Standing Still for Two Days: A Mental Status Examination That Found Catatonia in a 29-Year-Old Woman Admitted as "Unresponsive," Scored With the Bush-Francis Scale
[Student Name]
University of Phoenix
PMH/501: Neuropsychiatric Disorders
Week 2 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Ms. K., a 29-year-old graduate student, arrived at the emergency department with her roommate after two days of lying in bed, not speaking, eating or drinking. The emergency team documented her as "unresponsive, possible conversion disorder" after a normal head CT. Her roommate reports she had been increasingly sad and withdrawn for a month. I am asked to evaluate her. Because she cannot give a history, the mental status examination is the primary tool.
Mental Status Examination
Appearance: young woman lying supine, disheveled, eyes open, staring at the ceiling, not tracking.
Behavior: minimal spontaneous movement; when her arm is raised, it remains in the raised position for over a minute (posturing and catalepsy). When I gently move her arm, there is uniform resistance (rigidity). She resists having her eyes opened wider and turns away from attempts to examine her mouth (negativism). She does not blink in response to a threat.
Speech: mute; no verbal response to questions.
Mood: cannot be assessed verbally.
Affect: flat, no reactivity.
Thought process and content: cannot be assessed.
Perception: no observable response to internal stimuli.
Cognition: cannot be formally assessed; eyes open and appears awake.
Insight and judgment: cannot be assessed.
A patient who cannot speak can still be examined; the mental status examination is as much what the clinician sees as what the patient says.
Recognizing Catatonia
Her immobility, mutism, posturing, catalepsy, rigidity, negativism and staring are classic catatonic signs. Bush et al. (1996) developed and tested the Bush-Francis Catatonia Rating Scale, a 23-item scale with a 14-item screening instrument, and a standardized examination; two or more screening items present for at least 24 hours suggest catatonia. On the screening instrument, Ms. K. shows immobility, mutism, staring, posturing, negativism and rigidity, six items. Her full scale severity score is 21.
Why It Is Missed
Catatonia is more common than often recognized. Solmi et al. (2018) meta-analyzed studies across clinical samples and found a pooled catatonia prevalence of about 9%, occurring across mood disorders, psychotic disorders and medical conditions. Rasmussen et al. (2016) note that catatonia is frequently missed or mislabeled, as it was here, because clinicians associate it only with schizophrenia or do not examine for its signs.
Medical Causes to Exclude
Catatonia can result from medical and neurological conditions, including encephalitis, including autoimmune encephalitis, seizures such as nonconvulsive status epilepticus, metabolic disturbances, drug withdrawal and neuroleptic malignant syndrome (Rasmussen et al., 2016). I recommend vital signs with temperature monitoring, a metabolic panel, creatine kinase, complete blood count, toxicology screen, EEG to exclude nonconvulsive seizures and consideration of lumbar puncture and autoimmune antibody testing if the history or workup suggests encephalitis. Her vital signs are stable without fever, and creatine kinase is mildly raised from immobility.
The Lorazepam Challenge
Rasmussen et al. (2016) describe benzodiazepines, especially lorazepam, as first-line treatment and a lorazepam challenge as both diagnostic and therapeutic: a rapid improvement after an intravenous dose supports the diagnosis. Ms. K. receives lorazepam 2 mg intravenously. Within 20 minutes she begins to move her eyes to follow speakers and says, softly, "I'm so tired of everything." Her Bush-Francis score falls to 9.
Revisiting the Mental Status Examination
With speech restored, the examination can be extended: she reports depressed mood, hopelessness and passive thoughts of death for weeks, with no hallucinations. Her catatonia likely occurred in the context of a severe depressive episode, one of the most common associations.
Safety and Medical Risks
Catatonic patients who stop eating and drinking risk dehydration, kidney injury, blood clots and pressure injuries. She needs intravenous fluids, venous thromboembolism prophylaxis and suicide risk assessment now that she can speak.
Why Conversion Disorder Was the Wrong Label
Functional neurological disorder, formerly conversion disorder, can present with unresponsiveness, but it requires positive clinical signs inconsistent with neurological disease, and clinicians reach it only once other explanations have been weighed. Catatonic signs such as posturing, catalepsy and negativism point to a different syndrome with its own treatment. Labeling Ms. K. as having conversion disorder without examining for catatonia risked leaving a treatable, potentially dangerous condition untreated.
Malignant Catatonia
A small proportion of catatonic patients develop malignant catatonia, with fever, autonomic instability and rising creatine kinase, which can be fatal. Monitoring temperature, pulse and blood pressure closely in the first days is essential, and signs of malignancy would prompt urgent transfer and consideration of electroconvulsive therapy (Rasmussen et al., 2016).
Repeating the Scale
The Bush-Francis scale is useful not only for diagnosis but for tracking. Scoring it before and after each lorazepam dose, and daily thereafter, shows whether treatment is working and guides dose adjustments (Bush et al., 1996).
Documenting for Others
The note names each catatonic sign, the scale score, the medical workup, the response to lorazepam and the plan. Because catatonia is often missed, clear documentation ensures that the next team does not repeat the original error or start an antipsychotic prematurely.
What Her Roommate Knew
Collateral history from the roommate filled gaps the patient could not: a month of low mood, missed classes, poor appetite and a comment that "nothing matters." This information pointed toward depression as the context and raised the question of suicide risk even before Ms. K. could speak.
Why Not Start an Antidepressant Immediately
Once the depression was identified, the urge to start an antidepressant is understandable, but catatonia must be treated first, and the patient must be eating, drinking and medically stable. Antidepressants take weeks to work, while lorazepam or electroconvulsive therapy addresses the immediate danger.
Family Communication
Her parents, reached by phone, are frightened. I explain catatonia in plain terms, that it is a recognized syndrome with effective treatment and that her rapid response to lorazepam is a hopeful sign.
Nutrition and Hydration
After two days without food or fluid, she needs careful rehydration and, if she cannot eat soon, nutritional support, with monitoring of electrolytes for refeeding problems.
Communication With the Emergency Team
I explain the findings to the emergency physician, showing the catatonic signs at the bedside, so that the team understands the revised diagnosis, the monitoring needed and the plan to avoid antipsychotics for now.
Reassessment Schedule
The Bush-Francis scale will be scored each morning by the same examiner to keep ratings consistent across days.
Treatment Plan
Scheduled lorazepam, titrated to response, is continued. If catatonia does not resolve, electroconvulsive therapy is highly effective (Rasmussen et al., 2016). Antipsychotics are avoided while catatonia is active because of the risk of neuroleptic malignant syndrome. Her depression will be treated once catatonia resolves.
Conclusion
A structured mental status examination of a mute, motionless patient identified specific catatonic signs, scored with the Bush-Francis scale, turning a label of unresponsiveness into a treatable syndrome. Meta-analytic data show catatonia is common and often missed, and a lorazepam challenge both confirmed the diagnosis and began treatment, revealing an underlying severe depression that the examination could then assess.
References
Bush, G., Fink, M., Petrides, G., Dowling, F., & Francis, A. (1996). Catatonia. I. Rating scale and standardized examination. Acta Psychiatrica Scandinavica, 93(2), 129-136. https://doi.org/10.1111/j.1600-0447.1996.tb09814.x
Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016). Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World Journal of Psychiatry, 6(4), 391-398. https://doi.org/10.5498/wjp.v6.i4.391
Solmi, M., Pigato, G. G., Roiter, B., Guaglianone, A., Martini, L., Fornaro, M., Monaco, F., Carvalho, A. F., Stubbs, B., Veronese, N., & Correll, C. U. (2018). Prevalence of catatonia and its moderators in clinical samples: Results from a meta-analysis and meta-regression analysis. Schizophrenia Bulletin, 44(5), 1133-1150. https://doi.org/10.1093/schbul/sbx157
How this PMH 501 Week 2 example is structured
The PMH/501 Week 2 work usually covers the psychiatric interview and mental status examination. This paper presents a complete mental status examination in standard order for a patient who cannot give a history, then shows how structured examination turns an unexplained state into a recognizable syndrome. Students search this week as PMH 501 Week 2, PMH501 Wk 2 or PMH/501 Wk 2; all three are the same assignment.
PMH/501 Week 2 questions, answered
What does PMH/501 Week 2 usually ask for?
Many sections ask students to conduct and document a psychiatric interview and mental status examination, often for a case with unusual findings.
What is catatonia?
A syndrome of motor, behavioral and speech abnormalities, such as stupor, mutism, posturing, rigidity, negativism and echophenomena, that can occur with mood, psychotic, medical and neurological conditions.
How is catatonia treated?
Benzodiazepines, usually lorazepam, are first-line and often produce rapid improvement; electroconvulsive therapy is used when benzodiazepines fail or in malignant catatonia.
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