History
A detailed history can help identify factors that increase vulnerability or may have precipitated catatonia.
 

• Psychiatric history: Mood, psychotic, trauma-related, and neurodevelopmental conditions are most frequently associated.

• Medical and neurologic history: Consideration of metabolic, autoimmune, infectious, or structural contributors is often recommended.

• Medication and substance history: Reviewing current medications, recent medication changes or discontinuations, and substance use (including alcohol, cannabis, or other substances) can provide valuable context, as these factors are frequently discussed in relation to catatonia onset or worsening.

• Baseline and change over time: Understanding the patient’s typical functioning, recent changes from baseline, and the time frame in which these changes occurred can be important in distinguishing catatonia from other conditions and identifying potential triggers.
   

Collateral Information
Collateral information from family members and caregivers often provides crucial insight into changes that may not be apparent during a brief clinical encounter. Families and caregivers are frequently the first to notice early or subtle shifts in movement, responsiveness, or behavior but may not know which details are relevant to share. Because they are often in crisis, they may describe what they observe in everyday language rather than clinical terms.

Clinicians may find it helpful to ask specific, concrete questions rather than broad ones. Examples include:

• Has the person stopped speaking or begun whispering, repeating, or echoing words or phrases?

• Are they eating, drinking, or moving less than usual?

• Do they seem frozen, resist movement, or hold unusual postures for long periods?

• Have you noticed repetitive or purposeless movements?
   

Such targeted questions can uncover features that families did not recognize as significant—for instance, a patient repeatedly asking the same question may be demonstrating echolalia, which is highly suggestive of catatonia.
 

Because individuals experiencing catatonia are often unable to communicate or describe their own symptoms, collateral information from those who know the patient best is essential in establishing what is new or different from baseline and in supporting timely recognition. 

Observation and Examination
Careful observation remains central to assessment. Literature emphasizes both motor phenomena (immobility, rigidity, posturing, stereotypy, or mannerisms) and speech or behavioral features (mutism, echolalia, echopraxia, negativism).

A typical appointment may not allow sufficient time to fully assess the range or fluctuation of catatonic signs, which can change throughout the day or under different circumstances.

It is also important to recognize that current medications may influence presentation—some may mask catatonic features, while others may exacerbate them.

These factors underscore the value of ongoing observation and collateral input from families, who can describe changes across settings and time. Educating families about what to look for can strengthen early recognition and help ensure that relevant observations are communicated to the clinical team.

You may wish to refer families to The Catatonia Foundation website, where they can read in-depth about catatonia, learn how to advocate effectively, and download a patient and family brochure for additional support and education.

Structured Screening
Standardized tools support more consistent identification.

• The Bush–Francis Catatonia Rating Scale (BFCRS) includes a 14-item screen; the presence of two or more positive items is often described as suggestive of catatonia.

• The Northoff Catatonia Rating Scale (NCRS) also appears in the literature, with broader attention to affective and behavioral dimensions.

Using structured instruments provides a shared framework for documenting and monitoring symptoms.
 

For more information and downloadable tools, visit the Screening and Rating Scales section above. 
 

Medical and Neurological Workup
Medical evaluation plays an essential role in understanding both the underlying causes and potential complications of catatonia. The literature emphasizes that most patients with catatonia are assessed within secondary or inpatient care settings, reflecting the condition’s complexity and associated medical risks (Evidence-Based Consensus Guidelines for the Management of Catatonia, 2023).

According to the Consensus Guidelines, any first-episode presentation of catatonia should prompt a thorough medical and neurological workup to identify potential contributing or causative conditions. Even in recurrent episodes, clinicians are encouraged to confirm that a complete prior evaluation was performed, as new or evolving medical factors may emerge over time. These recommendations underscore the importance of a systematic approach to ruling out underlying causes and identifying concurrent medical issues that may influence management.

The Consensus Guidelines further advise that investigations be guided by the patient’s history, examination findings, and likely differential diagnoses. Commonly discussed components include:

• Laboratory studies: Basic metabolic and endocrine panels, inflammatory markers, and serum iron; additional testing as indicated for metabolic, infectious, or autoimmune conditions.

• Toxicology screening: Urine drug screens may help identify substances that could contribute to presentation.

• Neuroimaging: CT or MRI of the brain is often considered for first-episode catatonia or when the diagnosis is uncertain, to evaluate for structural, inflammatory, or neoplastic processes.

• Electroencephalography (EEG): Particularly valuable when seizures, encephalitis, or altered consciousness are possible contributors; continuous monitoring can be helpful when available.

• Autoimmune and paraneoplastic testing: In suspected autoimmune encephalitis, serum and CSF testing for NMDA-receptor and other relevant autoantibodies may be indicated.
   

The Consensus Guidelines also emphasize that any hospital workup should weigh the potential risks and benefits of detailed investigation. Extensive medical testing may heighten anxiety, and catatonia itself has been closely associated with heightened physiological and psychological arousal. In some patients, prolonged uncertainty or repeated investigations may intensify distress or worsen catatonic features.

A well-considered medical and neurological workup therefore serves not only to identify or rule out underlying causes but also to inform care planning, monitoring, and prevention of complications such as dehydration, malnutrition, or autonomic instability.
 

Lorazepam Challenge
A lorazepam challenge is frequently discussed in the literature as both a diagnostic and therapeutic tool. It involves the careful administration of lorazepam—commonly 1–2 mg given intravenously, intramuscularly, or orally—while observing for short-term improvement in catatonic features. A positive response, typically evident within minutes when given intravenously or within an hour when given orally, can support the diagnosis of catatonia and help guide further treatment planning.

The procedure should always occur in a monitored clinical setting, as patients may have medical comorbidities or require observation for sedation or respiratory effects. Even a partial response can provide valuable diagnostic insight. It's important to note that while rapid improvement strongly suggests catatonia, a lack of response does not rule it out.

For an educational overview of how this process is described in practice, see the Psychopharmacology Institute Catatonia Series – Lorazepam Challenge.