Catatonia is a complex disorder that affects how the brain processes movement and awareness, causing people to react unusually to the world around them or sometimes not react at all. Though it has been studied since 1874, this condition remains widely misunderstood and underdiagnosed, affecting roughly 1 in 10 people who need psychiatric hospital care.

What is Catatonia?

Catatonia is a neuropsychiatric syndrome, which means it involves both brain function and mental health, characterized by unusual motor behavior and altered awareness. When someone experiences catatonia, their brain struggles to properly control movement, communication, and responses to their surroundings. The condition was first named and described by German psychiatrist Karl Kahlbaum in 1874, yet it continues to puzzle medical professionals today.^[1]

People with catatonia may appear frozen in place, unable to speak or move, or conversely, they may display excessive, purposeless movements and agitation. The condition disrupts several critical brain areas responsible for movement, senses like vision and hearing, memory, thinking abilities, motivation, emotions, and self-control. This widespread brain involvement explains why catatonia can manifest in so many different ways and why it remains challenging to recognize and diagnose.^[1]

For decades, doctors mistakenly believed catatonia only occurred in people with schizophrenia. This misconception led to countless missed diagnoses. We now understand that catatonia can happen alongside many different psychiatric conditions, neurological disorders, and general medical illnesses. The condition can develop suddenly or gradually, and episodes may last from hours to weeks, months, or even years. Some people experience repeated episodes throughout their lives.^[2]

How Common is Catatonia?

Catatonia affects far more people than most realize, though exact numbers vary depending on the setting and population studied. Research shows that catatonia occurs in approximately 0.5% to 2.1% of people receiving outpatient psychiatric care. However, the prevalence increases dramatically among those requiring hospitalization for mental health conditions, affecting around 10% of psychiatric inpatients.^[1]

Most studies examining the occurrence of catatonia in acute psychiatric hospital settings find rates between 5% and 20%. Some research suggests that among patients being evaluated for possible delirium (a state of confusion and altered consciousness), anywhere from 12% to 37% may actually have catatonia instead, depending on which diagnostic criteria doctors use.^[7]

The condition does not discriminate based on race, sex, or ethnicity, affecting all populations equally. However, catatonia appears to be more common in elderly patients and in people with certain underlying conditions. Despite its relative frequency in hospital settings, catatonia remains highly underdiagnosed. Many healthcare providers, particularly those outside of psychiatry, may not recognize the signs, leading to delayed treatment and potentially serious complications.^[1]

What Causes Catatonia?

The precise underlying cause of catatonia remains unknown, and researchers still cannot explain why it affects some people but not others with similar medical or psychiatric conditions. However, studies have revealed that catatonia involves disruptions in a specific neural circuit connecting several parts of the brain. This circuit includes the medial and lateral areas of the orbital frontal lobe (the front part of the brain involved in decision-making), the caudate nucleus and globus pallidus (parts of the brain’s movement control center), and the thalamus (a relay station for sensory information).^[3]

Scientists believe catatonia develops when abnormal chemical signals in the brain trigger malfunctions in this movement-regulating circuit. Several neurotransmitter imbalances appear to play a role, though different people may experience different chemical disruptions. These include inadequate activity of dopamine at specific brain receptors, deficient signaling by GABA (a calming brain chemical), and excessive activity at glutamate receptors. This helps explain why medications affecting these brain chemicals can sometimes trigger or improve catatonia.^[7]

Catatonia almost always occurs secondary to another underlying illness rather than appearing on its own. Psychiatric disorders represent the most common trigger, particularly mood disorders such as bipolar disorder and depression, which account for the majority of catatonia cases. Psychotic disorders like schizophrenia can also cause catatonia, though this association is less common than once believed. Beyond psychiatric conditions, various neurological problems including brain infections, strokes, seizures, and tumors can precipitate catatonia.^[2]

General medical conditions can also trigger catatonic episodes. These include metabolic disturbances affecting how the body processes nutrients and maintains chemical balance, autoimmune diseases where the body attacks its own tissues, severe infections, kidney or liver failure, and certain hormonal imbalances. Importantly, some medications can induce catatonia, particularly neuroleptics (antipsychotic medications) and sudden withdrawal from benzodiazepines (anti-anxiety medications). In pregnant women, catatonia can sometimes occur as a complication of pregnancy.^[5]

Who is at Risk?

Certain groups of people face higher risk of developing catatonia based on their underlying medical or psychiatric conditions. Individuals with mood disorders, particularly bipolar disorder and severe depression, represent the highest-risk group. These conditions account for the majority of catatonia cases seen in clinical practice. People with autism spectrum disorder also show increased susceptibility to developing catatonia, though the relationship between autism and catatonia remains poorly understood.^[3]

Those with existing psychiatric conditions requiring inpatient treatment face elevated risk, as do elderly patients who may have multiple medical problems. People taking antipsychotic medications, especially older “typical” antipsychotics, have increased vulnerability to developing catatonia or its dangerous cousin, neuroleptic malignant syndrome. Anyone with a previous episode of catatonia faces risk of recurrence, with some experiencing periodic catatonia that returns repeatedly over time.^[6]

Medical risk factors include having a serious infection, particularly one affecting the brain, experiencing metabolic problems such as imbalances in blood chemistry, or dealing with neurological conditions like epilepsy. People undergoing significant stress, trauma, or major life changes may be more vulnerable. Those who abuse substances or who suddenly stop taking benzodiazepines after long-term use also face heightened risk. Pregnancy represents another risk period when catatonia can emerge as a rare but serious complication.^[2]

Recognizing the Symptoms

Catatonia presents with a wide array of symptoms that can vary dramatically from person to person. According to the American Psychiatric Association’s diagnostic manual, there are twelve officially recognized symptoms. To diagnose catatonia, a person must exhibit at least three of these signs. The most common symptom is stupor, a state where the person appears awake but cannot move, speak, or respond to things happening around them.^[1]

Mutism, or being very quiet or completely silent without another medical explanation, frequently occurs in catatonia. Some people display catalepsy, maintaining whatever position someone else places them in, as if they were a mannequin. Waxy flexibility describes when a person offers slight, even resistance as someone moves their limbs into different positions, then holds those poses. These particular signs are quite specific to catatonia and help distinguish it from other conditions.^[1]

Negativism involves either not responding to the environment or actively resisting external stimuli without logical reason. A person might refuse to follow instructions or do the opposite of what is asked. Posturing means spontaneously holding unusual positions against gravity for extended periods. Some people show mannerisms, performing normal movements in odd, exaggerated, or caricatured ways, or stereotypies, repeating the same purposeless movements over and over.^[2]

Grimacing involves maintaining the same facial expression for long periods, often with stiff facial muscles, sometimes appearing as an inappropriate smile. Echolalia means repeating words or phrases that others say, while echopraxia involves mimicking others’ movements. Agitation counts as a symptom only when it occurs without being a response to external stimuli, meaning the person seems upset or irritable for no apparent reason related to their surroundings.^[1]

Beyond these twelve official criteria, other signs may appear. Some people experience extreme excitement, pacing, aggressive behavior, or inability to stay still. Others may stare blankly for prolonged periods, show difficulty following instructions, or demonstrate automatic obedience, following all commands even if harmful. The condition can severely impact eating and drinking, with some people refusing food and water entirely. Basic body functions like temperature regulation, breathing, and heart rate may become unstable, particularly in severe cases.^[3]

Types of Catatonia

Medical professionals recognize different forms of catatonia based on the predominant symptoms and activity levels. Understanding these types helps with recognition and treatment. The retarded or hypokinetic form represents what most people envision when they think of catatonia. People with this type show minimal movement and response. They may sit or lie motionless for hours, maintaining unusual positions without apparent discomfort. Speech is minimal or absent, and they seem disconnected from their environment despite being awake.^[4]

The excited or hyperkinetic form presents very differently, with excessive, purposeless activity. These individuals appear restless, may pace continuously, make repetitive movements, or act impulsively. They might become combative or seem delirious. Despite the high activity level, their movements lack purpose or goal-direction. Some people repeat others’ words or actions obsessively. This form can be dangerous as the person may injure themselves or others and risk exhaustion from constant activity.^[4]

Some patients exhibit a mixed presentation, showing features of both retarded and excited types, sometimes alternating between periods of immobility and periods of agitation. The symptoms can shift during a single episode, making the condition particularly confusing to observers. Understanding that catatonia exists on a spectrum rather than as distinct categories helps healthcare providers recognize milder or atypical presentations.^[3]

Malignant catatonia represents the most severe and dangerous form. This life-threatening condition involves extreme motor symptoms combined with autonomic instability, meaning the body cannot properly control basic functions. People with malignant catatonia develop fever, rapid or irregular heartbeat, unstable blood pressure, profuse sweating, and altered consciousness. Without prompt treatment, this form can be fatal. It shares many features with neuroleptic malignant syndrome, a dangerous reaction to antipsychotic medications, and some experts consider them variations of the same underlying problem.^[3]

The Subjective Experience

When people recover from catatonia and can describe their experience, they often reveal intense inner turmoil despite their outward appearance of stillness or detachment. Research involving self-reports from patients shows that the internal experience centers less on the movement changes and more on overwhelming emotional and cognitive disturbances. Many describe experiencing intense emotions they felt unable to control, creating significant psychological distress even when they appeared calm externally.^[8]

Common themes that emerge from patient accounts include overwhelming anxiety, intense fear, and profound depression. People often describe feeling trapped inside their own body, aware of their surroundings but unable to respond or communicate. Some report experiencing paralysis of will, knowing they should move or speak but finding themselves unable to initiate the action. The experience has been compared to the “freeze” response seen in animals facing extreme threat, where the body becomes immobilized as a survival mechanism.^[8]

Many patients describe heightened fear without clear cause, feeling terrified yet unable to express or escape from the fear. Others report strong yearning for loved ones or feeling disconnected from people around them. Some experience intense ambivalence, feeling pulled toward two opposing actions simultaneously, which manifests externally as the inability to complete movements or the appearance of being “stuck” between actions. Understanding this internal suffering helps healthcare providers recognize that people with catatonia, even when appearing unresponsive, may be experiencing significant psychological distress that requires compassionate care.^[8]

Preventing Catatonia

Since catatonia typically occurs secondary to other conditions, prevention focuses primarily on managing underlying illnesses that increase risk. People with mood disorders should work closely with their healthcare providers to maintain stable treatment and monitor for early warning signs of catatonia. Regular psychiatric care and medication compliance for those with bipolar disorder or severe depression may reduce the risk of catatonic episodes.^[14]

For individuals with autism spectrum disorder, who face elevated risk, caregivers and healthcare providers should remain alert to signs of emerging catatonia, particularly during periods of stress or major life changes. Maintaining supportive environments and addressing sources of anxiety may help reduce vulnerability. Anyone who has experienced catatonia before should ensure their healthcare team knows this history, as it increases the risk of recurrence.^[17]

Medication management plays an important preventive role. Doctors should use caution when prescribing antipsychotic medications, particularly older typical antipsychotics, in people at risk for catatonia. When these medications are necessary, careful monitoring helps detect early signs of problems. People taking benzodiazepines long-term should never stop these medications abruptly, as sudden withdrawal can trigger catatonia. Instead, any dose reduction should happen gradually under medical supervision.^[12]

Early intervention when symptoms first appear represents the most effective form of prevention for severe catatonia. Family members and caregivers should be educated about early warning signs so they can seek prompt medical attention. Recognizing and treating catatonia in its early stages, before it becomes severe, generally leads to better outcomes and may prevent progression to life-threatening malignant catatonia. Anyone developing unexplained changes in movement, speech, or responsiveness, particularly if they have risk factors, should receive immediate medical evaluation.^[6]

How Catatonia Affects the Body

Catatonia fundamentally disrupts the normal pathways that control voluntary movement and connect movement to intention and planning. The condition affects a specific neural circuit involving deep brain structures responsible for initiating, maintaining, and stopping movements. When this circuit malfunctions, people lose the ability to smoothly transition between actions or to properly regulate their motor activity. This explains why some people freeze mid-movement while others cannot stop moving.^[13]

The brain areas affected by catatonia include the basal ganglia, a collection of structures deep in the brain that coordinate movement and help translate intentions into actions. The circuit also involves the frontal lobes, which plan and organize behavior, and the thalamus, which acts as a relay station for movement signals. When communication between these areas becomes disrupted, the result is the characteristic motor dysregulation of catatonia. This shares similarities with other movement disorders like Parkinson’s disease, though the underlying mechanisms differ.^[7]

At the chemical level, catatonia involves imbalances in several neurotransmitters. Dopamine, a chemical messenger crucial for movement control, shows reduced activity at certain brain receptors in catatonia. This helps explain why dopamine-blocking medications like antipsychotics can worsen or trigger catatonia, while medications that enhance dopamine activity may improve it. GABA, the brain’s main inhibitory neurotransmitter, also shows deficient signaling in catatonia, which explains why benzodiazepines that boost GABA activity often provide dramatic improvement.^[7]

Another neurotransmitter system implicated in catatonia involves glutamate and its NMDA receptors. Excessive signaling through these pathways may contribute to catatonic symptoms, which explains why medications blocking NMDA receptors, such as ketamine, can sometimes help. The autonomic nervous system, which controls automatic body functions like heart rate, blood pressure, temperature, and breathing, can also become dysregulated in catatonia, particularly in severe cases. This autonomic instability becomes most dangerous in malignant catatonia, where the body loses ability to maintain stable vital functions.^[13]

The condition affects more than just movement and autonomic function. Brain areas responsible for processing sensory information, forming and retrieving memories, maintaining attention and concentration, experiencing and expressing emotions, and exercising judgment and self-control all show impaired function during catatonic episodes. This widespread disruption helps explain the cognitive and emotional difficulties people experience alongside the motor symptoms. The multiple brain systems affected also account for why catatonia can present so differently between individuals and why it can be mistaken for other conditions like delirium or severe depression.^[1]