Signs & Diagnosis
Catatonia can look different from person to person. It can take many forms, change over time, and appear in many settings—psychiatric, neurologic, or general medical. It can also occur in autism and other developmental conditions, among older adults, and in people with medical or neurological illness.
Recognizing catatonia early allows for effective treatment and helps prevent serious medical complications.
Accurate diagnosis involves a systematic and collaborative assessment by a healthcare professional familiar with how to evaluate catatonia.
Because symptoms can fluctuate, overlap with other conditions, and appear differently across settings, collaboration among clinicians, families, and caregivers is essential.
Families often provide the most complete understanding of a person’s usual functioning (baseline) and describe changes over time. These observations are often the key to recognizing catatonia and understanding the context in which it developed.
Recognizing the Signs
Catatonia should be considered as a possible diagnosis when a person exhibits substantially altered levels of motor activity (either subdued or excessive), abnormal speech, and/or abnormal behavior, especially when it is greatly inappropriate to context and/or comes on suddenly.
The signs of catatonia generally fall into four categories — motor or movement, speech and communication, behavior and interaction, and affective and automatic.
It’s important to note that catatonia is not static. The different signs may wax and wane, they may appear to be volitional, and they may be very confusing. These signs are often noticed first by families or caregivers as different from their loved one’s typical baseline.
Motor Signs include:
Immobility or stupor, rigidity, waxy flexibility (limb stays in place when moved), posturing, negativism (resisting without reason), repetitive or purposeless movements (rocking, pacing, tapping), or agitation that isn’t purposeful.
Speech and Communication Signs include:
Not speaking (mutism), whispering, echoing others’ words (echolalia), repeating the same phrases (verbigeration), or looping over the same ideas or worries (perseveration). These can sound like rumination or obsessive thinking, but they often reflect a disruption in how speech and movement are connected.
Behavior and Interaction Signs include:
Withdrawal from others, not eating or drinking, exaggerated gestures (mannerisms), imitating others’ movements (echopraxia), sudden impulsive actions, or exaggerated cooperation (automatic obedience).
Affective and Autonomic Signs include:
Flat or blunted emotion, sudden emotional shifts, or physical signs such as fever, fast heartbeat, or changes in blood pressure.
Why Diagnosis Can Be Challenging
Catatonia is often misunderstood or missed—even in medical and psychiatric settings.
Common reasons include:
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Limited awareness or training among healthcare professionals about catatonia and how to recognize it
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First contact is with internists, emergency room physicians, intensivists, ICU physicians, psychologists, and social workers, who may not be familiar with the signs of catatonia
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Overlap with other conditions, such as depression, psychosis, or movement disorders
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Time-limited evaluations, which make it hard to see the full range of symptoms
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Symptoms that wax and wane, making catatonia appear inconsistent, volitional, or behavioral
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Families’ shared observations of changes from baseline—often the first sign that something is wrong—are too often dismissed or minimized
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Families are unaware of what’s relevant to report, especially as they are experiencing a crisis
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Family members, experiencing overwhelm themselves, may have difficulty communicating what they are observing
The Catatonia Foundation is working diligently to address these challenges through awareness and education of healthcare professionals and families/caregivers, providing advocacy resources, and facilitating collaboration among clinicians, researchers, and families/caregivers. Together, we can change the course of catatonia care so patients do not have to needlessly suffer while seeking an appropriate diagnosis.
Structured Assessment Tools
Because catatonia presents with so many different signs and varies from person to person, using a vetted assessment can greatly improve recognition and diagnosis so that patients can receive proper and timely treatment.
It’s important to note that catatonia presents in a variety of ways - stuporous (akinetic), excited (hyperkinetic), mixed (both stuporous and excited), periodic (recurring in cycles), and malignant (life threatening). It’s also important to recognize that catatonia occurs across a wide range of populations and circumstances—including children and adolescents, individuals with autism or other neurodevelopmental disorders, and older adults or those with complex medical illness. For an in-depth description of these presentations, click here.
While many rating scales were developed, two are most commonly used — the Bush-Francis Catatonia Rating Scale and the Northoff Catatonia Rating Scale. Two recent international resource guidelines on catatonia recommend these two scales in general and recommend the BFCRS as the preferred structured measure for clinical assessment and monitoring.
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Bush–Francis Catatonia Rating Scale (BFCRS)
The BFCRS — a 23-sign tool used for identifying and tracking catatonia in medical, neurological, and psychiatric settings.
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The first 14 signs are investigated: if two or more signs are present, this is considered a positive screen for catatonia.
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Following a positive screen, the 23-item full scale is investigated to measure the severity of the signs and how they change over time with treatment.
Overlap with other conditions should not rule out a diagnosis of catatonia, and it’s important to take into account that the patient’s distress may be attributable to catatonia in these circumstances. For example, a person with catatonia can appear psychotic or delusional (disconnected from reality or distorted beliefs), experience regression of cognitive or developmental abilities, stuck in looped thinking of doom and gloom, or have self-injurious or sudden, unprovoked aggression (even in an individual on the autism spectrum).
For the full list of specific signs (and descriptions) listed on the BFCRS in the order they are presented, click here.
For a copy of the BFCRS and resources on how to use the scale, click here.
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Northoff Catatonia Rating Scale (NCRS)
The NCRS is a detailed 40-item scale often used in research or neurological settings. It groups symptoms into motor, behavioral, and affective categories and highlights emotional features such as fear, anxiety, and emotional blunting.
Unlike BFCRS, the NCRS requires that at least one feature be present in each of its three domains (motor, affective, and behavioral).
Formal Diagnostic Criteria (DSM-5-TR)
A formal diagnosis is made when specific diagnostic criteria set forth in the DSM-5-TR are met—three or more characteristic symptoms are present, such as stupor, mutism, posturing, negativism, echolalia, or echopraxia. This framework defines the minimum threshold for recognizing catatonia as a clinical syndrome and allows it to be coded in medical and psychiatric records.
For the full list of specific symptoms (and descriptions) listed on the DSM-5-TR in the order they are presented, click here.
The DSM-5-TR provides three ways catatonia can be coded: catatonia associated with another mental disorder, catatonic disorder due to another medical condition, and unspecified catatonia.
How Clinicians Evaluate Catatonia
A careful evaluation helps confirm whether catatonia is present and what might be contributing.
History: Reviewing medical, neurological, and psychiatric background; trauma and recent illness; medications; substance use; and changes from baseline.
Collateral Information: Families and caregivers provide crucial insight beyond what can be observed in a brief clinical encounter. Their observations about changes from the person’s usual behavior, movement, communication, and responsiveness often clarify patterns, identify fluctuations, and highlight early warning signs that might otherwise be missed.
Structured Screening: Clinicians may use standardized tools such as the BFCRS or the NCRS to document and rate catatonic signs in a consistent way.
Clinical Examination: Drawing on items from these scales, clinicians directly test and observe for signs listed on one of the structured screening scales and assess for autonomic instability (e.g., fluctuations in heart rate, blood pressure, or temperature). These assessments help distinguish catatonia from other neurological or psychiatric conditions.
Click here for the full BFCRS list of signs
Medical and Neurological Workup: Exploring possible causes, including metabolic, infectious, or autoimmune conditions such as anti-NMDA receptor encephalitis. Typical investigations may include laboratory studies (e.g., metabolic panels, thyroid function, autoimmune and infectious markers), neuroimaging (CT or MRI), and electroencephalography (EEG). The extent of testing depends on clinical context and is guided by the patient’s presentation.
Lorazepam Challenge: The lorazepam challenge test is often used to help confirm catatonia. It involves giving a small, carefully monitored dose of lorazepam and watching for improvement in symptoms over a short period of time—often within minutes to hours. The test is simple, low-cost, and generally safe, and a positive response (rapid reduction in catatonic signs) provides strong support for the diagnosis. However, a negative or partial response does not rule out catatonia, as clinical judgment and context remain essential in interpreting the results.
Together, these approaches provide a structured yet individualized framework for recognizing catatonia and identifying any underlying causes.
Dr. Max Fink explains the Bush-Francis Catatonia Rating Scale and the Lorazepam Challenge.
Timely Recognition and Its Importance
Timely identification of catatonia is crucial—not only for successful treatment, but also for preventing serious medical complications that can arise when the condition goes unrecognized.
Why Timely Identification Matters
Early recognition of catatonia can make a profound difference in outcome.
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High treatability: When catatonia is identified, treatments such as lorazepam and electroconvulsive therapy (ECT) are often highly effective.
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Avoid worsening: Antipsychotic medications can sometimes cause or aggravate catatonia; if needed, atypical antipsychotics are used with caution.
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Reduce complications: Prompt treatment lowers the risk of malnutrition, dehydration, self-injury, aggression, and autonomic instability.
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Prevent mortality: Malignant catatonia is a medical emergency—delayed treatment can be life-threatening.
“Any physician who recognizes catatonia has an effective treatment in his hands. Catatonia is a treatable syndrome.”
— Max Fink, M.D.
Complications That Can Occur When Catatonia Is Unrecognized
If catatonia goes unrecognized, serious medical complications can develop due to immobility, reduced intake, or physiological stress, including:
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Aspiration and pneumonia
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Dehydration
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Malnutrition or severe weight loss
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Muscle contractures or pressure ulcers
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Vitamin or electrolyte imbalance
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Urinary tract infections
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Blood clots (deep vein thrombosis or pulmonary embolism)
Recognizing catatonia promptly and supporting hydration, nutrition, and mobility can help reduce these risks and improve recovery outcomes.
Working Together for Accurate Recognition
Because catatonia can shift quickly and mimic other conditions, accurate recognition depends on collaboration among healthcare professionals, patients, families, and caregivers.
Families’ observations—such as repeating phrases, staying still for long periods, or unexplained negativism—often provide the clues that lead to diagnosis and recovery.
Read lived experiences of catatonia on our Patient Stories page.
Disclaimer
The information on this page is provided for educational purposes only. It does not constitute medical advice or replace professional evaluation, diagnosis, or treatment.
Anyone showing possible signs of catatonia is encouraged to seek prompt assessment by a qualified healthcare provider.