Catatonia isn’t just mysterious, it’s one of the most treatable yet misunderstood syndromes in psychiatry.

In this episode, I continue my conversation with Dr. Mark Oldham, diving deep into what to actually do when you suspect catatonia. We talk through the Lorazepam challenge, what a “positive” response really means, and why sometimes a single dose can look like a miracle. We also dig into the gray zones—how to approach patients who don’t respond, when to move to ECT, and what to do when catatonia overlaps with delirium or psychosis.

Dr. Oldham shares his framework for identifying special cases, from benzodiazepine withdrawal to clozapine discontinuation, and explains why history-taking, not algorithms, is psychiatry’s most powerful diagnostic tool.

Takeaways:

Start simple, but think deeply. Lorazepam remains first-line for catatonia, but the absence of RCTs means clinical reasoning still leads the way.
ECT is definitive and underused. For refractory or malignant catatonia, ECT is often curative, but access and consent barriers remain a major challenge.
Not all catatonia is the same. Withdrawal states, chronic schizophrenia, and periodic catatonia each demand tailored interventions.
Delirium and catatonia can coexist. Treat both cautiously, start low, go slow, and always look for autoimmune or neurological causes.
History is your best guide. Behind every catatonic presentation is a story, missing it can mean missing the cure.

Selected references:

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