Clinical Vignette
Patient: "Mr. J," 26-year-old man with known Schizophrenia, brought to the emergency department by group home staff after 36 hours of near-complete immobility and refusal to eat or drink.
Chief Concern: Group home staff: "He suddenly stopped moving yesterday morning. He won't eat, won't talk, and he's been standing in the same position by his bed. We can move his arms but they stay wherever we put them."
History of Present Illness: Mr. J was diagnosed with Schizophrenia at age 21 and has been stable on olanzapine 20mg daily for 2 years at his group home. Two days ago, staff noted he became increasingly quiet and withdrew to his room. By the following morning, he was standing motionless beside his bed, unresponsive to verbal cues. Staff observed that when they repositioned his arms, they remained in the new position (waxy flexibility). He has not eaten or consumed fluids for 36 hours. He does not speak but appears to be awake and tracking movement with his eyes. His olanzapine dose was not recently changed. No recent infections, fever, or medication changes reported.
Medical History: Schizophrenia (diagnosed age 21). No other medical conditions. Current medication: olanzapine 20mg daily.
Mental Status Exam: Alert (eyes open, tracking examiner). Immobile in standing position. Does not respond to verbal commands. Waxy flexibility present (arms maintain positions when moved). Mild rigidity in upper extremities. No spontaneous movements except eye tracking. Occasional stereotyped lip-smacking. Temperature 37.1°C. Vitals otherwise stable.
Step 1: Identifying Catatonia (DSM-5-TR Criteria)
DSM-5-TR requires three or more of the following 12 features: (1) stupor, (2) catalepsy, (3) waxy flexibility, (4) mutism, (5) negativism, (6) posturing, (7) mannerism, (8) stereotypy, (9) agitation (not influenced by external stimuli), (10) grimacing, (11) echolalia, (12) echopraxia.
(1) Stupor: No psychomotor activity; not actively relating to environment.
Mr. J is immobile and unresponsive to verbal cues despite being alert (eyes tracking). PRESENT.
(2) Catalepsy: Passive induction of a posture held against gravity.
Staff report arms remain in positioned locations (gravity-defying maintained postures). PRESENT.
(3) Waxy flexibility: Slight, even resistance to positioning by examiner.
Mild resistance followed by maintenance of new position. PRESENT.
(4) Mutism: No or very little verbal response (not applicable if known aphasia).
No verbal output despite intact speech capability (documented in prior assessments). PRESENT.
(8) Stereotypy: Repetitive, non-goal-directed motor movements.
Occasional stereotyped lip-smacking observed. PRESENT.
Criterion count: 5 of 12 features present (stupor, catalepsy, waxy flexibility, mutism, stereotypy). ≥3 required.
Five catatonic features identified. CATATONIA CONFIRMED.
Step 2: Medical vs. Psychiatric Etiology
Once catatonia is identified, the critical next step is determining etiology. DSM-5-TR categorizes catatonia as: (1) Catatonia Associated with Another Mental Disorder, (2) Catatonic Disorder Due to Another Medical Condition, or (3) Unspecified Catatonia. Medical causes must be excluded before attributing catatonia to a psychiatric condition.
| Feature | NMS | Catatonia (Psychiatric) | Autoimmune Encephalitis | This Patient |
|---|---|---|---|---|
| Temperature | High fever (>38°C, often >40°C) | Usually normal or low-grade | Variable | 37.1°C (normal) |
| Rigidity type | Lead-pipe rigidity | Waxy flexibility | Variable | Waxy flexibility (catatonia) |
| Autonomic instability | Tachycardia, diaphoresis, BP lability | Usually stable | Variable | Vitals stable |
| CK level | Markedly elevated (>1000) | Normal or mildly elevated | Normal | Pending labwork |
| Antipsychotic timing | After dose increase or new agent | Variable | Not relevant | Stable dose x 2 years |
| White count | Often elevated (leukocytosis) | Normal | Variable | Pending labwork |
| Response to benzodiazepine | Does not improve | Often responds dramatically | Does not improve | Diagnostic trial indicated |
Etiology Assessment
Normal temperature, waxy flexibility (rather than lead-pipe rigidity), stable vitals, and stable antipsychotic dose argue against NMS. The presentation is most consistent with catatonia associated with Schizophrenia. A lorazepam challenge (1-2mg IV) is both diagnostic and therapeutic: improvement within minutes strongly supports a catatonic syndrome and argues against NMS.
Diagnostic Formulation
Diagnostic Conclusion
Catatonia Associated with Schizophrenia (F20.2 + F06.1): Five of 12 DSM-5-TR catatonic features identified (stupor, catalepsy, waxy flexibility, mutism, stereotypy). Medical etiologies (NMS, autoimmune encephalitis, metabolic derangement) require laboratory exclusion but clinical presentation favors psychiatric catatonia. Underlying Schizophrenia is the associated mental disorder. Immediate lorazepam challenge recommended.
Teaching Points
- Catatonia is a syndrome, not a diagnosis. DSM-5-TR requires the clinician to specify the associated condition (another mental disorder such as Schizophrenia, Bipolar Disorder, or MDD; or a medical condition). Catatonia can occur in the context of mood disorders, psychotic disorders, neurodevelopmental disorders, and medical conditions.
- The lorazepam challenge (1-2mg IV/IM) is both diagnostic and therapeutic. A positive response (reduction in catatonic features within 5-10 minutes) confirms the catatonic syndrome and initiates treatment. If lorazepam is ineffective, electroconvulsive therapy (ECT) is the definitive treatment.
- NMS and catatonia share surface features (immobility, rigidity, mutism) but differ in critical ways: NMS produces lead-pipe rigidity and high fever; catatonia produces waxy flexibility and normal or low-grade temperature. This distinction has direct treatment implications: benzodiazepines treat catatonia but do not treat NMS; dopamine agonists treat NMS but not catatonia.
- Catatonia is a medical emergency when it involves refusal to eat or drink (as in this case). Dehydration, malnutrition, deep vein thrombosis, and pulmonary embolism are life-threatening complications of prolonged immobility.
- The Bush-Francis Catatonia Rating Scale (BFCRS) is the standard clinical tool for assessing and monitoring catatonic features. It evaluates 23 items and provides a severity score that can be tracked over the course of treatment.