Psych Residency Companion LogoPsych Residency Companion
PPP073 – Catatonia: Diagnosis and Treatment
PPP073 – Catatonia: Diagnosis and Treatment
In this detailed discussion with Dr. Michael Cummings, Dr. Puder explores the history, diagnosis, differential, and treatment of catatonia. Often underdiagnosed, catatonia is a serious neuropsychiatric syndrome that can arise from mood disorders, schizophrenia, medical conditions, or drug effects. They break down key features such as mutism, stupor, echolalia, and waxy flexibility. The conversation also covers the lorazepam challenge test, ECT for refractory cases, and how to differentiate catatonia from other conditions.
Training Year: PGY1-PGY2Duration: 44:00
Listen on Source Platform

Listen to Episode

No audio source available for this episode.

Episode Notes

🔍 Topics & Tags

#Catatonia #Diagnosis #Benzodiazepines #ECT #DifferentialDiagnosis #Psychopharmacology #PGY1-PGY2 Guest:: Dr. Michael Cummings

Metadata

Podcast:: Psychiatry and Psychotherapy Podcast
Episode:: PPP073 – Catatonia: Diagnosis and Treatment
Link:: Apple Podcast
Embed: Apple Podcast PublishDate:: 2020-12-04

✅ Pre-Lesson Quiz (Before You Listen)

1. What is the most common initial symptom of catatonia?
A. Hallucinations
B. Delusions
C. Speech latency
D. Hyperactivity

2. What is a hallmark response that confirms catatonia diagnosis during a lorazepam challenge?
A. Increased hallucinations
B. Resolution of symptoms within minutes
C. Onset of lateral nystagmus
D. Emergence of new symptoms

3. Which of the following conditions is most commonly confused with catatonia?
A. Major neurocognitive disorder
B. Delirium
C. Panic disorder
D. Autism

4. What medication class should be used with caution (or avoided) in delirium but is first-line in catatonia?
A. SSRIs
B. Benzodiazepines
C. Antipsychotics
D. Mood stabilizers

5. What is a key safety reason to escalate lorazepam quickly in catatonia?
A. To avoid serotonin syndrome
B. To prevent misdiagnosis
C. To avoid progression to mutism and death
D. To improve sleep hygiene

🧠 Summary

In this detailed discussion with Dr. Michael Cummings, Dr. Puder explores the history, diagnosis, differential, and treatment of catatonia. Often underdiagnosed, catatonia is a serious neuropsychiatric syndrome that can arise from mood disorders, schizophrenia, medical conditions, or drug effects. They break down key features such as mutism, stupor, echolalia, and waxy flexibility. The conversation also covers the lorazepam challenge test, ECT for refractory cases, and how to differentiate catatonia fro...

⏱️ Timestamps & Highlights

  • 00:30 | Catatonia overview: history, types (stupor vs. excitement), motor signs.
  • 04:15 | DSM features: mutism, stupor, echolalia, echopraxia, waxy flexibility.
  • 07:10 | Disease trajectory: delays in speech, decreased intake, weight loss.
  • 10:30 | Always secondary: catatonia arises from psych, medical, or neuro disorders.
  • 14:20 | Diagnostic challenge: history + lorazepam challenge test.
  • 18:00 | Clinical pearls: freezing, fear, delayed responses.
  • 22:40 | Benzodiazepine responders vs. ECT candidates.
  • 26:15 | Use of Ativan: escalate quickly to full response, taper slowly.
  • 30:00 | Mechanisms: polyvagal theory, shutdown states, chronic dorsal vagal activity.
  • 34:20 | Differential: NMS, serotonin syndrome, delirium—all compared to catatonia.
  • 39:45 | Neuroimaging and neurochemistry: frontal hypoactivity, low GABA-A.
  • 44:00 | Prognosis is good if identified early; high index of suspicion is key.

📝 Key Takeaways

  • Catatonia is a motor and behavioral syndrome that can arise from mood disorders, schizophrenia, substance use, or medical causes.
  • Key signs: mutism, stupor, echolalia, waxy flexibility, posturing, and delayed speech.
  • Lorazepam challenge test (1–2 mg IV/IM) can be diagnostic and therapeutic; response is often rapid.
  • ECT is highly effective in refractory or life-threatening catatonia.
  • Differentiate catatonia from NMS, serotonin syndrome, delirium, and dissociation.
  • Rapid escalation of Ativan is recommended; taper slowly to avoid relapse.
  • Maintain high clinical suspicion and involve collateral to confirm timeline of progression.

🔍 Quiz Answer Key & Explanations

  1. C. Speech latency often precedes mutism and is an early subtle sign of catatonia.
  2. B. A positive lorazepam challenge results in rapid reversal of catatonic signs.
  3. B. Delirium and catatonia can both present with stupor and confusion, but differ in attention and treatment response.
  4. B. Benzodiazepines can worsen delirium but are essential for treating catatonia.
  5. C. Catatonia can be fatal if not treated promptly; rapid intervention prevents complications like DVT, dehydration, and death.

🧠 After-the-Episode Review

  • Catatonia presents as a spectrum of motor, speech, and behavioral disturbances, most notably mutism, stupor, and echophenomena.
  • It is never a standalone diagnosis; always secondary to another illness (e.g., MDD, schizophrenia, withdrawal, or neurologic/metabolic causes).
  • The lorazepam challenge test (1–2 mg IV/IM) is both diagnostic and therapeutic—observe changes 5–20 minutes post-administration.
  • Benzodiazepines should be escalated rapidly to a response, with tapers done extremely slowly to avoid relapse.
  • If there’s no response, consider ECT as a highly effective next step—often life-saving.
  • Differentiate carefully from NMS (high CK, rigidity, antipsychotic use), serotonin syndrome (GI upset, hyperreflexia), and delirium (waxing/waning attention).
  • Early recognition and treatment significantly improve outcomes.

📚 Further Reading & Resources

  • Bush, G., Fink, M., Petrides, G., Dowling, F., & Francis, A. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129–136.
  • Rasmussen, S. A., & Mazurek, M. F. (2019). Catatonia and its treatment. The Lancet Psychiatry, 6(7), 620–630.
  • American Psychiatric Association. (2013). DSM-5.
  • NIMH: Catatonia Overview

🙏 Credits

Host: Dr. David Puder
Guest: Dr. Michael Cummings
Transcript processed using aTrain:
Armin Haberl, Jürgen Fleiß, Dominik Kowald, Stefan Thalmann (2024). Take the aTrain. Journal of Behavioral and Experimental Finance, 41, 100891. https://doi.org/10.1016/j.jbef.2024.100891