Role of the MDT in care and treatment

There are several roles for Physiotherapy in catatonic patients. At the more severe end, work to reduce the risk of muscle contractures is very important for long-term outcomes and function. This patient group may develop a degree of sarcopenia from misuse and malnutrition.

For more mobile patients, or those who are fluctuant in presentation, repeated and often dynamic plans around how to reduce falls risk (and support mobility) may be required. This can be particularly important for patients who exhibit periods of excessive activity.

They may advise on suitable mobility aids, or equipment/strategies to facilitate transfers.

For those patients who have previously been immobile and are starting to engage in activity again, there is a role for physiotherapy in general rehabilitation to improve strength, stamina and mobility.

Environmental assessment can be useful to optimize the patient’s safety in the immediately surrounding area. It may be that temporary equipment is required while the patient is more catatonic, to facilitate mobility, dignity and care. Identification and promotion of meaningful activity and engagement is also of value, utilizing a person-centred approach and focussing on sensory strategies.

Patients may have low intake, or limited variability of intake. The aim is to maintain nutritional state, and reduce the loss of muscle and physiological reserve secondary to immobility. For this reason, advice on what foods to offer, and any supplementation can be very useful.

At the time of writing this guideline, there is no evidence base for the use of music or art therapy for catatonic patients. We have retained this section as some individual patients may benefit, and consideration of referral can be made on a case-by-case basis.

Both modalities work to gently support a physical and emotional re-connection, and tend to view catatonia from a trauma perspective, with an assumption that the shutdown and withdrawal are rooted in an overwhelmed emotional state. Work seeks relational connection, and to seek out small and subtle openings to encourage reconnection. Both art and music can be means to create a therapeutic environment, where interaction with others can be tolerable.

Targeted use of music can provide cognitive stimulation to patients, as well as reinforcing of the normal day/night cycle. Choosing music that a patient enjoys when well can also be humanising, and can be a point of connection between staff and an otherwise potentially un-interactive patient.

Much like with fluctuating activity levels necessitating a dynamic plan from Physiotherapy, a varied plan for times of low interactivity compared to high activity, may be needed. In particular for patients whose intake occurs in a rushed fashion, advice to help reduce the risk of choking is hugely important. Communication needs can also be considered, and it may be that Speech & Language Therapy are able to provide advice on ‘Augmentative and Alternative Communication’, ranging from simple paper-based to more advanced technology.

Psychology can have a role working directly with patients (via assessment, formulation and in providing therapy), but also indirectly through team formulation and case consultation. The latter can be particularly important in working to understand a markedly impaired patient’s presentation, and can help empower teams to effectively and appropriately respond. Those with chronic catatonic presentations, especially where biological management has not been straight forward, may benefit from discussion. Psychology can work with the rest of the MDT to make interventions and care as trauma-informed as possible. This may focus on safety, choice, collaboration, empowerment, and building trust.

Prior research has explored the emotions and cognitive experiences of patients while catatonic (Zingela 2022). Prominent themes included overwhelming anxiety, fear, low mood and a sense of being trapped. Should the period of catatonia be considered as a trauma in itself for the patient, later care should bear this in mind. General principles for such patients would include trying to build a sense of safety, helping them to return to structure and routine, and management of PTSD symptoms should they develop. It may be useful to review your local trauma guideline.

Psychology has a distinct role to play in patients who have autism, where specialist behavioural strategies can be effective in helping to manage symptoms. Please see the section called 'Intellectual disability and/or autism' under Treatment.