Journal Article Annotations
2026, 1st Quarter
Catatonia
Annotations by Samuel Kohrman, MD, Laura Duque, MD, and Can Kilciksiz, MD
March, 2026
PUBLICATION #1
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 is a prospective observational study assessing the cooccurrence of catatonia and delirium in hospitalized general medical service patients and treatment outcomes with lorazepam. The study sample included 718 patients of 16 (2.2%) met criteria for catatonia and 178 (24.8%) met criteria for delirium, and of 15 patients (2.1%) met criteria for both catatonia and delirium concurrently. It is important to note that 8.4% of patients with delirium also met criteria for catatonia. 7 of 15 patients with concurrent catatonia and delirium received lorazepam treatment (dosage ranges from 0.5 mg to 3 mg daily). 3 of 7 concurrent catatonia and delirium patients received lorazepam treatment had full resolution of catatonia (no signs on the Bush-Francis Catatonia Rating Inventory) within a mean time of 5.33 days and 4 of 7 response without full resolution (>50% reduction in Bush-Francis Catatonia Rating Scale) within a mean time of 4.25 days, and none of 7 patients received lorazepam treatment exhibited exacerbation of delirium.
Strength and weaknesses: This is one of the few studies investigating the co-occurrence of catatonia and delirium in hospitalized patients. One of the main strengths of this study is its prospective design demonstrating effectiveness and safety of lorazepam treatment in concurrent catatonia and delirium. This study also highlighted the most common signs of catatonia in this population (immobility, rigidity, mutism, withdrawal, and posturing/catalepsy) which may help clinicians identify and diagnose catatonia with concurrent delirium. However, the sample size (n=7) of patients who received lorazepam treatment was small, and details on other treatments considered were limited.
Relevance: Though DSM5-TR criteria exclude the possibility of concurrent catatonia and delirium, recent studies including the summarized study and our clinical experience show that patients can have concurrent catatonia and delirium presentation. It is important for psychiatrists and non-psychiatrist clinicians to be aware of this possible comorbid presentation and recognize catatonia in delirium and vice versa. Timely diagnosis of catatonia in delirium with more precise screening thresholds (e.g. 4 positive items of Bush-Francis Catatonia Rating Scale in medical settings), investigating most common underlying etiologies, and further management with low dose of lorazepam may be an effective and safe approach. Precise diagnosis and management of catatonia in delirium may decrease risks related to excessive antipsychotic use, progression to malignant catatonia, and overall complications related to untreated catatonia.
PUBLICATION #2
Electrographic Features of Catatonia with and without Comorbid Delirium
James Luccarelli, Joshua R Smith, Niels Turley, Jonathan P Rogers, Haoqi Sun, Samuel I Kohrman, Gregory Fricchione, M Brandon Westover
Abstract:
Objective: Catatonia is an underdiagnosed disorder characterized by speech and motor abnormalities. EEG examinations may improve the accuracy of a catatonia diagnosis, but clinical and electrographic correlations have not been established. The authors describe catatonic features and EEG findings in a large multisite retrospective cohort.
Methods: The clinical records in two health care systems were searched for patients with an EEG recording and a catatonia assessment with the Bush-Francis Catatonia Rating Scale conducted within 24 hours of each other. Included patients were retrospectively screened for delirium through a chart-based assessment. Augmented inverse propensity weighting (AIPW) was used to estimate the causal effects of delirium and catatonia on the presence of an abnormal EEG finding.
Results: Overall, 178 patients met inclusion criteria, 144 (81%) of whom had catatonia. Among the patients with catatonia, 43% also had delirium. EEG abnormalities were present among 43% of patients with catatonia, including 28% of patients with catatonia without delirium and 69% of the patients with co-occurring catatonia and delirium. Individual catatonic signs and EEG abnormalities showed only a weak correlation. In AIPW models, a delirium diagnosis was associated with significantly higher odds for an abnormal EEG finding (OR=6.75; 95% CI=2.83-16.14), whereas a diagnosis of catatonia was not (OR=1.83, 95% CI=0.79-4.24).
Conclusions: EEG abnormalities are common among individuals with catatonia, but these are difficult to disentangle from abnormalities resulting from co-occurring delirium. Further research is needed to define the role of EEG examinations in the assessments of catatonia and delirium.
Keywords: Catatonia; Delirium; Diagnosis and Classification in Neuropsychiatry; EEG.
Annotation
The finding: This retrospective multisite cohort study identified 178 inpatients who had both a structured catatonia evaluation and an EEG within 24 hours of each other. Catatonia was present in 81% of patients, and among those, 43% also had concurrent delirium. EEG irregularities were far more common when delirium co-occurred with catatonia (69%) than when catatonia was present alone (28%). Causal modeling demonstrated that delirium (not catatonia) independently predicted EEG abnormalities, and individual catatonic signs showed only weak correlations with specific EEG patterns. The capacity of an abnormal EEG to distinguish a medical from a psychiatric underlying cause was modest.
Strength and weaknesses: Strengths include the large multisite sample, standardized EEG reporting, and a robust statistical approach to confounding. Limitations include non-systematic catatonia screening, retrospective chart-based delirium ascertainment, and a sample drawn exclusively from two academic centers with a predominantly White patient population, limiting generalizability to community hospitals and more demographically diverse settings where catatonia may be even less recognized.
Relevance: For C-L psychiatrists evaluating patients with overlapping motor, cognitive, and behavioral changes, this study cautions against interpreting EEG abnormalities as evidence of catatonia when delirium is also present. It reinforces the importance of simultaneously and systematically assessing for both syndromes at the bedside rather than relying on neurophysiological data to arbitrate between them.