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psych.catatonia.core.v1PRODUCTION
psych.catatonia.core.v1

Catatonia — transdiagnostic syndrome; lorazepam challenge + titration → ECT for refractory / malignant (DSM-5-TR 2022; Bush 1996 PMID 8729911; Sienaert 2014 PMID 24523668)

psychiatryacutesubacuteadultgeriatricpregnancy
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm DSM-5-TR 2022 catatonia criteria — ≥ 3 of 12 features; identify whether catatonia is associated with another mental disorder (bipolar / MDD / schizophrenia spectrum) OR due to another medical condition (autoimmune encephalitis / CNS infection / metabolic / endocrine / structural / drug-withdrawal) OR unspecified (DSM-5-TR 2022)

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Advance rule
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Catatonia diagnosis confirmed (DSM-5-TR ≥ 3/12) AND working hypothesis on underlying cause documented (Sienaert 2014)

Patient inputs (23)

Geriatric patients require lower lorazepam dose; FDA black-box AP mortality in elderly with dementia compounds the AP-avoidance rule (Sienaert 2014; APA 2024)

Anti-NMDAR encephalitis incidence higher in young females (ovarian teratoma 58% adult female cases); ECT is safe in pregnancy across all trimesters (Dalmau 2011 PMID 21163445; Anderson + Reti 2009)

Bipolar / MDD / schizophrenia spectrum / FEP — most common catatonia causes in adult psychiatric inpatient (~ 25-50% mood; 10-25% psychotic; Rosebush + Mazurek 1990); routes underlying-cause treatment (Sienaert 2014)

Anti-NMDAR / autoimmune encephalitis, CNS infection, metabolic (hyponatraemia, hyperammonaemia, uraemia, DKA), endocrine (thyroid storm, myxoedema), stroke, intracranial hypertension, NCSE — must rule out before assuming primary psychiatric (Sienaert 2014; Walther + Strik 2016)

Recent antipsychotic exposure → NMS overlap risk; recent clozapine discontinuation → clozapine-withdrawal catatonia; baclofen / GABAergic withdrawal; serotonergic load → SS differential (APA 2024; Sienaert 2014; Lally + Tully 2018)

DSM-5-TR 2022 diagnostic threshold — ≥ 3 of 12 features required for the catatonia specifier

Baseline CBC; infection screen; clozapine REMS ANC if applicable (APA 2024)

Electrolyte derangement (hyponatraemia, hypercalcaemia, uraemia) can present with catatonic features (Sienaert 2014; Walther + Strik 2016)

Hepatic encephalopathy + hyperammonaemia can present with catatonic features (Sienaert 2014)

Thyroid storm + severe myxoedema can present with catatonic features (Sienaert 2014)

DKA / severe hypoglycaemia can present with catatonic features (Sienaert 2014; cross-ref endo.dka.core.v1)

CK elevation in malignant catatonia + NMS overlap; baseline + serial monitoring (Caroff 2007; APA 2024)

Urine drug screen mandatory — substance intoxication / withdrawal can drive catatonia-like presentations (Sienaert 2014; DSM-5-TR 2022)

MRI brain to exclude structural / autoimmune / demyelinating cause; recommended for unexplained catatonia (Sienaert 2014; Walther + Strik 2016)

EEG to exclude NCSE + autoimmune encephalitis (extreme delta brush in anti-NMDAR encephalitis ~ 30% sensitivity, very high specificity); seizures can mimic / coexist with catatonia (Sienaert 2014; Schmitt 2012)

ECG baseline — QTc assessment before ECT or any AP exposure; QT-prolonging effects of psychotropics (APA 2024)

Tachycardia / labile BP / diaphoresis / hyperthermia signal malignant catatonia OR NMS overlap — life-threatening (Mann + Caroff 1986; Sienaert 2014)

Hyperthermia > 38.5 °C with rigidity + AMS → malignant catatonia / NMS overlap → ICU (Sienaert 2014; Caroff 2007)

Autonomic instability assessment (Sienaert 2014)

C-SSRS — mutism / negativism may mask intent; bipolar / MDD-driven catatonia carries elevated suicide risk (Palmer Arch Gen Psychiatry 2005 PMID 16172208; APA 2024)

Bush-Francis Catatonia Rating Scale 23-item severity instrument; BFCSI first 14 items used for screening; ≥ 2 BFCSI items diagnostic (LR+ ≈ 8 per Bush 1996 PMID 8729911)

Anti-NMDAR receptor antibodies (CSF preferred) when young female + subacute behavioural change + dyskinesia + autonomic instability + seizures + cognitive decline (Dalmau 2011 PMID 21163445; Graus 2016 criteria; Pollak 2020 PMID 32078818)

CRP / PCT — infection screen (sepsis with delirium can overlap clinically with catatonia)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningmalignant_catatonia
    Catatonia + hyperthermia > 38.5 °C + autonomic instability + rigidity + AMS — life-threatening; ddx NMS (especially if recent AP exposure); mortality high without prompt ICU + ECT (Mann + Caroff 1986; Sienaert 2014; Caroff 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnms_overlap_with_catatonia
    Catatonic features + NMS clinical features (recent AP exposure + hyperthermia + lead-pipe rigidity + AMS + autonomic instability + CK elevation per Levenson criteria) — life-threatening; routes to AP-driven sibling dossiers (APA 2024; Caroff 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninganti_nmdar_encephalitis_with_catatonia
    Catatonic features + young patient (especially female) + subacute behavioural change + ≥ 1 of seizures / orofacial dyskinesia / autonomic instability / decreased consciousness / cognitive decline + supporting features (CSF lymphocytic pleocytosis OR EEG abnormality including extreme delta brush OR MRI T2/FLAIR abnormality) — life-threatening organic mimic (Dalmau 2011 PMID 21163445; Graus 2016 criteria; Pollak 2020 PMID 32078818; Titulaer 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatatonia_at_diagnosis_lorazepam_challenge
    Confirmed catatonia (DSM-5-TR ≥ 3/12 features OR BFCSI ≥ 2 items per Bush 1996 PMID 8729911) — 2 mg IV / IM lorazepam challenge diagnostic + therapeutic; ~ 80% respond within 30-60 min (Sienaert 2014 PMID 24523668; Bush 1996)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_to_benzo_at_24_72h
    No response to lorazepam at adequate dose (8-24 mg/day) × 24-72 h — refractory catatonia; ECT 2nd line; DO NOT add antipsychotic (Sienaert 2014 PMID 24523668; Petrides + Fink 1996)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatatonia_in_pregnancy
    Catatonia in pregnancy at any trimester — severe; ECT is safe across all trimesters (Anderson + Reti 2009); lorazepam acceptable but consider neonatal withdrawal risk near delivery; the alternative (untreated severe catatonia) carries fetal + maternal morbidity higher than treated ECT (Sienaert 2014; Anderson + Reti 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereavoid_antipsychotics_in_catatonia
    Active catatonia — antipsychotics worsen catatonia + increase NMS risk; the single most important anti-pattern in catatonia management (Sienaert 2014 PMID 24523668; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereclozapine_withdrawal_catatonia
    Catatonic features within days-weeks of abrupt clozapine discontinuation in clozapine-responsive schizophrenia patient — restart clozapine + lorazepam first; ECT if refractory; do NOT switch to alternative AP (Lally + Tully 2018; Sienaert 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecatatonia_in_dementia_or_geriatric
    Catatonia in patient with dementia or age > 65 — moderate severity; heightened concern for organic / reversible cause; lower lorazepam initial dose (1 mg IV); ECT acceptable for severe; FDA black-box AP mortality in elderly with dementia compounds AP-avoidance rule (Sienaert 2014; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildunderlying_medical_workup_complete
    Catatonia presentation — full medical workup (metabolic + infectious + neuroimaging + EEG + autoimmune) must be complete before assuming primary psychiatric cause; mild severity gate to prevent diagnostic shortcuts (Sienaert 2014; Walther + Strik 2016; DSM-5-TR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Catatonia lorazepam ladder — challenge → titration → ECT for refractory + malignant rescue (Sienaert 2014 PMID 24523668; Bush 1996 PMID 8729911; APA 2024)
axis: catatonia_lorazepam_ladderstep 1 - Step 1 — Lorazepam challenge 2 mg IV / IM diagnostic + therapeutic (~ 80% respond) (Bush 1996 PMID 8729911; Sienaert 2014 PMID 24523668)
Selected step "Step 1 — Lorazepam challenge 2 mg IV / IM diagnostic + therapeutic (~ 80% respond) (Bush 1996 PMID 8729911; Sienaert 2014 PMID 24523668)" — Catatonia confirmed (DSM-5-TR ≥ 3/12 OR BFCSI ≥ 2 items); no contraindication to benzodiazepine (severe respiratory failure without airway support, severe hepatic failure relative caution) (Sienaert 2014)
  • lorazepam
    first line
    benzodiazepine
    2 mg IV / IM challenge (1 mg in geriatric / dementia / debilitated) • IV / IM • single challenge; re-rate BFCRS at 5-10 min (IV) or 15-30 min (IM) (max: 2 mg single challenge dose (geriatric: 1 mg))
    triggers: catatonia_at_diagnosis, bfcsi_positive, dsm_5_tr_catatonia_features_3_or_more
    Bush 1996 PMID 8729911 / Sienaert 2014 PMID 24523668 — lorazepam challenge is BOTH diagnostic AND therapeutic; positive response (≥ 50% BFCRS reduction) confirms catatonia and opens the titration ladder; ~ 80% response rate within 30-60 min
    rxcui 6470

outpatient playbook — drug actions (4)

  1. 1. continue lorazepam at effective dose for 4-12 weeks post-remission, then taper slowly per response
    Per inpatient maintenance dose; taper by 1-2 mg/week as tolerated • PO • BID-TID then taper
    trigger: Outpatient continuation post-stabilisation (Sienaert 2014)
    Sienaert 2014 — premature taper risks catatonia relapse; many patients require months of lorazepam maintenance
  2. 2. underlying-disorder treatment optimisation (sibling routing)
    Lithium / valproate for bipolar maintenance (APA bipolar 2024 / BALANCE); SSRI / SNRI for MDD maintenance (APA 2023); low-dose AP for schizophrenia-spectrum AFTER catatonia resolved (APA 2024) • PO • daily
    trigger: Underlying disorder identified (APA 2024)
    APA 2024 — long-term underlying-disorder treatment is foundational to relapse prevention; AP re-introduction in schizophrenia-spectrum cases requires close NMS / EPS / re-catatonia monitoring
  3. 3. maintenance ECT q 2-6 weeks if recurrent catatonia despite optimisation
    NA — procedure • NA • q 2-6 weeks
    trigger: Recurrent catatonia within 12 months despite optimised underlying-disorder treatment (Sienaert 2014; Petrides + Fink 1996)
    Sienaert 2014 / Petrides + Fink 1996 — maintenance ECT prevents recurrence in patients with refractory mood / psychotic disorder driving catatonia
  4. 4. continue clozapine for clozapine-withdrawal-catatonia recovery cases; do NOT switch APs during catatonia history
    Per prior therapeutic dose; trough 350-600 ng/mL • PO • BID-TID
    trigger: Clozapine-withdrawal-catatonia history (Lally + Tully 2018)
    Lally + Tully 2018 — clozapine is the only AP shown to resolve clozapine-withdrawal catatonia; continued indefinitely with REMS ANC monitoring

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: DSM-5-TR ≥ 3 of 12 catatonia features (stupor / catalepsy / waxy flexibility / mutism / negativism / posturing / mannerism / stereotypy / agitation / grimacing / echolalia / echopraxia) (DSM-5-TR 2022); Bush-Francis Catatonia Screening Instrument (BFCSI) ≥ 2 items positive — LR+ ≈ 8 for catatonia (Bush et al Acta Psychiatr Scand 1996 PMID 8729911); New-onset stupor / mutism / immobility unexplained by sedation, intoxication, or primary neurologic deficit (Sienaert 2014 PMID 24523668).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Catatonia — transdiagnostic syndrome; lorazepam challenge + titration → ECT for refractory / malignant (DSM-5-TR 2022; Bush 1996 PMID 8729911; Sienaert 2014 PMID 24523668)** (psych.catatonia.core.v1).
Phenotype framing: Catatonia due to mood disorder (bipolar manic / depressed / MDD with catatonic features) vs psychotic disorder (schizophrenia / FEP / schizoaffective) vs medical (autoimmune encephalitis / CNS infection / metabolic / endocrine / stroke / NCSE) vs drug-withdrawal (clozapine / baclofen / GABAergic) vs drug-induced (AP-induced akinetic mutism, serotonergic load) vs malignant catatonia vs NMS overlap (DSM-5-TR 2022; Sienaert 2014; Walther + Strik 2016)
Scope: Confirm DSM-5-TR 2022 catatonia criteria — ≥ 3 of 12 features; identify whether catatonia is associated with another mental disorder (bipolar / MDD / schizophrenia spectrum) OR due to another medical condition (autoimmune encephalitis / CNS infection / metabolic / endocrine / structural / drug-withdrawal) OR unspecified (DSM-5-TR 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Catatonia lorazepam ladder — challenge → titration → ECT for refractory + malignant rescue (Sienaert 2014 PMID 24523668; Bush 1996 PMID 8729911; APA 2024)** — step "Step 1 — Lorazepam challenge 2 mg IV / IM diagnostic + therapeutic (~ 80% respond) (Bush 1996 PMID 8729911; Sienaert 2014 PMID 24523668)".
1. lorazepam 2 mg IV / IM challenge (1 mg in geriatric / dementia / debilitated) IV / IM single challenge; re-rate BFCRS at 5-10 min (IV) or 15-30 min (IM) (benzodiazepine, first line) — Bush 1996 PMID 8729911 / Sienaert 2014 PMID 24523668 — lorazepam challenge is BOTH diagnostic AND therapeutic; positive response (≥ 50% BFCRS reduction) confirms catatonia and opens the titration ladder; ~ 80% response rate within 30-60 min

Setting playbook (outpatient) — Sustained underlying-disorder treatment (mood / psychotic / medical) + relapse prevention + lorazepam taper per response + maintenance ECT if recurrent + psychoeducation (Sienaert 2014; APA 2024)
2. continue lorazepam at effective dose for 4-12 weeks post-remission, then taper slowly per response Per inpatient maintenance dose; taper by 1-2 mg/week as tolerated PO BID-TID then taper — Outpatient continuation post-stabilisation (Sienaert 2014) (Sienaert 2014 — premature taper risks catatonia relapse; many patients require months of lorazepam maintenance)
3. underlying-disorder treatment optimisation (sibling routing) Lithium / valproate for bipolar maintenance (APA bipolar 2024 / BALANCE); SSRI / SNRI for MDD maintenance (APA 2023); low-dose AP for schizophrenia-spectrum AFTER catatonia resolved (APA 2024) PO daily — Underlying disorder identified (APA 2024) (APA 2024 — long-term underlying-disorder treatment is foundational to relapse prevention; AP re-introduction in schizophrenia-spectrum cases requires close NMS / EPS / re-catatonia monitoring)
4. maintenance ECT q 2-6 weeks if recurrent catatonia despite optimisation NA — procedure NA q 2-6 weeks — Recurrent catatonia within 12 months despite optimised underlying-disorder treatment (Sienaert 2014; Petrides + Fink 1996) (Sienaert 2014 / Petrides + Fink 1996 — maintenance ECT prevents recurrence in patients with refractory mood / psychotic disorder driving catatonia)
5. continue clozapine for clozapine-withdrawal-catatonia recovery cases; do NOT switch APs during catatonia history Per prior therapeutic dose; trough 350-600 ng/mL PO BID-TID — Clozapine-withdrawal-catatonia history (Lally + Tully 2018) (Lally + Tully 2018 — clozapine is the only AP shown to resolve clozapine-withdrawal catatonia; continued indefinitely with REMS ANC monitoring)

Non-pharmacologic actions:
- CBT for underlying disorder (APA 2024; NICE 2024)
- Family psychoeducation on catatonia recognition + relapse prevention + medication adherence (APA 2024; Sienaert 2014)
- Psychoeducation on catatonia early warning signs (mutism episodes, immobility, posturing) — return to ED if any (Sienaert 2014; APA 2024)
- Substance use treatment if active SUD (APA 2024; NICE 2024)
- Sleep hygiene + circadian rhythm stabilisation (Frank Int J Bipolar Disord 2015)
- Lifestyle counselling: exercise, diet, alcohol avoidance, social rhythm (APA 2024)
- Case management / care coordination (APA 2024)

AVOID / contraindication checks:
- AVOID_antipsychotics_in_active_catatonia (Sienaert 2014; APA 2024) — APs worsen catatonia + increase NMS risk; the single most important anti pattern; resume AT LOW DOSE only AFTER catatonia resolved in schizophrenia spectrum driven cases with close NMS monitoring
- Lorazepam_respiratory_depression_in_elderly_or_debilitated_patients_requires_close_monitoring (Sienaert 2014)
- Dantrolene_hepatotoxicity_monitor_LFT (DailyMed)
- Bromocriptine_psychiatric_worsening_can_occur_in_psychotic_underlying_disorder_monitor (APA 2024)
- ECT_in_pregnancy_safe_across_trimesters_obs_anaesthesia_co_management_required (Anderson + Reti 2009)
- Do_not_discontinue_clozapine_in_clozapine_withdrawal_catatonia_restart_clozapine (Lally + Tully 2018)
- NMS_discontinue_all_antipsychotics_immediately_supportive_bromocriptine_dantrolene_ECT (APA 2024; Caroff 2007)
- Do_not_assume_primary_psychiatric_until_organic_workup_complete_metabolic_infectious_neuroimaging_EEG_autoimmune (Sienaert 2014; Walther + Strik 2016)

Monitoring

Regimen monitoring:
- BFCRS daily during acute phase (Bush 1996 PMID 8729911)
- Vital signs q 2 4h during lorazepam titration (Sienaert 2014)
- Temperature q 4 6h until malignant features excluded (Mann + Caroff 1986)
- CK q 12 24h until malignant catatonia NMS excluded (Caroff 2007)
- Respiratory rate SpO2 continuous while titrating lorazepam (Sienaert 2014)
- Nutritional intake daily NG feeding if mutism prevents oral intake (Sienaert 2014)
- DVT prophylaxis in immobile patient (Sienaert 2014)
- ECG QTc before ECT and before any AP re introduction (APA 2024)
- C-SSRS at every clinical encounter once mutism resolves (Palmer Arch Gen Psychiatry 2005)
- Clozapine ANC per REMS if clozapine restarted (APA 2024; clozapine REMS)
- Anti NMDAR antibody follow up if initial positive (Dalmau 2011; Titulaer 2013)
- Maintenance ECT q 2 6 weeks if recurrent catatonia despite underlying disorder optimisation (Sienaert 2014)

Setting (outpatient) monitoring:
- BFCRS at each visit during taper, then q 3 months in maintenance (Bush 1996)
- C-SSRS at every visit (Palmer 2005)
- Underlying-disorder severity (YMRS / PHQ-9 / PANSS) at each visit (APA 2024)
- Medication adherence + level monitoring (lithium / valproate / clozapine ANC) (APA 2024)
- Metabolic panel if on AP-restart (APA/ADA 2004; APA 2024)
- AIMS q 6 months if on AP (APA 2024)
- Maintenance ECT effectiveness assessment q 3 months if applicable (Sienaert 2014)
- Anti-NMDAR antibody titres q 3-6 months if positive history (Titulaer 2013)

Follow-up plan: Continue lorazepam at effective dose for 4-12 weeks post-remission then taper slowly per response (Sienaert 2014); treat underlying disorder long-term (lithium / valproate for bipolar maintenance; antipsychotic at low dose AFTER catatonia resolved if schizophrenia spectrum — with close NMS monitoring; SSRI / antidepressant for MDD); maintenance ECT q 2-6 weeks if recurrent catatonia despite optimisation; relapse prevention (medication adherence, substance avoidance, stress management) (Sienaert 2014; APA 2024)
- Close-out criterion: Maintenance plan in place with underlying-disorder treatment + relapse prevention (Sienaert 2014)

Monitoring phase: BFCRS daily during acute phase to track response (Bush 1996); vital signs q 2-4 h while titrating lorazepam (sedation / respiratory depression risk); temperature + CK q 12-24 h while malignant features possible; nutritional intake daily; DVT prophylaxis in immobile patient; QTc before / during AP-free management (Sienaert 2014; APA 2024)

Disposition

Current setting: outpatient — Sustained underlying-disorder treatment (mood / psychotic / medical) + relapse prevention + lorazepam taper per response + maintenance ECT if recurrent + psychoeducation (Sienaert 2014; APA 2024)

Disposition criteria:
- Continue outpatient psychiatry indefinitely for underlying-disorder maintenance (APA 2024)
- Step to community mental health if stable + supported + underlying disorder controlled (APA 2024)
- Refer to neurology if anti-NMDAR encephalitis history (Dalmau 2011)
- Refer to clozapine clinic if on clozapine for ongoing ANC monitoring (APA 2024)
- Refer to ECT maintenance clinic if maintenance ECT ongoing (Sienaert 2014; Petrides + Fink 1996)

Escalation triggers (move to higher acuity):
- Recurrent catatonic features (mutism / immobility / posturing) → ED for lorazepam challenge + admission (Sienaert 2014)
- Active SI with intent / plan / means → ED + possible inpatient admission (APA 2024; Palmer 2005)
- Relapse of underlying disorder (mania / depression / psychosis) with catatonic features → ED + admission (APA 2024; Sienaert 2014)
- Anti-NMDAR antibody relapse (rising titre + behavioural change) → neurology + immunotherapy (Titulaer 2013)
- Clozapine ANC < 1000/uL → hold + urgent haematology consult (APA 2024; clozapine REMS)

Patient Action Plan

**Catatonia action plan — relapse prevention + early warning signs (Sienaert 2014; APA 2024)**
Personalised values: underlying_disorder_diagnosis, current_lorazepam_dose, maintenance_ECT_schedule_if_applicable, identified_supports, crisis_line_numbers, psychiatrist_contact, previous_catatonia_episode_features.

**Doing well — underlying disorder controlled, no catatonic features, medication adherent (Sienaert 2014; APA 2024)** (green):
Triggers:
- No mutism, immobility, or posturing episodes (Sienaert 2014)
- Sleeping and eating normally (APA 2024)
- Engaging with family + supports (APA 2024)
- Taking medications as prescribed (APA 2024)
- Not using substances (APA 2024)
- Attending appointments (APA 2024)
Actions:
- Take lorazepam + underlying-disorder medication every day as prescribed — do not stop without discussing with your psychiatrist (Sienaert 2014)
- Attend all psychiatry appointments (APA 2024)
- Maintain regular sleep schedule and daily routine (APA 2024)
- Avoid alcohol and substances — these can trigger relapse (APA 2024)
- Keep crisis line numbers accessible (APA 2024)
- Attend maintenance ECT sessions if scheduled (Sienaert 2014)

**Caution — early warning signs of catatonia or underlying disorder relapse (Sienaert 2014; APA 2024)** (yellow):
Triggers:
- Brief episodes of mutism or "freezing up" (Sienaert 2014)
- Slowing down of movements or speech (Sienaert 2014)
- Difficulty starting tasks or making decisions (Sienaert 2014)
- Holding unusual postures or making repetitive movements (Sienaert 2014)
- Mood symptoms returning (depression / mania features) (APA 2024)
- Missed medication doses in the past week (APA 2024)
- Using alcohol or substances again (APA 2024)
- Sleeping much more or much less than usual (APA 2024)
Actions:
- Contact your psychiatrist within 24-48 h — do not wait for your next scheduled appointment (Sienaert 2014)
- Resume medication if you have missed doses (APA 2024)
- Reach out to a support person or family member (APA 2024)
- Avoid all substances including alcohol (APA 2024)
- Increase structure — follow daily routine, attend appointments (APA 2024)
Contact provider when:
- Any warning sign persists > 2 days despite coping strategies (Sienaert 2014)
- Frequent or prolonged mutism episodes (Sienaert 2014)
- Family / friends notice you "freezing up" or holding unusual postures (Sienaert 2014)
- Thoughts of hurting yourself or others (Palmer 2005; APA 2024)
- Stopped taking medication for ≥ 3 days (APA 2024)

**Medical alert — frank catatonia, malignant features, active suicidality (Sienaert 2014; APA 2024)** (red):
Triggers:
- Unable to speak, move, or eat for hours (Sienaert 2014)
- Holding a fixed posture for hours that cannot be re-positioned by others (Sienaert 2014)
- Severe muscle stiffness with high fever — possible malignant catatonia (Mann + Caroff 1986)
- Heart racing or blood pressure swings + confusion + sweating + stiffness (Sienaert 2014; Caroff 2007)
- Thoughts or plans to end your life (Palmer 2005)
- Severe agitation, aggression, or self-harm (APA 2024)
Actions:
- Call 988 (US) / your local crisis line / emergency services NOW (APA 2024)
- Go to the nearest emergency department — do not be alone (Sienaert 2014)
- Tell someone you trust what is happening immediately (APA 2024)
- If fever + stiff muscles — go to ED immediately (possible malignant catatonia or NMS per APA 2024; Sienaert 2014)
- Do not take more medication than prescribed (APA 2024)
- Do not use any substances (APA 2024)
Contact provider when:
- Any red zone trigger — emergency department immediately (Sienaert 2014; APA 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Catatonia + hyperthermia > 38.5 °C + autonomic instability + rigidity + AMS — life-threatening; ddx NMS (especially if recent AP exposure); mortality high without prompt ICU + ECT (Mann + Caroff 1986; Sienaert 2014; Caroff 2007)
- [LIFE_THREATENING] Catatonic features + NMS clinical features (recent AP exposure + hyperthermia + lead-pipe rigidity + AMS + autonomic instability + CK elevation per Levenson criteria) — life-threatening; routes to AP-driven sibling dossiers (APA 2024; Caroff 2007)
- [LIFE_THREATENING] Catatonic features + young patient (especially female) + subacute behavioural change + ≥ 1 of seizures / orofacial dyskinesia / autonomic instability / decreased consciousness / cognitive decline + supporting features (CSF lymphocytic pleocytosis OR EEG abnormality including extreme delta brush OR MRI T2/FLAIR abnormality) — life-threatening organic mimic (Dalmau 2011 PMID 21163445; Graus 2016 criteria; Pollak 2020 PMID 32078818; Titulaer 2013)

Citations

- DSM-5-TR (2022) catatonia specifier + Bush-Francis 1996 PMID 8729911 (BFCRS canonical) + Fink + Taylor 2003 textbook + Sienaert 2014 PMID 24523668 (clinical review) + APA Practice (literature) [PMID:8729911](https://pubmed.ncbi.nlm.nih.gov/8729911/)
- Cited evidence (PMID 24523668) [PMID:24523668](https://pubmed.ncbi.nlm.nih.gov/24523668/)
- Cited evidence (PMID 21163445) [PMID:21163445](https://pubmed.ncbi.nlm.nih.gov/21163445/)
- Cited evidence (PMID 32078818) [PMID:32078818](https://pubmed.ncbi.nlm.nih.gov/32078818/)
- Cited evidence (PMID 16172208) [PMID:16172208](https://pubmed.ncbi.nlm.nih.gov/16172208/)

Last reconciled with current guidelines: 2026-05-15.
References
  • DSM-5-TR (2022) catatonia specifier + Bush-Francis 1996 PMID 8729911 (BFCRS canonical) + Fink + Taylor 2003 textbook + Sienaert 2014 PMID 24523668 (clinical review) + APA Practice (literature) — PMID:8729911
  • Cited evidence (PMID 24523668) — PMID:24523668
  • Cited evidence (PMID 21163445) — PMID:21163445
  • Cited evidence (PMID 32078818) — PMID:32078818
  • Cited evidence (PMID 16172208) — PMID:16172208