What Is Catatonia and Why Is It an Emergency?

Catatonia is often misunderstood as a person simply “freezing,” refusing to speak, or choosing not to cooperate. In reality, it is a serious neuropsychiatric syndrome that affects movement, speech, behavior, and the ability to respond to the surrounding world.

Karl Kahlbaum first described catatonia as a distinct syndrome in 1874. For many years, it was viewed almost exclusively as a form of schizophrenia. Modern medicine now recognizes that catatonia can occur with many psychiatric, neurological, and general medical conditions. In some cases, it can become life-threatening and require immediate hospital care. [1]

What Does Catatonia Look Like?

Catatonia can involve an extreme reduction in movement, a dramatic increase in activity, or unusual movements that appear disconnected from the situation.

Under the diagnostic criteria commonly used in the United States, a person must show at least three characteristic signs. These may include:

• Stupor or very little response to the environment
• Mutism or little to no speech
• Remaining in an unusual position for a long time
• Resistance to instructions or attempts to change position
• Waxy flexibility, in which the body remains in a position after someone moves it
• Repetitive, purposeless movements
• Unusual facial expressions or mannerisms
• Repeating another person’s words (echolalia)
• Copying another person’s movements (echopraxia)
• Severe agitation that is not directed toward a clear goal

Symptoms may appear suddenly, fluctuate during the day, or shift from immobility to intense agitation. A person may seem disconnected, but this behavior should never be dismissed as stubbornness, manipulation, or lack of motivation. [1, 2]

Reduced Movement and Catatonic Stupor

In hypoactive catatonia, movement and communication become severely limited. A person may stop speaking, eating, drinking, or responding to others. Some remain in uncomfortable positions for long periods.

Another possible sign is negativism. The person may resist movement or instructions without an obvious reason. This resistance is part of the syndrome rather than a deliberate decision.

Prolonged immobility can lead to dehydration, malnutrition, pressure injuries, blood clots, pneumonia, muscle damage, and kidney problems. These complications explain why catatonia cannot safely be managed through observation alone. [1]

Excited Catatonia

Catatonia does not always mean stillness. In its hyperactive form, a person may display intense, repetitive, or unpredictable activity.

The movements are usually not purposeful. The person may pace, shout, repeat words, imitate others, make abrupt gestures, or become suddenly destructive. This state can create a risk of accidental injury, aggression, exhaustion, or harm to the person or those nearby.

Periods of excitement and stupor may alternate, making the condition especially confusing for families and even healthcare professionals.

Malignant Catatonia

Malignant catatonia is the most dangerous form. Along with behavioral and movement changes, it may cause:

• Fever
• Severe muscle rigidity
• Rapid heart rate
• Unstable blood pressure
• Heavy sweating
• Changes in alertness
• Breathing or circulation problems

This is a medical emergency. Without rapid treatment, malignant catatonia can be fatal. It may also resemble neuroleptic malignant syndrome, a serious reaction associated with medications that block dopamine, including certain antipsychotics. [1]

What Can Cause Catatonia?

Catatonia is a syndrome rather than one single disease. Finding the underlying cause is an essential part of treatment.

It may occur with:

• Major depression or bipolar disorder
• Schizophrenia-spectrum and other psychotic disorders
• Autism spectrum disorder
• Encephalitis, including anti-NMDA receptor encephalitis
• Seizures or nonconvulsive status epilepticus
• Stroke, traumatic brain injury, or structural brain disease
• Severe infections or metabolic disturbances
• Endocrine, autoimmune, liver, or kidney disorders
• Medication effects, intoxication, or substance withdrawal
• Abrupt withdrawal of benzodiazepines or clozapine
• Neuroleptic malignant syndrome

A systematic review found that medical causes are particularly important among patients in medical, surgical, critical-care, and older-adult populations. This is why catatonia should never automatically be attributed to a psychiatric diagnosis. [2, 5]

How Is Catatonia Diagnosed?

There is no single laboratory test that confirms catatonia. Diagnosis begins with careful observation, a physical examination, vital-sign monitoring, medication review, and information from relatives or caregivers.

Patients may be unable to describe what is happening, so details from people who witnessed the onset can be crucial.

Clinicians often use the Bush–Francis Catatonia Rating Scale to identify and measure symptoms. The complete scale contains 23 items, while its first 14 items can be used as a screening tool. [3]

Depending on the situation, the medical evaluation may also include blood and urine testing, brain imaging, an electroencephalogram, toxicology testing, or a lumbar puncture. These investigations help identify infections, seizures, metabolic problems, autoimmune encephalitis, medication reactions, and other possible causes. [1, 2]

How Is Catatonia Treated?

Treatment usually has three immediate goals: relieve the catatonic symptoms, protect the body from complications, and treat the condition that caused the syndrome.

Benzodiazepines, especially lorazepam, are commonly used as first-line treatment. A clinician may administer a lorazepam challenge and observe whether movement, speech, or responsiveness improves. A positive response can support the diagnosis, although a lack of immediate improvement does not necessarily rule catatonia out. [1, 2, 4]

Electroconvulsive therapy, or ECT, is another established treatment. It may be used when benzodiazepines do not produce enough improvement, when the condition is severe, or when malignant catatonia is suspected. In urgent cases, delaying ECT may increase the danger. [1, 2, 4]

Hospital care may also include hydration, nutrition, pressure-injury prevention, protection against blood clots, temperature control, and close monitoring of breathing, circulation, and kidney function.

Antipsychotic medications require particular caution. In some situations, especially malignant catatonia or suspected neuroleptic malignant syndrome, dopamine-blocking medications can worsen the condition. Medication decisions must therefore be made by clinicians after evaluating the likely cause. [1, 2]

When to Seek Emergency Help

Call 911 or go to the nearest emergency department when a person suddenly:

• Stops speaking or responding
• Remains motionless for an unusual length of time
• Refuses or becomes unable to eat and drink
• Develops severe, purposeless agitation
• Shows rigidity, fever, confusion, or unstable vital signs
• Changes rapidly after starting, stopping, or changing a medication

Do not assume that the person is choosing this behavior. Do not change prescribed medications without medical guidance.

Catatonia is frightening, but it is often treatable. The most important factor is time. Early recognition, careful medical evaluation, and prompt treatment can prevent severe complications and save a life.

References

• Wilson, J. E., Oldham, M. A., Francis, A., et al. (2025). Resource Document on Catatonia. American Psychiatric Association. Relevant pages: 3–28 and 46–48. This document provides a current US-focused review of catatonia’s history, diagnostic criteria, clinical forms, medical evaluation, treatment, complications, and emergency management.
• Rogers, J. P., Oldham, M. A., Fricchione, G., et al. (2023). Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 37(4), 327–369. DOI: 10.1177/02698811231158232. The guideline reviews psychiatric and medical causes, diagnostic assessment, benzodiazepine treatment, ECT, malignant catatonia, medication-related cases, and supportive care.
• Bush, G., Fink, M., Petrides, G., Dowling, F., & Francis, A. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129–136. DOI: 10.1111/j.1600-0447.1996.tb09814.x. This publication introduced the 23-item Bush–Francis Catatonia Rating Scale and its 14-item screening instrument, establishing a standardized method for identifying and measuring catatonic signs.
• Bush, G., Fink, M., Petrides, G., Dowling, F., & Francis, A. (1996). Catatonia. II. Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatrica Scandinavica, 93(2), 137–143. DOI: 10.1111/j.1600-0447.1996.tb09815.x. This study examines clinical responses to lorazepam and ECT and supports their central role in the treatment of catatonia.
• Oldham, M. A. (2018). The probability that catatonia in the hospital has a medical cause and the relative proportions of its causes: A systematic review. Psychosomatics, 59(4), 333–340. DOI: 10.1016/j.psym.2018.04.001. This systematic review demonstrates the importance of investigating neurological and other medical causes, particularly in general hospitals, critical-care settings, and older patients.