Catatonia: recognize it with the Bush-Francis scale

A 41-year-old woman has been in the internal medicine ward for three days with pneumonia. The team notices that she barely speaks, spends long periods staring at the ceiling and does not eat on her own. The first hypothesis written down is "depression" or "hypoactive delirium". When the nurse lifts her arm to measure blood pressure, she notices that the arm stays in the air.

Catatonia is a psychomotor syndrome that appears in psychiatric and medical illnesses. For decades it was linked almost only to schizophrenia, and that association helped keep it hidden in general wards. Today it is known to be common, treatable and, when unrecognized, potentially severe.

This text shows how to recognize catatonia with the Bush-Francis scale, what the targeted examination adds, how the lorazepam challenge fits into diagnostic reasoning and why the next question is always about the cause.

Key points

• The diagnosis requires at least three catatonic signs.
• The Bush-Francis scale is the most used and the only one validated by a lorazepam challenge.
• Several signs only appear when the examiner actively looks for them.
• A significant share of patients has a medical cause, especially in the central nervous system.
• Neuroleptic malignant syndrome and malignant catatonia can be clinically indistinguishable.

What catatonia is and why it goes unnoticed

The British Association for Psychopharmacology guideline recalls that, in 1976, two articles challenged the idea that catatonia belonged to schizophrenia and showed that it appears in a wide range of psychiatric and medical illnesses (Rogers et al., 2023). Even so, the historical association persists and contributes to the syndrome not being considered outside psychiatry.

The quiet patient does not draw attention

In the routine of a ward, the agitated patient mobilizes the team, while the motionless and silent patient seems calm. They ask for nothing, cause no trouble and can spend hours in the same position without anyone finding it strange. That quietness is precisely what hides catatonia.

Another reason is the habit of explaining the picture by an already known diagnosis. If the patient has depression, the mutism becomes sadness; if they have schizophrenia, it becomes withdrawal; if they are elderly and hospitalized, it becomes drowsiness or confusion. In each case, the question about catatonia stops being asked because a ready explanation already exists.

How common it is

The guideline summarizes that about 9 in every 100 patients in mental health services have features of catatonia, but adds a caveat: larger studies found lower numbers (Rogers et al., 2023). In studies with more than 1000 patients, the prevalence was 2.3 in every 100. The variation between studies depends on the setting and the method of assessment.

A historical and clinical review shows that the way of looking also changes the result. When trained clinicians applied the Bush-Francis scale and the result was compared with prolonged, unobtrusive observation by an experienced clinician, the observation found significantly higher scores (Ungvari et al., 2023). Part of catatonia goes unnoticed because it is not looked for.

In groups less often remembered

In children and adolescents, a nationwide study in the United States identified 900 discharges from general hospitals with a diagnosis of catatonia in one year, with a mean age of 15.6 years (Luccarelli et al., 2022). The authors concluded that the diagnosis is rare in general hospitals, but comes with important psychiatric and medical comorbidities.

In older adults, a systematic review highlights that underrecognition is common and that research in this population is scarce (Jaimes-Albornoz et al., 2022). The British guideline adds that errors have been reported in which catatonia in older adults was taken for delirium, psychosis, stroke, dementia or coma (Rogers et al., 2023), a topic close to that of hypoactive delirium in hospitalized older adults.

The signs that define the syndrome

The diagnosis of catatonia by DSM-5-TR criteria requires a picture dominated by at least three of twelve signs (Rogers et al., 2023): stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation without an external stimulus, grimacing, echolalia and echopraxia.

The most frequent signs

A 2016 review describes that, in a series of patients with catatonia, immobility and mutism appeared in more than 90 out of 100 (Rasmussen et al., 2016). Withdrawal, fixed gaze, negativism, posturing and rigidity were also frequent. In practice, the motionless and silent patient is the typical presentation, and it is precisely the one most often confused with depression or with sedation.

The threshold of three signs

The British guideline discusses the diagnostic threshold. An important study used the previous cutoff of two signs, but all the patients included ended up having at least three (Rogers et al., 2023). A cutoff of four signs is very specific, but it may miss cases. Poorly specific signs, such as tachycardia and anxiety, help little in diagnosis, although they serve to measure severity.

Catatonia can also be agitated

The classic image is of the motionless patient, but the list of signs includes agitation without an external stimulus (Rogers et al., 2023). In this form, the patient moves intensely and without purpose, repeats gestures or words and does not respond to the environment coherently.

This presentation is easily confused with mania, agitated psychosis or hyperactive delirium. What helps to think of catatonia is the presence of other signs on the list, such as stereotypies, echolalia or negativism, and the alternation between periods of agitation and immobility. The British guideline includes agitated catatonia among the findings that make the clinical cause more likely (Rogers et al., 2023).

The Bush-Francis scale in practice

The Bush-Francis scale has 23 items, added together to produce a total score (Edinoff et al., 2021). It overlaps with the DSM-5 criteria and adds other signs, such as ambitendency, automatic obedience, autonomic abnormality and combativeness.

Why it is the reference

In the British guideline's comparison table, the Bush-Francis scale appears as the most used in clinical practice and research, and it is the only one validated by a lorazepam test (Rogers et al., 2023). The guideline also notes that the scale was originally validated with a standardized clinical examination and that its screening instrument covers the DSM-5-TR criteria.

The historical review adds a practical detail: the scale takes about 5 to 10 minutes to apply, and raters should consult the notes from the previous 24 hours for the withdrawal and autonomic abnormality items (Ungvari et al., 2023). The same review notes that the scale is suitable for acute episodes but may not be enough for persistent forms.

The targeted examination

The guideline describes three forms of assessment: observation, provocation of signs and physical examination (Rogers et al., 2023). Catalepsy, rigidity and waxy flexibility only appear when the examiner manipulates the patient. A 2023 review on diagnosis and treatment recommends trying to provoke signs such as catalepsy, echopraxia and changes in tone (Rogers et al., 2023).

The same review draws attention to how to approach the patient. There is evidence that many people with catatonia perceive and remember what they experienced, and clinicians should interact with them as they would with someone who understands (Rogers et al., 2023). Empathy in clinical reasoning has a concrete role here.

A simple sequence at the bedside

For the student, it helps to turn the examination into a routine. First, observe the patient without interacting: body position, gaze, spontaneous movements. Then call the patient by name and talk, noting whether there is a response, whether speech is repeated or whether the patient turns to the opposite side.

Next, make broad gestures in front of the patient to see whether they imitate them, extend your hand to see whether they squeeze it automatically, and move the arms to feel the resistance. A limb placed in an unusual position that stays there after the examiner lets go indicates catalepsy. Finally, review the vital signs and the nursing notes.

This sequence does not replace the standardized instrument, but it ensures that the items that depend on manipulation are not left unassessed.

Sign	How to observe or provoke	What it suggests
Immobility or stupor	Observe spontaneous activity and response to the environment	Core sign, present in most patients
Mutism	Try to talk; observe spontaneous speech	Very frequent; it is not a synonym for depression
Catalepsy and posture	Position a limb and see whether the position is maintained	Requires manipulation by the examiner
Waxy flexibility	Move the limb and feel light, uniform resistance	Requires physical examination
Negativism	Give simple instructions and observe opposition	Resistance with no apparent reason
Echolalia and echopraxia	Observe repetition of the examiner's speech or gestures	More complex signs, not described in antipsychotic-induced catatonia
Autonomic abnormality	Review temperature, blood pressure, pulse and respiration over 24 hours	Severity and risk of the malignant form

Table source: Rogers and colleagues, 2023; Edinoff and colleagues, 2021; Hirjak and colleagues, 2021.

The lorazepam challenge as a diagnostic test

The British guideline considers lorazepam an effective and useful diagnostic test for catatonia (Rogers and colleagues, 2023). The challenge consists of assessing the signs with a standardized instrument before and after the medication.

How to interpret the result

A positive response is usually defined as a reduction of 50 out of every 100 catatonic signs on a standardized scale (Rogers and colleagues, 2023). A positive response makes the diagnosis more likely, but it is not 100 out of 100 specific. The 2023 review recommends considering the challenge when it is unclear whether catatonia is present (Rogers and colleagues, 2023).

The reasoning is the same as for any diagnostic test: the result changes the probability, it does not replace it, as discussed in pretest probability. Conditions such as stiff person syndrome also respond to benzodiazepines (Rogers and colleagues, 2023), and this must enter the interpretation.

The challenge does not replace the search for the cause

A clear response to lorazepam can bring relief to the team and the family, but it does not answer the most important question: why is this patient catatonic? Improvement of the signs can temporarily mask encephalitis, a metabolic change or a medication effect that is still present.

For this reason, the reasoning proceeds on two tracks at the same time. One confirms and monitors the syndrome with the scale. The other looks for the underlying disease with history, examination and targeted additional tests (Rogers and colleagues, 2023).

What happens after the response

In a consultation-liaison psychiatry study in Taiwan, 18 of 21 patients with catatonia due to a medical condition or a substance were free of catatonia with a protocol of lorazepam and diazepam (Lin and colleagues, 2017). Five of the 21 died, from various causes and at varying times after the episode. The finding is a reminder that the response of catatonia does not resolve the underlying disease.

Catatonia is not a final diagnosis: causes and differentials

The 2023 review summarizes the next question: if it is catatonia, which medical or psychiatric disease is behind it? Isolated catatonia, with no cause, is rare (Rogers and colleagues, 2023).

Medical causes are frequent

The British guideline cites evidence that about 20 out of every 100 patients with catatonia in unselected populations have an associated medical disease, a number that rises above 50 out of every 100 in acute medical and surgical settings and reaches almost 80 out of every 100 in older adults (Rogers and colleagues, 2023). Unlike delirium, 68.9 out of every 100 of the medical diseases behind catatonia were of the central nervous system.

The guideline also lists signs that make a clinical cause more likely: associated delirium, major autonomic changes, agitated catatonia, grasp reflex, pneumonia, a history of neurological disease and of epileptic seizures (Rogers et al., 2023).

Autoimmune encephalitis and other causes

A clinical review describes that anti-NMDA encephalitis accounts for 72 in 100 of the autoimmune causes of catatonia (Edinoff et al., 2021). Reports of patients with autism and intellectual disability show anti-NMDA encephalitis that presented with catatonia and neuroleptic malignant syndrome (Kiani et al., 2015), a scenario in which diagnosis is even harder. It is the kind of situation where it is worth practicing the differential diagnosis with clues.

The 2023 review lists other important clinical causes: lupus, viral or bacterial meningitis and encephalitis, HIV, thyroid disease, space-occupying lesion, head trauma, medications such as corticosteroids and ketamine, and withdrawal of clozapine or benzodiazepines (Rogers et al., 2023).

History-guided investigation

The recommendation is to consider blood tests, urine drug screening, lumbar puncture, electroencephalogram and neuroimaging according to the history and examination (Rogers et al., 2023). In the first episode or when the cause is not clear, the review suggests considering computed tomography or magnetic resonance imaging and testing for anti-NMDA antibodies in serum and, ideally, in cerebrospinal fluid.

The electroencephalogram has a specific role. A meta-analysis of 355 studies, with 707 patients, showed that an abnormal electroencephalogram predicted a clinical cause with sensitivity of 0.82 and specificity of 0.66, positive likelihood ratio of 2.4 and negative of 0.28 (Hosseini et al., 2023). A normal test reduces, but does not eliminate, the chance of a clinical cause.

Whether the cause is found or not, the differential diagnosis of catatonia involves conditions that mimic the syndrome and conditions that overlap with it.

Catatonia and delirium can coexist

A common mistake is to treat catatonia and delirium as mutually exclusive alternatives. The patient with hypoactive delirium is also quiet, poorly responsive and with a fixed gaze, and the British guideline includes associated delirium among the signs that make a clinical cause more likely (Rogers et al., 2023).

In practice, the question is not which of the two, but whether there are catatonic signs beyond the change in consciousness. Negativism, catalepsy, waxy flexibility or echolalia in a confused patient indicate that both syndromes may be present. In that case, the search for the clinical cause becomes even more urgent, and the targeted examination must be repeated as consciousness changes.

The overlap with neuroleptic malignant syndrome

The 2023 review describes neuroleptic malignant syndrome as possibly indistinguishable from malignant catatonia; what distinguishes it is the start or rapid increase of a dopamine antagonist (Rogers et al., 2023). The same review notes that catatonia is a strong risk factor for neuroleptic malignant syndrome.

A report describes a 58-year-old man with fever, tachycardia, rigidity and raised creatine phosphokinase, initially diagnosed with neuroleptic malignant syndrome (Desai et al., 2021). When fever and laboratory changes improved, but rigidity, waxy flexibility, mutism and stupor persisted, the diagnosis was revised to malignant catatonia. Reviewing the diagnosis as the condition evolves is an exercise in diagnostic uncertainty.

Antipsychotic-induced catatonia

A letter from German authors draws attention to antipsychotic-induced catatonia (Hirjak et al., 2021). The authors note that akinesia, stupor and mutism are common in this picture, while more complex signs, such as catalepsy, waxy flexibility, echolalia and echopraxia, have not been described with antipsychotic use and may suggest genuine catatonia.

Other conditions that mimic catatonia

The 2023 review lists other differentials (Rogers et al., 2023): stiff person syndrome, with specific antibodies and exaggerated exteroceptive reflexes; parkinsonian diseases, with insidious onset, tremor and asymmetry; drug-induced dystonia, without stupor; locked-in syndrome, with preserved vertical eye movement and blinking; coma, without resistance to eye opening; and functional neurological disorder.

Building the reasoning step by step

Recognizing catatonia can follow a simple sequence.

1. Suspect it in a patient who is immobile, silent, does not eat or holds strange postures.
2. Observe the patient and review the notes from the last 24 hours, including vital signs.
3. Examine actively: position limbs, move joints, give simple instructions.
4. Apply the Bush-Francis scale and count the signs; three or more support the diagnosis.
5. If in doubt, consider the lorazepam challenge as a diagnostic test.
6. Look for the cause: signs of a clinical cause, medications, drug withdrawal, encephalitis.
7. Assess antipsychotics in use and autonomic signs, because of the overlap with neuroleptic malignant syndrome.

Complications that recognition avoids

Catatonia is not just a curious finding on examination. The patient who does not move, eat or drink is exposed to dehydration, malnutrition, venous thrombosis, pressure skin injuries and aspiration pneumonia. The longer the syndrome goes unrecognized, the greater the chance that one of these complications becomes the main problem.

Early recognition allows simple care to be organized, such as hydration, mobilization, thrombosis prevention and monitoring of vital signs, while the cause is investigated. Autonomic signs deserve special attention, because they may indicate progression to the malignant form (Rogers et al., 2023).

Reassess with the same scale

Using the same scale in every assessment turns impressions into comparable data. A score that falls over the days shows response to care, and a score that rises or new autonomic signs call for immediate reassessment. This record also helps the next on-call physician know where the patient started from.

Back to the patient in the case

The 41-year-old patient has mutism, a fixed gaze, food refusal and catalepsy, which already adds up to more than three signs. The Bush-Francis scale helps record and quantify the picture (Edinoff et al., 2021). Pneumonia and clinical hospitalization are among the findings that, according to the guideline, make a clinical cause more likely (Rogers et al., 2023).

The next step is to look for the cause, review medications and consider the lorazepam challenge if there is still doubt (Rogers et al., 2023). Recording the signs with the scale, as discussed in organizing the reasoning in the medical record, allows the evolution to be followed and prevents the label of "depression" from closing the reasoning too early.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code.

The limits of using the game are described on the NEXO economy page. If you research clinical reasoning teaching, the page for researchers explains how to get in touch. Professionals who write or review cases find information in curation and in creators, and institutions can learn about the proposal on the partnerships page. Training clinical decision-making and searching for the right ICD-10 code complete this practice.

Frequently asked questions

How many signs are needed for the diagnosis?

By DSM-5-TR criteria, at least three of twelve signs (Rogers et al., 2023). The British guideline discusses that a cutoff of four signs is more specific, but may miss cases (Rogers et al., 2023).

Does the Bush-Francis scale take long to apply?

No. It takes about 5 to 10 minutes, with a review of the notes from the previous 24 hours for some items (Ungvari et al., 2023).

Does a response to lorazepam confirm catatonia?

It makes the diagnosis more likely, but it is not 100 out of 100 specific (Rogers et al., 2023). Other conditions, such as stiff person syndrome, also respond to benzodiazepines (Rogers et al., 2023).

Is catatonia always psychiatric?

No. About 20 out of 100 patients in unselected populations have an associated medical illness, and the proportion is higher in clinical settings and in older adults (Rogers et al., 2023).

Does the electroencephalogram help?

It helps separate medical from psychiatric causes. An abnormal electroencephalogram had a sensitivity of 0.82 for a medical cause, but a specificity of 0.66 (Hosseini et al., 2023).

Take-home messages

• Catatonia requires at least three signs and appears in psychiatric and medical illnesses.
• The Bush-Francis scale is the most used and takes only a few minutes.
• Catalepsy, rigidity and waxy flexibility only appear on a targeted examination.
• The lorazepam challenge increases the probability of the diagnosis, but it is not perfectly specific.
• Finding catatonia is the beginning: the cause must be sought.
• Neuroleptic malignant syndrome and malignant catatonia overlap and require continuous review of the diagnosis.

References

1. Desai S, Hirachan T, Toma A, et al. Malignant Catatonia Versus Neuroleptic Malignant Syndrome. Cureus. 2021. PMID 34306883.
2. Edinoff AN, Kaufman SE, Hollier JW, et al. Catatonia: Clinical Overview of the Diagnosis, Treatment, and Clinical Challenges. Neurol Int. 2021. PMID 34842777.
3. Hirjak D, Sartorius A, Kubera KM, et al. Antipsychotic-induced catatonia and neuroleptic malignant syndrome: the dark side of the moon. Mol Psychiatry. 2021. PMID 34012038.
4. Hosseini P, Whincup R, Devan K, et al. The role of the electroencephalogram (EEG) in determining the aetiology of catatonia: a systematic review and meta-analysis of diagnostic test accuracy. EClinicalMedicine. 2023. PMID 36636294.
5. Jaimes-Albornoz W, Ruiz de Pellon-Santamaria A, Nizama-Vía A, et al. Catatonia in older adults: A systematic review. World J Psychiatry. 2022. PMID 35317341.
6. Kiani R, Lawden M, Eames P, et al. Anti-NMDA-receptor encephalitis presenting with catatonia and neuroleptic malignant syndrome in patients with intellectual disability and autism. BJPsych Bull. 2015. PMID 26191422.
7. Lin CC, Hung YY, Tsai MC, et al. The Lorazepam and Diazepam Protocol for Catatonia Due to General Medical Condition and Substance in Liaison Psychiatry. PLoS One. 2017. PMID 28114315.
8. Luccarelli J, Kalinich M, Fernandez-Robles C, et al. The Incidence of Catatonia Diagnosis Among Pediatric Patients Discharged From General Hospitals in the United States: A Kids' Inpatient Database Study. Front Psychiatry. 2022. PMID 35573347.
9. Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatry. 2016. PMID 28078203.
10. Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2023. PMID 37039129.
11. Rogers JP, Zandi MS, David AS. The diagnosis and treatment of catatonia. Clin Med (Lond). 2023. PMID 37236789.
12. Ungvari GS, Caroff SN, Csihi L, et al. Catatonia: "Fluctuat nec mergitur". World J Psychiatry. 2023. PMID 37303935.