Suspected Catatonia
Patient with motor/behavioral abnormalities suggesting catatonia
All Pathways
PsychiatryEmergency
Catatonia Assessment & Treatment (BAP Guidelines)
Catatonia Assessment & Treatment (BAP Guidelines): Suspected Catatonia → Bush-Francis Catatonia Rating Scale (BFCRS) → BFCRS Screen Result → Screen Nega...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Bush-Francis Catatonia Rating Scale (BFCRS)
14-item screening (first 14 items)
- 1. Excitement - extreme hyperactivity
- 2. Immobility/stupor - extreme hypoactivity
- 3. Mutism - no/minimal verbal response
- 4. Staring - fixed gaze, poor eye contact
- 5. Posturing - maintaining positions spontaneously
- 6. Grimacing - maintenance of odd expressions
- 7. Echopraxia/echolalia - mimicking
- 8. Stereotypy - repetitive movements
- 9. Mannerisms - odd purposeful movements
- 10. Verbigeration - repetition of phrases
- 11. Rigidity - resistance to movement
- 12. Negativism - opposing/no response to stimuli
- 13. Waxy flexibility - maintains examiner-imposed position
- 14. Withdrawal - refusal to eat/drink/make eye contact
03Decision BFCRS Screen Result
Score ≥2 on screening items is positive
04Action Screen Negative
BFCRS <2, consider other diagnoses
- Depression with psychomotor retardation
- Schizophrenia negative symptoms
- Parkinsonism
- Non-convulsive status epilepticus
- Akinetic mutism (frontal lesion)
05Action Screen Positive (≥2)
Complete full 23-item BFCRS
06Action Medical Workup
Rule out organic causes
- CBC, BMP, LFTs, TFTs
- CK (elevated in catatonia)
- Lumbar puncture (anti-NMDAR encephalitis)
- Brain MRI
- EEG (rule out NCSE)
- Toxicology screen
- Consider autoimmune panel
07Decision Signs of Malignant Catatonia?
Medical emergency
- Fever/hyperthermia
- Autonomic instability
- Altered consciousness
- Very high CK levels
08Warning ⚠️ MALIGNANT CATATONIA
Life-threatening emergency
- ICU admission
- IV fluids, cooling if hyperthermic
- High-dose benzodiazepines
- URGENT ECT consultation
- Mortality high if untreated
09Action Electroconvulsive Therapy (ECT)
Highly effective for catatonia
- Response rate 80-100% (even if benzo-resistant)
- Bilateral electrode placement preferred
- Daily or every-other-day initially
- Continue until symptoms resolve
- May need maintenance ECT
- Continue benzodiazepines during ECT
10Outcome Resolution & Maintenance
Taper treatment gradually
- Continue treatment 2-4 weeks after resolution
- Slow benzodiazepine taper
- Treat underlying condition
- Monitor for recurrence
- May need maintenance ECT for recurrent catatonia
11Action Lorazepam Challenge Test
Diagnostic and therapeutic
- Lorazepam 1-2mg IV or IM
- Observe for 15-30 minutes
- Positive response: ≥50% reduction in BFCRS
- Response supports catatonia diagnosis
- May need to repeat for full response
12Decision Response to Lorazepam?
Assess within 30 minutes
13Action Benzodiazepine Maintenance
Continue scheduled lorazepam
- Lorazepam 2mg IV/IM q4-8h scheduled
- Titrate up to response (may need 8-24mg/day)
- Maximum response typically in 3-7 days
- Monitor for respiratory depression
- Taper gradually once symptoms resolve
14Warning ⚠️ Medications to AVOID
Can worsen catatonia
- AVOID antipsychotics initially (may worsen catatonia)
- If must use: low-dose atypical after benzos started
- AVOID if any NMS features present
- First-gen antipsychotics: higher NMS risk
- Path rejoins step 10Shared downstream outcome
15Action No/Partial Response
Consider ECT or augmentation
- If no response after 3-7 days of adequate lorazepam
- Consider adding: Amantadine 100mg BID or Memantine
- Proceed to ECT evaluation
- Path rejoins step 09Shared downstream outcome
Guideline Source
Evidence-Based Consensus Guidelines for the Management of Catatonia: Recommendations from the British Association for Psychopharmacology
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Catatonia can be caused by medical, neurological, or psychiatric conditions
- Always rule out organic causes before treating as psychiatric catatonia
- Malignant catatonia is life-threatening and requires urgent ECT
- Anti-NMDA receptor encephalitis mimics catatonia
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-11
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Frequently Asked Questions
What is the Catatonia Assessment & Treatment (BAP Guidelines)?
The Catatonia Assessment & Treatment (BAP Guidelines) is a emergency clinical algorithm for Psychiatry. It provides a structured decision tree to guide clinical decision-making, based on Evidence-Based Consensus Guidelines for the Management of Catatonia: Recommendations from the British Association for Psychopharmacology.
What guideline is the Catatonia Assessment & Treatment (BAP Guidelines) based on?
This algorithm is based on Evidence-Based Consensus Guidelines for the Management of Catatonia: Recommendations from the British Association for Psychopharmacology (DOI: 10.1177/02698811231158232).
What are the limitations of the Catatonia Assessment & Treatment (BAP Guidelines)?
Known limitations include: Catatonia can be caused by medical, neurological, or psychiatric conditions; Always rule out organic causes before treating as psychiatric catatonia; Malignant catatonia is life-threatening and requires urgent ECT; Anti-NMDA receptor encephalitis mimics catatonia. Individual patient factors may require deviation from these recommendations.
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