they should even ‘be here’. We would argue that Psychiatric teams are well placed to appreciate and understand such complex presentations, and to provide holistic care.

What we did

We were keen to produce something which could unite the symptoms and signs into a clear diagnosis, and unite the MDT around the patient. We boiled down the BAP guidelines to the core evidence-based interventions to create a local guideline. Inspired by the TIME Bundle for delirium, we then decided to make an equivalent for catatonia – the Catatonia Bundle.

This four-page tool walks the clinician and MDT through assessment, diagnosis, investigation and treatment. The final section focuses on holistic considerations around dignity, quality of life and family. We circulated our drafted resources to every sub-speciality we could find locally, as well as all members of the Psychiatric MDT. The engagement was positive, and helped us to refine exactly what each team member could bring. The final version was then kindly reviewed by the BAP Guideline’s lead author Dr Jonathan Rogers, before being put past our local Drugs & Therapeutics Committee.

The aim is that these resources can help teams to:

• make a timely, confident and clear diagnosis of catatonia
• identify and treat the underlying aetiology, as well as the catatonia
• manage physical health safely during this time
• consider the patient’s own experience and interpretation of events

Having a Catatonia Bundle for a patient, can help to engage all members of the team, and bring them together around a shared narrative and understanding. We very much hope that this will improve care and outcomes for a condition that is known to be easier to treat early. Please have a look at the pages on Right Decisions, and consider using the materials in your area.

Catatonia bundle and Guideline | Right Decisions

Dr Ewan Mahony and Dr Cormac Maguire