Educational Disclaimer: This case study is for educational and informational purposes only. It does not constitute medical advice, clinical guidance, or a substitute for professional psychiatric evaluation. All diagnostic criteria referenced are from the DSM-5-TR (APA, 2022). Clinicians should rely on their professional training, direct patient assessment, and current evidence-based guidelines when making diagnostic and treatment decisions.

Clinical Vignette

Patient: "Mr. R," 28-year-old man with known schizophrenia, brought to the emergency department by his group home staff after he 'stopped moving, talking, and eating 3 days ago.'

Chief Concern: Group home staff: "Mr. R just stopped. Three days ago he was standing in the kitchen and froze. He hasn't moved from that position since unless we physically guide him. He won't speak, eat, or drink. When we position his arms, they stay wherever we put them. His eyes are open but he doesn't respond to us."

History of Present Illness: Mr. R has a 6-year history of schizophrenia (paranoid type, stable on clozapine). Three days ago, group home staff observed acute onset of motor immobility: he froze mid-action in the kitchen and has remained immobile since. Current presentation: (1) Stupor (no psychomotor reaction to environment, eyes open), (2) Catalepsy (maintains postures against gravity — arm raised by staff remains raised), (3) Waxy flexibility (slight consistent resistance to passive positioning, like bending candle wax), (4) Mutism (no verbal output for 3 days, previously verbal), (5) Negativism (when hand is extended for handshake, pulls arm back — motiveless resistance to instructions), (6) Posturing (maintains unnatural posture — one arm elevated, head tilted), (7) Staring (fixed gaze, no tracking of visual stimuli). He is NOT eating or drinking (3 days). Vital signs: temperature 99.2°F, HR 98, BP 130/85. Labs: CK mildly elevated (480 U/L), WBC normal. He is NOT on neuroleptics other than clozapine (lower catatonia risk than typical antipsychotics). No recent clozapine dose change.

Medical History: Schizophrenia (diagnosed age 22). Clozapine 400mg daily (stable for 2 years). No prior catatonic episodes. No NMS history.

Mental Status Exam: Patient sitting immobile in chair. Eyes open, fixed gaze. No eye tracking. No response to verbal commands. No response to name. When arm is raised by clinician, it remains elevated for >3 minutes (catalepsy with waxy flexibility). When asked to extend hand, pulls hand back (negativism). No speech. No spontaneous movement. Vital signs stable. No rigidity (differentiates from NMS). No tremor.

Step 1: Catatonia DSM-5-TR Criteria (≥3 of 12 features)

(1) Stupor: no psychomotor activity; not actively relating to environment

3 days of immobility. Eyes open, no response. PRESENT.

(2) Catalepsy: passive induction of posture held against gravity

Arms stay where positioned. Maintains posture against gravity >3 minutes. PRESENT.

(3) Waxy flexibility: slight, even resistance to positioning

Present (like bending candle wax). PRESENT.

(4) Mutism: no or very little verbal response (NOT aphasia)

No verbal output for 3 days. Previously verbal. PRESENT.

(5) Negativism: opposition or no response to instructions or external stimuli

Pulls arm back when handshake offered. Motiveless resistance. PRESENT.

(6) Posturing: spontaneous, active maintenance of a posture against gravity

Arm elevated, head tilted — maintained voluntarily. PRESENT.

(7) Staring: fixed gaze

Fixed gaze, no tracking. PRESENT.

TOTAL: 7 of 12 features present.

Also absent: mannerism, stereotypy, agitation, echolalia, echopraxia. 7/12 — FAR EXCEEDS 3/12 THRESHOLD.

Step 2: Catatonia Differential and Emergency Assessment

Condition Features Differentiation This Patient
Catatonia (psychiatric) Motor immobility, catalepsy, waxy flexibility, mutism Responds to benzodiazepine challenge Clinical presentation consistent
NMS Rigidity (lead-pipe), high fever, autonomic instability, very high CK Rigidity is LEAD-PIPE (not waxy); high fever; very high CK No lead-pipe rigidity, mild fever, modest CK elevation — NMS less likely
Neurological causes Status epilepticus, encephalitis, stroke EEG, MRI, LP as indicated No focal signs, LP/EEG ordered if benzodiazepine challenge negative
Medical causes Hepatic encephalopathy, uremia, metabolic derangement Labs, metabolic panel Labs pending—initial metabolic panel normal

Urgent Treatment: Benzodiazepine Challenge

Catatonia is a MEDICAL EMERGENCY when oral intake ceases (dehydration, malnutrition, DVT from immobility, rhabdomyolysis). The benzodiazepine challenge (lorazepam 1-2mg IV) is both diagnostic and therapeutic: a positive response (improvement within 5-10 minutes) confirms catatonia and guides treatment.

Diagnostic Formulation

Diagnostic Conclusion

Catatonia Associated with Schizophrenia (F20.2 + F06.1): 7 of 12 DSM-5-TR catatonic features present. Medical emergency (no oral intake x3 days). Treatment: (1) IMMEDIATE: Lorazepam 1-2mg IV (benzodiazepine challenge — both diagnostic and therapeutic). (2) If response positive: scheduled lorazepam (1-2mg IV q6-8h). (3) If benzodiazepine challenge fails or response is partial: ECT (electroconvulsive therapy — most effective treatment for medication-resistant catatonia). (4) IV fluids and nutritional support. (5) DVT prophylaxis (immobility). (6) Monitor CK (rhabdomyolysis risk). (7) Do NOT increase antipsychotic (may worsen catatonia). (8) Hold clozapine until catatonia resolves, then reassess.

Teaching Points

  • DSM-5-TR defines catatonia by the presence of ≥3 of 12 clinical features: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation (not influenced by external stimuli), grimacing, echolalia, and echopraxia. Catatonia is not a standalone diagnosis in DSM-5-TR — it is always associated with another condition (schizophrenia, mood disorder, medical condition, or unspecified).
  • Benzodiazepines (specifically lorazepam) are FIRST-LINE treatment for catatonia. The benzodiazepine challenge (1-2mg IV lorazepam) serves both diagnostic and therapeutic purposes: a positive response (improvement in catatonic features within 5-10 minutes) confirms the diagnosis and guides treatment. Response rates: 60-80%.
  • ECT (electroconvulsive therapy) is the MOST EFFECTIVE treatment for catatonia that does not respond to benzodiazepines. ECT has response rates of 80-100% even in benzodiazepine-resistant cases. Catatonia is one of the clearest indications for ECT in all of psychiatry.
  • Catatonia must be distinguished from Neuroleptic Malignant Syndrome (NMS). Both can present with immobility and elevated CK. Key differentiators: NMS has LEAD-PIPE rigidity (rigid, unyielding to passive movement) while catatonia has WAXY FLEXIBILITY (slight, smooth resistance). NMS typically has very high fever (>104°F) and very high CK (>1000 U/L). Catatonia may have mild elevation of both.
  • Antipsychotic medications should NOT be increased during catatonia — they may WORSEN the episode. This is counterintuitive because catatonia often occurs in the context of schizophrenia, prompting the reflex to increase antipsychotics. However, dopamine blockade can exacerbate catatonic motor symptoms. Benzodiazepines and ECT are the appropriate treatments.