Diagnosis

The two major psychiatric manuals, DSM-5 and ICD-11, now have very similar criteria for the diagnosis of catatonia. DSM-5 requires the presence of 3 of the following 12 clinical features:

  1. Stupor (a state of reduced responsiveness)
  2. Catalepsy (patient adopts positions that they are put in by the examiner)
  3. Waxy flexibility (light resistance to repositioning)
  4. Mutism (minimal or absent speech)
  5. Negativism (automatic and motiveless resistance to instructions)
  6. Posturing (spontaneous adoption of positions that are held for an abnormal length of time)
  7. Mannerisms (exaggerated example of normal action)
  8. Stereotypies (repetitive, non-goal-directed movements)
  9. Psychomotor agitation (increased activity unrelated to external stimuli)
  10. Grimacing (abnormally fixed facial expression)
  11. Echolalia (repetition of another person’s speech)
  12. Echopraxia (mimicry of another person’s movements)

Some of these features may be elicited simply by observation. A comprehensive catatonia examination is provided below, adapted from Bush et al., 1996

Watch Catatonia examination on YouTube.
 

Examination

Signs to be elicited

Observe the patient carefully, initially ideally without them being aware of your presence

Posturing (spontaneous adoption of positions that are held for an abnormal length of time)

Mannerisms (exaggerated example of normal action)

Stereotypies (repetitive, non-goal-directed movements)

Psychomotor agitation (increased activity unrelated to external stimuli)

Grimacing (abnormally fixed facial expression)

Introduce yourself and offer to shake hands. If ambitendency is not elicited, this can be amplified by offering your hand and stating, ‘Do not shake my hand.’

Ambitendency (ambivalent back-and-forth movements)

Attempt to engage in conversation

Mutism (minimal or absent speech)

Echolalia (repetition of another person’s speech)

Scratch your head in an exaggerated manner. Repeat on the other side.

Echopraxia (mimicry of another person’s movements)

Assess muscle tone, asking the patient to keep their arms relaxed.

Gegenhalten (resistance to movements that is equal and opposite to the force applied by the examiner)

Take the patient’s radial pulse while holding their arm elevated for at least 10s, then let go.

Catalepsy (patient adopts positions that they are put in by the examiner)

Tachycardia (increased heart rate)

Ask the patient to put their arms horizontally out in front of them and not to let you move them.

Mitmachen (passive movement of the patient’s limbs with the examiner despite instructions to the contrary) or Mitgehen (extreme form of Mitmachen in which even the slightest pressure causes the limb to move)

Measure vital signs

Tachycardia (increased heart rate)

Hypertension (increased blood pressure)

Pyrexia (increased temperature)

Examine food and fluid intake charts

Poor oral intake