catatonia

Evidence-based consensus
guidelines for the
management of catatonia:
Recommendations from the British Association for Psychopharmacology
Journal of Psychopharmacology 2023, Vol. 37(4) 327–369
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Background

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia.
This Guideline covers:
Diagnosis,
Aetiology,
Clinical features
Descriptive epidemiology of catatonia
Clinical assessments, including history, physical examination and
investigations are then considered
Treatment Catatonia – Definition
3 Selected important medical conditions that may underlie catatonia
4 Clinical features
Given that catatonic signs can fluctuate over time, catatonic signs should be examined both cross-sectionally and longitudinally using the diagnostic systems ICD-11 and DSM-5-TR or one of the available clinical rating scales
The characteristic motor signs include mannerisms, stereotypy, festination, athetotic movements, dyskinesias, Gegenhalten, posturing, catalepsy, waxy flexibility (flexibilitas cerea), rigidity, muscular hypotonus, sudden muscular tone alterations and akinesia.
5 Descriptive epidemiology
Rogers et al. (2021) estimated an incidence of catatonia in the general population, in London, UK, finding that catatonia occurred in 10.6 (95% CI: 10.0–11.1) per 100,000person-years, but this also relied upon the mention of catatonia in the healthcare notes.
In a large recent study in US non-federal general hospitals, a discharge diagnosis with an ICD-10 catatonia code occurred in 0.05% of hospital admissions
6 Clinical assessment
Selected salient points in a history from a person with catatonia
7 Clinical assessment
Physical examination for patients with catatonia
8 Recommendations on the assessment of catatonia
• Initial assessment and treatment of catatonia should be conducted within secondary care
• Catatonia should be considered as a differential diagnosis whenever a patient exhibits a substantially altered level of activity or abnormal behaviour, especially where it is grossly inappropriate to the context
• A collateral history should be sought wherever possible
• The history should include identification of possible medical and psychiatric disorders underlying catatonia, as well as prior response to treatment
• Physical examination should include assessment for catatonic signs, signs of medical conditions that may have led to the catatonia and signs of medical complications of catatonia.
• When assessing a patient with catatonia, clinicians should interact with the person as if they are able to understand what is being said to them
9 Means of assessment of catatonia
10 Comparison of commonly used catatonia rating scales
11 Representation of items on motor tone across diagnostic manuals and major rating scales
12 Recommendations on the use of investigations in catatonia
• Investigations, such as blood tests, urine drug screen, lumbar puncture, electroencephalography and neuroimaging, should be considered based on history and examination findings, taking into account the possible diagnoses that may mimic catatonia and the possible underlying aetiology of the catatonia
• In patients experiencing a first episode of catatonia or where the diagnosis underlying catatonia is unclear, consider a CT or MRI scan of the brain
• In patients experiencing a first episode of catatonia or where the diagnosis underlying catatonia is unclear, consider assessing for the presence of antibodies to the NMDA receptor and other relevant autoantibodies in serum and CSF
• In patients with risk factors for seizures, possible evidence of a seizure or possible encephalitis, consider performing an EEG (with continuous monitoring if available).
13 Challenge tests
DSM-5-TR has included a diagnosis of unspecified catatonia to encourage early treatment while a search for an underlying disorder can continue.
Challenge tests may provide support in clarifying diagnosis and appropriate treatment.
This section is limited to the use of benzodiazepines and zolpidem as a diagnostic and therapeutic ‘challenge test’.
These agents are discussed in greater detail in section ‘GABA-ergic pharmacotherapies’
14 Example protocol for a lorazepam challenge for catatonia
15 Recommendations on the use of challenge test
When a diagnosis of catatonia is uncertain, a diagnostic challenge using lorazepam should be considered. (B)
• When a diagnosis of catatonia is uncertain, a diagnostic challenge using zolpidem may be considered. (C)
In suspected or confirmed cases of catatonia, a lorazepam challenge may be used to predict future response to benzodiazepines. (B)
16 Differential diagnosis of catatonia
17 Differential diagnosis of catatonia
18 Recommendations on the general approach to treating catatonia
Treatment for catatonia should be instituted quickly after identification of catatonia and it is not always necessary to await results of all investigations before commencing treatment. (D)
• Prescribing outside of a product licence is often justified in catatonia, but where a prescriber does this, they should take particular care to provide information to the patient or carer and obtain consent, where possible, taking advice where necessary. (S)
Catatonia treatment should consist of specific treatment for the catatonia, treatment of any underlying disorder and prevention and management of complications of catatonia. (S)
When deciding between benzodiazepines and ECT as a first-line treatment, consider the following factors: side effect profile, whether there is an underlying disorder that is likely to be responsive to ECT (such as depression or mania) and availability of ECT. (S)
• ECT should be available in any settings where catatonia may be treated, including in psychiatric and general hospitals. (S)
19 Recommendations on the general approach to treating catatonia
Where benzodiazepines have not resulted in remission, ECT should be used.
Where catatonia has resulted from benzodiazepine withdrawal, restart a benzodiazepine. (D)
If clozapine and benzodiazepines are administered concomitantly, titrate slowly and closely monitor vital signs. (S)
Where catatonia does not respond to first-line therapy, re-evaluate the diagnosis. (D)
• Where catatonia has resulted from clozapine withdrawal, restart clozapine if possible and, if necessary, use ECT. (D)
• If catatonia is chronic and mild in the context of schizophrenia, consider a trial of clozapine. (C)
20 Recommendations on the general approach to treating catatonia
Where benzodiazepines have not resulted in remission, ECT should be used.
• Where catatonia has resulted from clozapine withdrawal, restart clozapine if possible and, if necessary, use ECT. (D)
Where catatonia has resulted from benzodiazepine withdrawal, restart a benzodiazepine. (D)
If catatonia is chronic and mild in the context of schizophrenia, consider a trial of clozapine. (C)
If clozapine and benzodiazepines are administered concomitantly, titrate slowly and closely monitor vital signs. (S)
Where catatonia does not respond to first-line therapy, re-evaluate the diagnosis. (D)
21 Recommendations on the use of GABA-ergic medications in catatonia
Where benzodiazepines are used for catatonia, available routes of administration may include oral, sublingual, IM and IV. The choice of route should be decided based on clinical appropriateness, rapidity of the required response, patient preference, local experience and availability. (S)
Where benzodiazepines are used for catatonia, lorazepam is generally the preferred agent. (S)
Where lorazepam is used for catatonia, high doses above the licensed maximum may be necessary to achieve maximal effect. An adequate trial may be considered complete when catatonia is adequately treated, titration has been stopped due to side effects or dose has reached at least 16mg per day. (C)
• Benzodiazepines for catatonia should not be stopped abruptly but rather tapered down. The speed of the taper depends on a balance of the therapeutic benefits and the risks of withdrawal effects against the possibility of dependence and the risks of long-term harm from benzodiazepines. (S)
If catatonia relapses on withdrawal of benzodiazepines, a clinician should ensure that any underlying condition has been adequately treated and a slower taper may be tried. (S)
22 Recommendations for the use of ECT in catatonia
• Where ECT is administered, bilateral ECT should be considered. (S)
• Where ECT is administered in acute catatonia, it should be given at least two times weekly. (S)
• Number of ECT sessions should be decided on the basis of treatment response, risks and side effects. (S)
23 Recommendations on the use of other therapies
• Where first-line therapies for catatonia are unavailable, cautioned, ineffective or only partially effective, consider a trial of an NMDA receptor antagonist, either amantadine or memantine. (C)
• Where first-line therapies and NMDA receptor antagonists are unavailable, cautioned, ineffective or only partially effective, consider a trial of levodopa, a dopamine agonist, carbamazepine, valproate, topiramate or a SGA. (D)
• Antipsychotic medications should be avoided where there is no underlying psychotic disorder. (C)
• Where catatonia exists in the context of an underlying psychotic disorder, if antipsychotic medications are used, they should be prescribed with caution after an evaluation of the potential benefits and risks, including the risk of NMS. Additional caution should be exercised if there is low serum iron or a prior history of NMS. If antipsychotic medications are used, a SGA should be used with gradual titration, and co- administration of a benzodiazepine should be considered. (S)
• Where ECT is indicated but unavailable, consider treatment with rTMS or tDCS. (D)
24 Recommendation on periodic catatonia
In the maintenance phase of periodic catatonia, consider prophylactic treatment with lithium. (D)
25 Recommendations for the treatment of malignant catatonia
In malignant catatonia, discontinue all dopamine antagonists. (D)
• In malignant catatonia, commence a trial of lorazepam at 8mg/day (PO, IM or IV), titrating up according to response and tolerability up to a maximum of 24mg/day. (C)
If there is partial or no response to lorazepam within 48–72 h in malignant catatonia, institute bilateral ECT once or twice daily for up to 5 days until malignant catatonia abates, followed by ECT three times per week until there is sustained improvement, usually 5–20 treatments in total. (D)
26 Recommendations for the treatment of Neuroleptic malignant syndrome
In NMS, discontinue all dopamine antagonists. (C)
In NMS, discontinue anticholinergic drugs. (S)
In NMS, supportive care should be provided. This consists of assessment and appropriate management of airway, ventilation, temperature and swallow. Fluid input/output should be monitored, and aggressive fluid resuscitation should be used where required. There should be assessment for hyperkalaemia, renal failure and rhabdomyolysis. There should be careful monitoring for complications such as cardiorespiratory failure, aspiration pneumonia, thromboembolism and renal failure, alongside early consideration of high-dependency care. (S)
For mild, early NMS, characterised by mild rigidity, catatonia or confusion, temperature
For moderate NMS, characterised by moderate rigidity, catatonia or confusion, temperature=38°C–40°C and HR=100–120,
consider a trial of lorazepam. Consider a trial of bromocriptine or amantadine. Consider ECT. (C)
If clinical features persist, consider bilateral ECT three times weekly or, in severe cases, once or twice daily, until NMS abates. Continue ECT three times per week until there is sustained improvement to a total of 5–20 treatments. (C)
Delay restarting antipsychotics by at least 2weeks after resolution of an NMS episode to reduce the risk of recurrence. (C) 27
• For severe NMS, characterised by severe rigidity, catatonia or coma, temperature>40°C and HR>120, consider a trial of lorazepam and consider dantrolene. Consider bromocriptine or amantadine. Consider ECT. (C). Recommendations for antipsychotic-induced catatonia
When catatonia is attributed to antipsychotic administration, consider discontinuing the antipsychotic. (C)
Once catatonia is treated, if an antipsychotic is still necessary, commence at a low dose and titrate gradually, closely monitoring for side effects. (S)
• In more severe cases or cases that do not resolve with antipsychotic discontinuation, consider a trial of a benzodiazepine. (C)
28 Recommendations for catatonia in the children and adolescents
Catatonia is known to occur in children as young as 5years and clinicians should screen for catatonia whenever clinical suspicion exists. (S)
When assessing for the presence of paediatric catatonia, the PCRS should be used. (C)
• Evaluation of catatonia aetiologies in children and adolescents should include the same range of disorders as found in adults. (S)
• First-line management for paediatric catatonia includes a lorazepam challenge test, lorazepam in increasing doses and bilateral ECT. (D)
29 Recommendations for catatonia in older adults
In older adults, care should be taken to identify medical disorders underlying catatonia. (S)
First-line treatment of catatonia in the older adults consists of benzodiazepines, often at lower doses than among younger adults, and ECT. (D)
• Catatonia should be considered in the differential diagnosis for an apparent rapidly progressive dementia or ‘failure to thrive’ clinical presentations in older adults. (S)
30 Recommendations for catatonia in the perinatal period
If catatonia is severe and the woman suffers from a mental illness, the psychiatric and obstetric team should make a joint decision as to which inpatient setting is most appropriate for treatment. Contact between the mother and baby should be encouraged as much as is possible and appropriate. Psychiatric care should be provided by a psychiatrist experienced in the management of perinatal mental illness. (S)
• If catatonia is severe and presents high risks to the physical health of the mother and child, and treatment of the underlying condition has been ineffective or would lead to an unacceptable delay, specific treatment for catatonia should be considered. (S)
The risks of any specific treatment should be carefully weighed against the risks of other treatments or no treatments. (S)
31 Recommendations for catatonia during pregnancy
Screening and selection of patients for ECT should be conducted by a psychiatrist experienced in ECT, in consultation with both a psychiatrist with appropriate expertise in perinatal psychiatry and an obstetrician. (D)
• If delivery is expected within a few weeks, alternative options, such as induction of labour or Caesarean section should be considered by the obstetrician, anaesthetist, paediatrician and psychiatrist. (S)
If specific treatment for catatonia is required, lorazepam at doses up to 4mg/day should be considered initially. (S)
• If lorazepam is not effective at up to 4mg/day, and the risks to the health of the mother and/or the child are high, the use of ECT can be considered (S)
32 Recommendations for catatonia during breastfeeding
If treatment with lorazepam at doses higher than 4mg/day is used, the mother should not breastfeed because of a lack of evidence of its safety. If possible and appropriate, lactation can be maintained during the period of high lorazepam dosing by expressing and discarding milk. (S)
Women can resume breastfeeding after ECT treatments. (C)
33 Recommendations for catatonia in autism spectrum disorder
Clinical vigilance is warranted for the assessment of catatonia in autism spectrum disorder given its high prevalence. (C)
First-line interventions in mild cases of catatonia are psychological interventions and/or lorazepam, but the standard treatments for catatonia (i.e. benzodiazepines in escalating dosages and/or bilateral ECT) should be considered in moderate to severe cases. (D)
• Diagnosis of catatonia in autism spectrum disorder requires a marked change from baseline presentation. (S)
34 Recommendations for catatonia in kidney, liver and lung disease
In renal impairment, lorazepam dosing does not usually need to be altered, but consider additional monitoring for side effects. (C)
• In mild or moderate hepatic impairment, lorazepam dosing does not usually need to be altered, but caution should be exercised when considering lorazepam in severe hepatic impairment. (B)
In severe respiratory disease, consider giving ECT as a first-line treatment rather than benzodiazepines. (D)
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