Location
Philadelphia, PA
Start Date
17-4-2026 1:30 PM
End Date
17-4-2026 2:30 PM
Description
Introduction
Catatonia is a psychomotor syndrome involving disturbances in behavior, motor tone, and volition. However, distinguishing catatonia from the negative symptoms or disorganized behavior in schizophrenia spectrum disorders can prove to be quite difficult, leading to potential misattribution.
Methods
We conducted a retrospective chart review of a single patient case at LVHN Pocono Behavioral Health Unit (BHU). Standardized assessments such as the Dynamic Appraisal of Situational Aggression (DASA) and Bush-Francis Catatonia Rating Scale were reviewed to assess the patient’s status during hospitalization.
Case
We report the case of a 43-year-old male with chronic schizoaffective disorder presenting to the ED from his group home for worsening agitation and disorganized paranoia. Initial working diagnosis was acute exacerbation of schizoaffective disorder. Upon evaluation, findings included negativism, pressured speech, and aggression. No evidence of stupor or mutism, patient denied suicidal ideations but admitted to homicidal ideations toward group home members. Upon admission to the BHU, the patient was placed in a padded room on a 1:1 visual for psychosis. Medication regimen of scheduled haloperidol, lithium, and olanzapine were initiated. DASA score ranged from 3-7 during his first week on inpatient treatment, suggesting a continued high risk of violence. Patient was not showing improvement in psychiatric status despite changes in medication. On hospital day 7 (HD#7) safety measures progressed to locked seclusion and later 4-point-restraints, patient had not slept in 2 days. At this point, we discussed the possibility of an alternative diagnosis. Review of behavioral trends on current admission showed abrupt shifts between lucidity and incoherence with agitation and emotional dysregulation. It was noted that this presentation may represent agitated catatonia in a patient with underlying psychosis, rather than psychotic decompensation alone. Bush-Francis Catatonia Rating Scale was determined to be 14. Lorazepam trial was initiated. Patient was monitored and noted by nursing staff to appear “mildly calmer”, he was downgraded to 2-point-restrains and fell asleep. Patient status varied over the next week. By HD#14 patient was on 3.5 mg of lorazepam TID and oxcarbazepine 300 mg BID along with aforementioned medications, DASA score decreased to 0, and he appeared to be improving. Over the course of his 28-day hospital stay, highest dose of lorazepam administered was 4 mg TID. Patient was eventually stabilized on a multidisciplinary treatment plan focusing on psychotherapy and a psychopharmacology regimen of haloperidol, lithium, sertraline, olanzapine, oxcarbazepine, and lorazepam. He was discharged back to his group home.
Discussion
Catatonia remains underrecognized in schizophrenia spectrum disorders due to symptomatic overlap with psychotic decompensation. In this case, persistent agitation and fluctuating lucidity despite antipsychotic therapy prompted reassessment and identification of catatonia, leading to lorazepam initiation with subsequent clinical improvement. However, diagnostic uncertainty delayed benzodiazepine initiation for nearly one week, and discharge was further prolonged due to outpatient restrictions on lorazepam tapering. This case highlights how delayed recognition and disposition barriers can extend hospitalization and underscores the importance of maintaining a high index of suspicion for catatonia in patients with schizophrenia spectrum disorders.
Embargo Period
6-2-2026
Included in
Catatonia Masquerading as Decompensated Psychosis: A Case Report and Review of Diagnostic Approach
Philadelphia, PA
Introduction
Catatonia is a psychomotor syndrome involving disturbances in behavior, motor tone, and volition. However, distinguishing catatonia from the negative symptoms or disorganized behavior in schizophrenia spectrum disorders can prove to be quite difficult, leading to potential misattribution.
Methods
We conducted a retrospective chart review of a single patient case at LVHN Pocono Behavioral Health Unit (BHU). Standardized assessments such as the Dynamic Appraisal of Situational Aggression (DASA) and Bush-Francis Catatonia Rating Scale were reviewed to assess the patient’s status during hospitalization.
Case
We report the case of a 43-year-old male with chronic schizoaffective disorder presenting to the ED from his group home for worsening agitation and disorganized paranoia. Initial working diagnosis was acute exacerbation of schizoaffective disorder. Upon evaluation, findings included negativism, pressured speech, and aggression. No evidence of stupor or mutism, patient denied suicidal ideations but admitted to homicidal ideations toward group home members. Upon admission to the BHU, the patient was placed in a padded room on a 1:1 visual for psychosis. Medication regimen of scheduled haloperidol, lithium, and olanzapine were initiated. DASA score ranged from 3-7 during his first week on inpatient treatment, suggesting a continued high risk of violence. Patient was not showing improvement in psychiatric status despite changes in medication. On hospital day 7 (HD#7) safety measures progressed to locked seclusion and later 4-point-restraints, patient had not slept in 2 days. At this point, we discussed the possibility of an alternative diagnosis. Review of behavioral trends on current admission showed abrupt shifts between lucidity and incoherence with agitation and emotional dysregulation. It was noted that this presentation may represent agitated catatonia in a patient with underlying psychosis, rather than psychotic decompensation alone. Bush-Francis Catatonia Rating Scale was determined to be 14. Lorazepam trial was initiated. Patient was monitored and noted by nursing staff to appear “mildly calmer”, he was downgraded to 2-point-restrains and fell asleep. Patient status varied over the next week. By HD#14 patient was on 3.5 mg of lorazepam TID and oxcarbazepine 300 mg BID along with aforementioned medications, DASA score decreased to 0, and he appeared to be improving. Over the course of his 28-day hospital stay, highest dose of lorazepam administered was 4 mg TID. Patient was eventually stabilized on a multidisciplinary treatment plan focusing on psychotherapy and a psychopharmacology regimen of haloperidol, lithium, sertraline, olanzapine, oxcarbazepine, and lorazepam. He was discharged back to his group home.
Discussion
Catatonia remains underrecognized in schizophrenia spectrum disorders due to symptomatic overlap with psychotic decompensation. In this case, persistent agitation and fluctuating lucidity despite antipsychotic therapy prompted reassessment and identification of catatonia, leading to lorazepam initiation with subsequent clinical improvement. However, diagnostic uncertainty delayed benzodiazepine initiation for nearly one week, and discharge was further prolonged due to outpatient restrictions on lorazepam tapering. This case highlights how delayed recognition and disposition barriers can extend hospitalization and underscores the importance of maintaining a high index of suspicion for catatonia in patients with schizophrenia spectrum disorders.