Underlying/associated conditions

Management in pregnancy is not addressed in this guideline, but reference can be made to the British Association of Psychopharmacology 2023 guidelines  for the evidence base. Equally, those with renal, liver and respiratory disease may require specific consideration of Lorazepam doses, and potentially more expeditious use of ECT to gain symptom control.

Careful consideration should be given to the role of antipsychotics, and the relationship between their prescribing and the development of catatonia.

In some cases, catatonia can be precipitated by antipsychotics, with this being more associated with hypokinesia and a withdrawal presentation. Should the antipsychotic be felt likely to be responsible, withdrawal of this drug should be the first measure. Introduction of Lorazepam may be considered if there is a lack of, or slow, response. Lower potency or partial antagonist antipsychotics are less implicated, and may be switched to if an antipsychotic is necessitated.

Similarly, if Neuroleptic Malignant Syndrome is felt to have been precipitated, antipsychotics should be withdrawn, and full case review of the indication and lower risk options may be considered further down the line after recovery.

It is important to draw the distinction between the above, and where psychosis is felt to be the driver behind the syndrome of catatonia. In such cases, as the cause should be treated, antipsychotics are indicated. An individual case consideration should be given over the most appropriate agent, and monitoring of any impact on the degree of catatonic features. Clozapine can be efficacious in more chronic catatonia, and it should be noted that withdrawal of Clozapine can even precipitate catatonia itself (in which case re-instating treatment is typically effective).

Antipsychotics should be avoided unless there is a clear indication (e.g. psychosis).