Catatonia

Updated April 12, 2025

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of catatonia are prepared by our editorial team based on guidelines from the British Association for Psychopharmacology (BAP 2023), the United States Department of Defense (DoD/VA 2022), and the American Psychiatric Association (APA 2010).

Screening and diagnosis

Diagnostic criteria

As per BAP 2023 guidelines:

Include catatonia in the differential diagnosis of patients presenting with a substantially altered level of activity or abnormal behavior, especially where it is grossly inappropriate to the context.

Diagnose catatonia based on the presence of ≥ 3 catatonic signs according to the DSM-5-TR or the ICD-11.

DSM-5 diagnostic criteria for catatonia

Calculator

When to use

Stupor no psychomotor activity; not actively relating to environment)

Yes

Catalepsy passive induction of a posture held against gravity)

Yes

Waxy flexibility slight, even resistance to positioning by examiner)

Yes

Mutism no, or very little, verbal response; exclude if known aphasia)

Yes

Negativism opposition or no response to instructions or external stimuli)

Yes

Posturing spontaneous and active maintenance of a posture against gravity)

Yes

Mannerism odd, circumstantial caricature of normal actions)

Yes

Stereotypy repetitive, abnormally frequent, non-goal-directed movements)

Yes

Agitation not influenced by external stimuli)

Yes

Grimacing

Yes

Echolalia mimicking another's speech)

Yes

Echopraxia mimicking another's movements)

Yes

Calculation

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The calculator in question is the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) diagnostic criteria for catatonia. This scoring system is used in the field of psychiatry and applies to patients who are suspected of having catatonia, a syndrome characterized by a variety of motor abnormalities and behavioral changes. The DSM-5 diagnostic criteria for catatonia is used to identify and diagnose catatonia in patients, which can occur in the context of several disorders such as schizophrenia, bipolar disorder, major depressive disorder, or can be due to a general medical condition or as an adverse reaction to substances. The clinical utility of this calculator is to provide a standardized method for diagnosing catatonia, which can guide appropriate treatment strategies. It includes criteria such as catalepsy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerism, stereotypy, grimacing, echolalia, and echopraxia. There are no specific exclusion criteria for its use, but it should be noted that the presence of catatonia should prompt clinicians to search for an underlying cause, as catatonia is a syndrome and not a disease in itself. It is also important to differentiate cat

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Diagnostic investigations

History and physical examination: as per BAP 2023 guidelines, elicit a history to identify possible medical and psychiatric disorders underlying catatonia and prior response to treatment in history. Elicit a collateral history wherever possible.

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Bush-Francis Catatonia Rating Scale (BFCRS)

Calculator

When to use

1. Excitement (extreme hyperactivity, constant motor unrest apparently non-purposeful; not attributed to akathisia or goal-directed agitation)

Absent

Excessive motion, intermittent

Constant motion, hyperkinetic without rest periods

Full-blown catatonic excitement, endless frenzied motor activity

2. Immobility/stupor (extreme hypoactivity, immobile, minimally responsive to stimuli)

Absent

Sits abnormally still, may interact briefly

Virtually no interaction with external world

Stuporous, non-reactive to painful stimuli

3. Mutism (verbally unresponsive or minimally responsive)

Absent

Verbally unresponsive to majority of questions, incomprehensible whisper

Speaks < 20 words/5 min

No speech

4. Staring (fixed gaze, little or no visual scanning of environment, decreased blinking)

Absent

Poor eye contact, repeatedly gazes < 20 sec between shifting of attention, decreased blinking

Gaze held > 20 sec, occasionally shifts attention

Fixed gaze, non-reactive

5. Posturing/catalepsy (spontaneous maintenance of posture, including mundane, such as sitting or standing for long periods without reacting)

Absent

< 1 min

> 1 min to < 15 min

Bizarre posture, or mundane > 15 min

6. Grimacing (maintenance of odd facial expressions)

Absent

< 10 sec

< 1 min

Bizarre expression, or maintained > 1 min

7. Echopraxia/echolalia (mimicking of examiner's movements/speech)

Absent

Occasional

Frequent

Constant

8. Stereotypy (repetitive, non-goal-directed motor activity, such as finger-play, repeatedly touching, patting, or rubbing self; abnormality not inherent in act but in its frequency)

Absent

Occasional

Frequent

Constant

9. Mannerisms (odd, purposeful movements, such as hopping or walking tiptoe, saluting passers-by, or exaggerated caricatures of mundane movements; abnormality inherent in act itself)

Absent

Occasional

Frequent

Constant

10. Verbigeration (repetition of phrases or sentences, like a scratched record)

Absent

Occasional

Frequent, difficult to interrupt

Constant

11. Rigidity (maintenance of a rigid position despite efforts to be moved; exclude if cogwheeling or tremor is present)

Absent

Mild resistance

Moderate

Severe, cannot be repostured

12. Negativism (apparently motiveless resistance to instructions or attempts to move/examine patient; contrary behavior, does exact opposite of instruction)

Absent

Mild resistance and/or occasionally contrary

Moderate resistance and/or frequently contrary

Severe resistance and/or continually contrary

13. Waxy flexibility (during reposturing of patient, patient offers initial resistance before allowing themselves to be repositioned, similar to that of a bending candle)

Absent

Present

14. Withdrawal (refusal to eat, drink, and/or make eye contact)

Absent

Minimal oral intake/interaction for < 1 day

Minimal oral intake/interaction for > 1 day

No oral intake/interaction for ≥ 1 day

15. Impulsivity (patient suddenly engages in inappropriate behavior, such as runs down hallway, starts screaming, or takes off clothes, without provocation; afterwards can give no, or only a facile explanation)

Absent

Occasional

Frequent

Constant or not redirectable

16. Automatic obedience (exaggerated cooperation with examiner's request or spontaneous continuation of movement requested)

Absent

Occasional

Frequent

Constant

17. Mitgehen ("Anglepoise lamp" arm raising in response to light pressure of finger, despite instructions to the contrary)

Absent

Present

18. Gegenhalten (resistance to passive movement proportional to strength of the stimulus; appears automatic rather than willful)

Absent

Present

19. Ambitendency ([atient appears motorically "stuck" in indecisive, hesitant movement)

Absent

Present

20. Grasp reflex (per neurological examination)

Absent

Present

21. Perseveration (repeatedly returns to same topic or persists with movement)

Absent

Present

22. Combativeness (usually in an undirected manner, with no, or only a facile explanation afterwards)

Absent

Occasionally strikes out, low potential for injury

Frequently strikes out, moderate potential for injury

Serious danger to others

23. Autonomic abnormality (temperature, blood pressure, pulse, respiratory rate, diaphoresis)

Normal

Abnormality of 1 parameter excluding preexisting hypertension)

Abnormality of 2 parameters

Abnormality of ≥ 3 parameters

Calculation

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The Bush-Francis Catatonia Rating Scale (BFCRS) is a clinical calculator used in the field of psychiatry. It is specifically designed to assess the severity and type of catatonic symptoms in patients with psychiatric disorders, such as schizophrenia, mood disorders, or other mental health conditions. The BFCRS is a comprehensive tool that evaluates a wide range of catatonic signs, including motor, behavioral, and speech symptoms. The clinical utility of this calculator is to aid in the diagnosis of catatonia, monitor the progress of the condition, and evaluate the response to treatment. There are no specific exclusion criteria for its use, but it should be noted that the BFCRS is not a standalone diagnostic tool and should be used in conjunction with a comprehensive psychiatric evaluation.

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Laboratory tests
EEG
Neuroimaging
Lorazepam challenge test

Diagnostic procedures

Lumbar puncture: as per BAP 2023 guidelines, consider performing lumbar puncture based on history and examination findings, taking into account the possible diagnoses likely to mimic catatonia and the possible underlying etiology of the catatonia.

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Medical management

General principles: as per BAP 2023 guidelines, obtain initial assessment and initiate treatment of catatonia in secondary care.

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Benzodiazepines
Antipsychotics
NMDA receptor antagonists
Other agents

Therapeutic procedures

Electroconvulsive therapy: as per BAP 2023 guidelines, offer electroconvulsive therapy as a first-line treatment option in patients with catatonia.

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Transcranial magnetic stimulation

Specific circumstances

Pediatric patients: as per BAP 2023 guidelines, recognize that catatonia is known to occur in pediatric patients as young as 5 years. Screen for catatonia whenever clinically suspected.

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Elderly patients
Pregnant patients (during pregnancy)
Pregnant patients (breastfeeding)
Pregnant patients (postnatal period)
Patients with comorbidities
Patients with depression
Patients with autism spectrum disorder
Patients with periodic catatonia
Patients with malignant catatonia
Patients with neuroleptic malignant syndrome
Patients with antipsychotic-induced catatonia

Follow-up and surveillance

Assessment of treatment response: as per BAP 2023 guidelines, use a validated instrument, such as the Bush-Francis Catatonia Rating Scale or the Northoff Catatonia Rating Scale, for the assessment of treatment response.

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