Ryan S. Sultan, MD

Creator: Ryan S. Sultan
Published: 2015-03-23

Catatonia in Children and Adolescents

Pediatric Neuropsychiatry Case Conference

→ Clinical Case Conference

Ryan S. Sultan, MD
Assistant Professor of Clinical Psychiatry
Columbia University Irving Medical Center / Weill Cornell Medicine

Originally Presented: March 2015 - Pediatric Neuropsych Case Conference

Case: Altered Mental Status in an Adolescent with Psychiatric History

Introduction: The Hidden Diagnosis in Pediatric Psychiatry

Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral, and affective abnormalities. Despite being relatively common in pediatric psychiatric populations (estimated 10-20% of acutely ill psychiatric inpatients), it remains underrecognized and undertreated in children and adolescents.

⚠ Clinical Pearl

Catatonia is hidden in plain sight among different pediatric disorders. It can present in the context of:

Psychotic disorders (schizophrenia)
Mood disorders (major depression, bipolar disorder)
Autism spectrum disorder
Medical conditions (autoimmune encephalitis, metabolic disorders)
Medication reactions (neuroleptic malignant syndrome)

Case Presentation: "Roza"

Chief Complaint & Presentation

Roza, an adolescent with a complex psychiatric history, presented to the hospital with altered mental status (AMS), posturing, and psychomotor abnormalities. She had a history of multiple psychiatric admissions and trials of various psychotropic medications, including antipsychotics.

Psychiatric Timeline

Baseline Functioning: Prior psychiatric history with mood symptoms, psychotic features, and behavioral dysregulation. Multiple medication trials including aripiprazole (Abilify) and others.

Recent Course:

Early 2012: Discontinued Abilify
Neurology gave trial of Prozac → Possible manic episode
Progressive decline in functioning
Development of motor abnormalities and behavioral regression

Neurological History & Examination

Key Neurological Findings:

Posturing - Abnormal, fixed positioning of limbs
Catalepsy - Waxy flexibility, limb positioning maintained
Mutism or reduced speech
Staring - Reduced eye contact, fixed gaze
Grimacing
Stereotypies - Repetitive, purposeless movements
Negativism - Opposition to instructions

Videos of Patient (3/10/15)

[Note: Clinical videos were presented during conference showing patient's motor abnormalities, posturing, mutism, and response to benzodiazepine challenge]

Differential Diagnosis of Altered Mental Status with Motor Abnormalities

Condition	Key Features	How to Differentiate
Delirium	Fluctuating consciousness, inattention, disorganized thinking, acute onset	Consciousness level fluctuates; less likely to have sustained posturing
Neuroleptic Malignant Syndrome (NMS)	Fever, rigidity, altered mental status, autonomic instability, recent neuroleptic exposure	High fever (>102°F), elevated CK, autonomic instability prominent
NMDA Receptor Encephalitis	Psychiatric symptoms, seizures, movement disorder, autonomic instability, often young women	CSF pleocytosis, NMDA receptor antibodies, brain MRI changes
Catatonia	Motor immobility, posturing, waxy flexibility, mutism, negativism, stereotypies	Response to benzodiazepine challenge; Busch-Francis Scale >2
Conversion/Factitious/Volitional	Inconsistent examination, "give way" weakness, non-anatomic findings	Does not respond to benzodiazepines; no objective signs; inconsistent over time

Busch-Francis Catatonia Rating Scale (BFCRS)

The Busch-Francis Catatonia Rating Scale is the gold-standard assessment tool for diagnosing and quantifying catatonia severity. A score of 2 or more indicates clinically significant catatonia.

The 23 Items of the Busch-Francis Scale:

Item	Description	Score (0-3)
1. Excitement	Extreme hyperactivity, constant motor unrest	0-3
2. Immobility/Stupor	Extreme hypoactivity, immobile, minimal response	0-3
3. Mutism	No or minimal verbal response	0-3
4. Staring	Fixed gaze, decreased blinking	0-3
5. Posturing	Spontaneous, active maintenance of posture against gravity	0-3
6. Grimacing	Odd facial expressions	0-3
7. Echopraxia/Echolalia	Mimicking examiner's movements or speech	0-3
8. Stereotypy	Repetitive, purposeless movements	0-3
9. Mannerisms	Odd, purposeful movements	0-3
10. Verbigeration	Repetition of phrases or sentences	0-3
11. Rigidity	Resistance to passive movement	0-3
12. Negativism	Opposition to instructions or external stimuli	0-3
13. Waxy Flexibility	Slight resistance during repositioning, maintains position	0-3
14. Withdrawal	Refusal to eat, drink, or make eye contact	0-3
15. Impulsivity	Sudden, purposeless actions	0-3
16. Automatic Obedience	Exaggerated cooperation with examiner's requests	0-3
17. Mitgehen	Limb raised with light pressure despite instructions to resist	0-3
18. Gegenhalten	Resistance to passive movement proportional to force	0-3
19. Ambitendency	Appears stuck in indecisive movement	0-3
20. Grasp Reflex	Involuntary grasping when palm stimulated	0-3
21. Perseveration	Repetition of same response	0-3
22. Combativeness	Unprovoked aggression toward others	0-3
23. Autonomic Abnormality	Temperature, BP, pulse, or respiration dysregulation	0-3

Scoring: 0 = Absent, 1 = Mild, 2 = Moderate, 3 = Severe

Roza's Busch-Francis Score

Based on clinical presentation, Roza demonstrated multiple catatonic features including:

Posturing (score: 2-3)
Mutism (score: 2-3)
Staring (score: 2)
Grimacing (score: 2)
Stereotypies (score: 2)
Negativism (score: 2)
Rigidity (score: 2)

Total BFCRS Score: >14 - indicating severe catatonia

Catatonia in Children and Autism Spectrum Disorder

Catatonia has a special relationship with autism spectrum disorder (ASD). Wing & Shah (2000) described catatonia-like features in individuals with ASD:

Catatonic Features in ASD:

Increased passivity and lack of motivation
Reversal of circadian rhythms - Sleep-wake cycle disruption
Parkinsonian features - Slowness, rigidity, reduced facial expression
Excitement and agitation - Sudden behavioral escalation
Increased repetitive and ritualistic behavior - Beyond baseline autism symptoms

Clinical Consideration: Individuals with intellectual disability (ID) or autism may have high incidence of extrapyramidal symptoms (EPS) with antipsychotics. Is the rigidity from medication, catatonia, or both?

Medical Consequences of Catatonia

⚠ Life-Threatening Complications

Catatonia is not just a psychiatric curiosity—it can be medically dangerous and even fatal if untreated.

Serious Medical Complications:

Complication	Mechanism	Clinical Signs
Dehydration	Refusal to drink (withdrawal), immobility	Elevated BUN/Cr, dry mucous membranes, tachycardia
Malnutrition	Refusal to eat, inability to feed self	Weight loss, hypoalbuminemia, vitamin deficiencies
Aspiration Pneumonia	Immobility, dysphagia, inability to clear secretions	Fever, infiltrate on chest X-ray, hypoxia
Deep Vein Thrombosis (DVT)	Prolonged immobility, venous stasis	Leg swelling, pain, elevated D-dimer
Pulmonary Embolism (PE)	DVT embolizes to lungs	Sudden dyspnea, chest pain, hypoxia, tachycardia
Pressure Ulcers	Prolonged immobility, fixed posturing	Skin breakdown over bony prominences
Rhabdomyolysis	Prolonged muscle contraction, posturing	Elevated CK, myoglobin, dark urine, renal failure
Contractures	Prolonged fixed positioning	Loss of range of motion, joint stiffness
Autonomic Instability	Dysregulation of autonomic nervous system	Fever, tachycardia, labile BP, diaphoresis
Death	Malignant catatonia with autonomic storm	Hyperthermia, cardiovascular collapse

Mortality Rate: Historically, untreated malignant catatonia had mortality rates of 10-20%. With modern treatment (benzodiazepines, ECT), mortality has decreased significantly but remains a medical emergency.

Treatment of Catatonia in Children and Adolescents

1. Benzodiazepine Challenge/Treatment

Lorazepam (Ativan) is the gold-standard first-line treatment for catatonia.

Benzodiazepine Challenge Test:

Give 1-2 mg lorazepam IV or IM
Assess for improvement in catatonic symptoms within 10-15 minutes
Positive response confirms catatonia diagnosis
70-80% of catatonia patients respond to lorazepam

Ongoing Treatment Protocol:

Start lorazepam 1-2 mg PO/IV TID
Can increase up to 24 mg/day (in divided doses)
Continue until catatonic symptoms resolve
Taper gradually after stabilization (weeks to months)

2. Electroconvulsive Therapy (ECT)

ECT is the most effective treatment for catatonia, with response rates of 80-100%.

Indications for ECT in Pediatric Catatonia:

Lorazepam non-response - Failed adequate trial (>24 mg/day × 3-5 days)
Malignant catatonia - Autonomic instability, hyperthermia, life-threatening
Severe malnutrition/dehydration - Cannot wait for slower medication response
Life-threatening complications - PE, severe rhabdomyolysis

ECT Protocol for Catatonia:

Bilateral electrode placement (more effective for catatonia than unilateral)
3 sessions per week
Usually requires 6-12 treatments
Often see dramatic improvement after 1-3 treatments
ECT is safe in adolescents and even younger children when indicated

3. Role of Antipsychotics

Controversy: Should antipsychotics be used in catatonia?

Arguments AGAINST antipsychotics in catatonia:

Risk of worsening catatonia
Risk of neuroleptic malignant syndrome (NMS)
Many cases of catatonia triggered or worsened by antipsychotics

When antipsychotics MAY be considered:

After catatonia resolved with benzodiazepines/ECT
If underlying psychotic disorder requires treatment
Clozapine - Appears safest antipsychotic in catatonia (least EPS risk)
Use cautiously, at low doses, with close monitoring

4. Treatment of Motor Symptoms

If parkinsonian symptoms or rigidity present:

Benztropine (Cogentin) - Anticholinergic for EPS
However, distinguish true EPS from catatonia features
Lorazepam/ECT will improve catatonic rigidity

Discussion Points from Case Conference

1. Is Roza's Presentation More Thought Disorder Than Mood Disorder?

Catatonia can occur in context of:

Schizophrenia spectrum disorders - Especially with prominent thought disorder
Mood disorders - Major depression (most common), bipolar disorder
Autism spectrum - Particularly in adolescence
Medical conditions - Encephalitis, metabolic, autoimmune

Roza's baseline included both psychotic features and mood symptoms. The presence of catatonia doesn't definitively answer the underlying diagnosis—it's a syndrome that can occur across multiple conditions.

2. Treatment Considerations for Roza

Options under discussion:

Continue/optimize lorazepam - Increase dose if partial response
Consider ECT - If lorazepam non-response or life-threatening complications
Higher dose antipsychotic? - RISKY - could worsen catatonia
Clozapine? - Safest antipsychotic option if psychosis requires treatment
Begin treatment of motor symptoms with Cogentin? - May help if EPS component

Conference Consensus: Optimize lorazepam first. If inadequate response, strongly consider ECT given severity and medical risks.

3. What Does the Family Need?

Education about catatonia - What it is, why it happened, prognosis
Understanding of treatment plan - Benzodiazepines, possible ECT
Long-term planning - Preventing recurrence, monitoring for prodromal signs
Psychosocial support - Catatonia is frightening for families
Coordination with schools/services - Extended absence, functional recovery

4. Thoughts on Current Motor Symptoms

Differential of motor symptoms:

Catatonia (primary)
Antipsychotic-induced EPS (iatrogenic)
Part of autism spectrum baseline (developmental)
Combination of above

Individuals with intellectual disability/autism have higher incidence of EPS with antipsychotics. The motor symptoms could represent:

Pure catatonia (will respond to lorazepam/ECT)
Catatonia + antipsychotic EPS (needs both treatment and medication adjustment)
Autism baseline + catatonia overlay

Key Takeaways for Clinicians

Consider catatonia in any patient with altered mental status + motor abnormalities
- Use Busch-Francis Catatonia Rating Scale (score ≥2)
- Perform benzodiazepine challenge test
Catatonia is hidden in plain sight in pediatric populations
- Can occur with psychosis, mood disorders, autism, medical conditions
- Especially common in autism spectrum + psychosis overlap
Differential diagnosis is critical
- NMS - fever, autonomic instability, recent neuroleptic
- NMDA encephalitis - CSF antibodies, seizures
- Delirium - fluctuating consciousness
- Conversion - inconsistent, doesn't respond to lorazepam
Treatment algorithm:
1. First-line: Lorazepam (up to 24 mg/day)
2. Second-line: ECT (80-100% response rate)
3. Be cautious with antipsychotics - can worsen catatonia
4. Clozapine is safest antipsychotic if needed
Catatonia has serious medical consequences
- Dehydration, malnutrition, aspiration pneumonia
- DVT/PE, rhabdomyolysis, autonomic instability
- Mortality risk if untreated
- Requires medical monitoring and supportive care
ECT is safe and highly effective in pediatric catatonia
- Don't delay ECT if lorazepam non-response
- Bilateral placement, 3×/week, 6-12 treatments
- Can be life-saving in malignant catatonia

References

Wing L, Shah A. (2000). Catatonia in autistic spectrum disorders. British Journal of Psychiatry, 176, 357-362.
Clinebell K, et al. (2014). Guidelines for preventing medical complications of catatonia: case report and literature review. Journal of Clinical Psychiatry, 75(6), 644-651.
Daniels J. (2009). Catatonia: Clinical aspects and neurobiological correlates. Journal of Neuropsychiatry and Clinical Neurosciences, 21(4), 371-380.
Leonhard K. (1999). Early childhood catatonia. In: Leonhard K, Beckmann H (editor), Cahn CH (translator). Classification of endogenous psychoses and their differentiated etiology. 2nd ed., Vienna: Springer-Verlag, 330-383.
Dhossche D, Wachtel L. (2010). Catatonia is hidden in plain sight among different pediatric disorders: A review article. Pediatric Neurology, 43(5), 307-315.
Bush G, Fink M, Petrides G, Dowling F, Francis A. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129-136.

Related Resources

Clinical Case Presentations:

Tantrums & Emotional Dysregulation - Differential diagnosis in children
Off-Label Antipsychotic Prescribing - Medication safety considerations
Antipsychotics in ADHD - Adverse effects and monitoring

Pediatric Psychiatry Resources:

ADHD in Children - Ages 6-12 evaluation and treatment
ADHD in Adolescents - Teenage presentations
ADHD Diagnosis - Comprehensive assessment
ADHD Medications - Treatment options

Research & Education:

Research Publications - Peer-reviewed work
Conference Presentations - Academic talks
Clinical Articles - Educational content
Teaching & Education - Medical education
Academic CV - Professional background

For Professional Consultation
Contact Dr. Sultan