Catatonia

Catatonia and Delirium in a General Medical Setting: Prevalence and Naturalistic Treatment Outcome
Charles Mormando, Samuel Reinfeld, Nicholas Genova, Aimy Rehim, Ilana Yel, Andrew Francis, Adeeb Yacoub

Abstract:

Background: Catatonia is prevalent in the general hospital yet remains under-recognized. Of particular interest is the relationship between delirium and catatonia as recent studies have shown catatonia may co-occur with delirium. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision posits that catatonia does not exist in delirium, although studies have questioned this exclusion.

Objective: To assess the co-occurrence of catatonia and delirium in hospitalized general medical patients and to describe naturalistic treatment outcomes with lorazepam.

Methods: Data from a naturalistic quality improvement project were retrospectively analyzed. All consecutive admissions to 4 general medical units at the University Hospital at Stony Brook were screened within 48 h using the Bush-Francis Catatonia Screening Instrument and the Confusion Assessment Method. The diagnostic threshold on the Bush-Francis Catatonia Screening Instrument was set to 4 signs to increase specificity. The Bush-Francis Catatonia Rating Scale was utilized to monitor severity of positive screens. The quality improvement project included 718 consecutive patient admissions that are reviewed and analyzed in this report.

Results: Approximately 2.2% of the 718 patients met criteria for catatonia. Of the patients with catatonia, 93% also met criteria for co-occurring delirium. The prevalence of delirium in the sample was 24.8%, and 8.4% of patients with delirium also had catatonia. Of those with catatonia and delirium, 43.8% received treatment for catatonia with benzodiazepines. Of those treated, the clinical features of catatonia and delirium remitted in 43% of cases, whereas the signs of catatonia responded to treatment (>50% reduction in Bush-Francis Catatonia Rating Scale) in 57% of cases. All 16 cases of catatonia had 5 or more signs of catatonia, while the majority of the remaining 702 patients had 0-2 signs.

Conclusions: These data provide further evidence that catatonia coexists with delirium, and may respond to lorazepam. We found a bimodal distribution in the number of catatonic signs, suggesting catatonia may be a distinct syndrome among medical patients. Our results suggest that prospective treatment studies are warranted.

Keywords: ECT; benzodiazepine; catatonia; delirium; encephalopathy.

Annotation

The finding: This study screened 718 consecutive admissions to inpatient general medicine for both catatonia and delirium using standardized instruments. Catatonia was identified in 2.2% of patients, and 93% of those with catatonia also met criteria for delirium. Roughly 1 in 12 delirious patients (8.4%) also demonstrated catatonia when a stringent diagnostic threshold was applied. Among those receiving lorazepam for catatonia despite concurrent delirium, nearly half achieved complete resolution and all showed some clinical improvement within approximately five days. Overall the study challenges the DSM-5-TR exclusion of catatonia in delirium and routine avoidance of benzodiazepines in these cases.

Strength and weaknesses: Strengths include systematic screening of all admissions using validated instruments (BFCRS and CAM), conservative diagnostic thresholds to improve specificity, and prospective observation of naturalistic treatment outcomes in a real-world medical setting. Limitations include the observational, nonrandomized design, small number of catatonia cases, lack of standardized treatment protocols, homogeneous sample with older adults, and absence of EEG or biomarker data. Treatment response could not be definitively attributed to lorazepam alone given concurrent medical management.

Relevance: For CL psychiatrists, this study has immediate clinical relevance and reinforces the central role of CL psychiatry in guiding diagnosis and treatment when motor, behavioral, and cognitive syndromes overlap in medically ill patients. It demonstrates that catatonia frequently co-occurs with delirium in medical inpatients and is likely under-recognized when DSM-based exclusions are applied rigidly. The high overlap between these syndromes suggests both may share common pathophysiological mechanisms related to generalized brain dysfunction. The observed responsiveness to lorazepam highlights the risk of reflexive antipsychotic use in delirium without assessing for catatonia, which may worsen outcomes.

Unveiling the prognosis of adult catatonia: A systematic review
Charles Mormando, Samuel Reinfeld, Nicholas Genova, Aimy Rehim, Ilana Yel, Andrew Francis, Adeeb Yacoub

Abstract:

Introduction: Catatonia is a neuropsychiatric syndrome observed in psychiatric and physical conditions. Linked to neuroinflammation, schizophrenia spectrum disorders remain its principal diagnostic context. Short-term outcomes are favourable with prompt treatment. Long-term prognosis remains poorly understood. This systematic review aimed to evaluate long-term outcomes and mortality rates in individuals with catatonia.

Methods: We conducted a PRISMA-compliant systematic review (PROSPERO: CRD420251027945) searching PubMed, Web of Science, EMBASE, SCOPUS, PsycINFO, and non-peer-reviewed sources from database inception to July 12, 2025. We included studies of adults diagnosed with catatonia with a minimum 6-month follow-up. Catatonia diagnosis was based on criteria, scales, or clinical judgment. One-year mortality was estimated and compared to general population. Methodological quality was assessed using validated tools (NOS, JBI). Findings were synthesized narratively.

Results: Of 6431 records screened, 29 studies met inclusion criteria, encompassing 30,694 patients with catatonia and 11,830 controls. Mean follow-up was 8.1 years. Seventeen studies focused on schizophrenia. Quality of studies was heterogeneous; 58 % showed moderate concerns and 41 % were at high risk of bias. Post-1970s studies reported more episodes, readmissions, and chronicity in catatonic schizophrenia versus other schizophrenia subtypes. Poorer psychiatric outcomes were found when catatonia co-occurred with intellectual disability, depression, or physical illness. Catatonia associated with baseline suicidal ideation (>35 % patients) and follow-up autoimmunity. In 75 % of post-1970s studies, one-year mortality in catatonia cohorts was lower than adjusted population rates.

Conclusion: Catatonia is a marker of poor psychiatric long-term prognosis, without clear link to higher mortality. Early use of effective treatments preventing suicide or psychosis relapses may be considered.

Annotation

The finding: This systematic review of 29 studies (30,694 adults with catatonia; mean follow-up 8.1 years) examined what happens to adults after catatonia episodes. Catatonia was associated with poorer long-term psychiatric prognosis with patients experiencing more illness episodes, hospitalizations, and chronic impairment than counterparts without catatonia, particularly when the underlying condition involves schizophrenia spectrum disorders comorbid with depression, intellectual disability, or medical illness. However, most post-1970s studies did not show increased one-year mortality compared with the general population. Interestingly, follow-up revealed unexpected connections to autoimmune conditions and increased suicidality.

Strength and weaknesses: Strengths include a comprehensive search across multiple databases, long follow-up durations (up to >30 years), large cumulative sample size, and systematic assessment of psychiatric, medical, treatment, and mortality outcomes. However, study quality was heterogeneous, with over 40% at high risk of bias, substantial diagnostic heterogeneity across eras, and psychotic disorders dominated the literature (17 of 29 studies), potentially skewing conclusions toward this population.

Relevance: For C-L psychiatrists managing medically complex patients, these findings reframe how we should conceptualize catatonia during discharge planning and longitudinal care. The elevated baseline suicidality demands attention during follow-up. The emerging autoimmune connection suggests that appropriate workup and monitoring for immunological conditions may be warranted in some cases.