Catatonic schizophrenia was once considered a subtype of schizophrenia. However, the American Psychiatric Association (APA) removed it as a separate diagnosis in 2013 in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This change reflects a shift in how medical professionals understand catatonia.

Today, catatonia is recognized as a syndrome (a group of symptoms), rather than a distinct diagnosis. While catatonia can occur in people living with schizophrenia, it may also appear with other mental health or medical conditions. The hallmark symptoms of catatonia involve unusual movements or behaviors.

As of 2013, catatonic schizophrenia is no longer a formal diagnosis. What was once called catatonic schizophrenia is now described as schizophrenia with catatonic features.

Psychiatry experts now understand schizophrenia as a spectrum of symptoms rather than as distinct types. This means a person may be diagnosed with schizophrenia with or without symptoms of catatonia. What was once called “catatonic schizophrenia” is now seen as schizophrenia with catatonic features.

This article explains what catatonia is, including its signs, risk factors, and treatment options.

What Is Catatonia?

Catatonia refers to a group of symptoms that involve unusual movements or behaviors. It may be linked to how the brain processes signals that control muscle movements. This disruption in brain function can cause people with catatonia to react to their surroundings in ways that may seem unusual or out of sync with the situation.

Cause of Catatonia

The exact cause of catatonia isn’t fully understood. However, researchers believe that brain chemicals called neurotransmitters may play a role. One possible cause involves disruptions in GABA, a neurotransmitter that helps regulate movement, mood, and cognition (brain function). Other theories suggest that low dopamine or high glutamate levels may also contribute to catatonia.

Types of Catatonia

There are several types of catatonia, each defined by different patterns of behavior. The three most common are:

• Excited — Involves increased movement, such as pacing or repetitive movements
• Withdrawn — Involves little to no response to people or surroundings, including long periods of immobility or lack of speech or facial expression
• Mixed — Includes features of both excited and withdrawn types

Studies estimate that 10 percent to 25 percent of people living with schizophrenia experience catatonia. Studies have also shown that 45 percent of people with catatonia have underlying mood disorders or other medical conditions.

Studies estimate that between 10 percent and 25 percent of people living with schizophrenia experience catatonia.

Risk Factors for Catatonia and Schizophrenia

Although the causes of catatonia are not fully understood, certain factors may increase a person’s risk. These include having a psychiatric, neurological, or other medical condition. In some cases, suddenly stopping medications for mental health conditions, such as antipsychotics or mood stabilizers, may also trigger catatonia.

Schizophrenia also doesn’t have a single known cause. However, research suggests that several risk factors may increase a person’s likelihood of developing the condition, such as:

• Having a family history of schizophrenia
• Using recreational drugs or other substances, especially at a young age
• Being exposed to certain viruses, infections, or chemicals that can affect brain development
• Living in a high-stress or unsafe environment
• Experiencing malnutrition before or shortly after birth
• Being born with a low birth weight

Symptoms of Schizophrenia With Catatonia

What was once called catatonic schizophrenia is now described as schizophrenia with catatonic features. This means a person experiences symptoms of both schizophrenia and catatonia.

Common symptoms of schizophrenia include:

• Hallucinations — Sensing things that aren’t there, such as hearing voices
• Delusions — Holding beliefs that are clearly false or not based in reality
• Disorganized thinking or movement — For example, switching topics midsentence or making unusual or repetitive movements
• Negative symptoms — A decrease in usual functioning, such as showing limited emotion, reduced speech, or social withdrawal

When catatonia occurs with schizophrenia, a person may also show unusual movements or behaviors. These can include staying in the same position for a long time, holding stiff or awkward poses, or becoming unusually agitated or overly active.

The DSM-5-TR (a text revision of DSM-5) includes the following 12 characteristic signs of catatonia.

Catalepsy

Catalepsy describes a state where a person holds a rigid pose that someone else places them in. They don’t move out of the position on their own, but they may take on a new one if moved. This behavior is involuntary and can last for extended periods.

Echolalia and Echopraxia

Echolalia is when someone involuntarily repeats words or sounds they hear. Echopraxia is the involuntary imitation of someone else’s movements or gestures.

These behaviors may occur in catatonia or other neurological or developmental conditions, such as autism or Tourette syndrome. Echolalia is also common in young children as they learn to speak, and is not usually a cause for concern unless it continues beyond the typical age of language development.

Posturing and Grimacing

Posturing involves holding an unusual or uncomfortable body position for a long time. Unlike catalepsy, the person places themselves in the pose rather than being moved into it.

Grimacing refers to holding a facial expression, often tense or distorted, regardless of the situation.

Stereotypy

Stereotypy means repeating the same motion over and over without an obvious purpose. These movements may seem random or disconnected from what’s going on around the person.

Mutism

Mutism is when someone speaks very little or not at all, even when expected to respond. Mutism in catatonia is diagnosed only when other causes, such as primary speech or language disorders, are ruled out.

Stupor

Stupor refers to a complete lack of response to the environment, including to pain or voices. It is often what people mean when they describe a “catatonic state.”

Waxy Flexibility

Waxy flexibility describes how a person’s arm or leg stays in place after being moved, as if the muscles offer light resistance and then slowly release. The motion is similar to bending warm wax.

Mannerism

Mannerism means doing a typical action, such as waving or walking, in an odd, exaggerated, or out-of-context way. The action itself may be normal, but the timing, setting, or repetition makes it seem unusual.

Negativism

Negativism is resistance to instructions or external stimuli. A person may either not respond at all or may do the opposite of what’s asked. They may, for example, turn away when asked to look at someone.

Agitation

Agitation in catatonia refers to excessive movement or restlessness that doesn’t seem triggered by anything around the person. It’s different from ordinary agitation, which usually has an emotional or situational cause.

Treatment Options for Schizophrenia With Catatonia

Antipsychotic medications are commonly prescribed to treat schizophrenia. However, in people with catatonia, some antipsychotics may make symptoms worse. They may also raise the risk of a rare but serious condition called malignant catatonia.

This form of catatonia can affect parts of the nervous system that control automatic functions, such as breathing and heart rate, and may be life-threatening. Because of this risk, antipsychotics aren’t usually recommended to manage schizophrenia with catatonia.

Antipsychotics aren’t usually used to manage schizophrenia with catatonia.

The first-line treatment for catatonia is typically a type of medication called benzodiazepines. These medications work by boosting the effects of GABA, a brain chemical that helps control mood and movement. Lorazepam is the most commonly used benzodiazepine for catatonia. Studies show that between 60 percent and 90 percent of people with catatonia experience improvement with this treatment.

If benzodiazepines aren’t effective, doctors may recommend electroconvulsive therapy (ECT). ECT involves applying a controlled electrical current to the brain while the person is under anesthesia, causing a brief seizure.

This treatment can quickly improve symptoms of catatonia and is considered safe and effective for most people. ECT is often the first choice when someone has malignant catatonia because it can work quickly to prevent serious complications.

When catatonia symptoms improve, it’s important to return to a full treatment plan to manage schizophrenia. These treatments may include antipsychotic medications, mood stabilizers, and talk therapy.

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