Catatonia interferes with a patient’s ability to communicate, especially when an episode is severe, protracted, or characterized by prominent mutism, excitement, or speech oddities . This means patients are often unable to describe their experiences during an acute episode. In this paper, we explore the catatonic experience using self-reports collected during at follow-up from participants who screened positive for catatonia.
The psychological experience of catatonia: Patients with catatonia describe experiencing very intense emotional states. In the Northoff et al.  paper on the subjective experience of catatonia, 24 patients with catatonia provided self-reports at the 3-week point following an episode of catatonia. Their experience was less focused on the change in their movements and more on the change in their cognitive or affective experience. This included intense emotions that could not be controlled. There was also ambivalence, which correlates with one of the signs that may be observed in catatonia, namely ambitendency. This is the motor manifestation of being caught in two opposing actions at the same time. Northoff et al.  went on to categorize domains for assessment of the subjective experience of catatonia, which included the patient’s subjective description of their altered motor function, their interaction with their environment, and their emotional and cognitive experiences during the catatonic episode.
Rosebush and Mazurek  found that most patients felt very anxious during the catatonic episode, and 15% thought they were either already dead or were going to die. Shorter and Fink  and Moskowitz  characterized catatonia as a state of extreme fear that manifests as freezing, like that seen in some animals who respond with immobility or freezing when faced with danger. Shorter and Fink , address this in their book on catatonic stupor, The Madness of Fear, and ask whether catatonia is a mostly a neurological phenomenon with no psychological explanation behind it or whether it is a case of the mind remaining active during catatonia, even though one is unable to communicate.
From the 1900, catatonia was postulated to have a psychology of its own with symptoms seen as symbolic of underlying psychological drivers . Around the same time, Wernicke proposed the concept of motor psychosis which was understood to view catatonia as “abnormalities of motion and of speech which were independent of thought or will” . Northoff postulated that it was the intensity of emotions, whether positive (as in catatonic excitement) or negative (as in catatonic stupor), that triggered catatonia .
Fear or a heightened state of anxiety have also been described during a catatonic episode [1–8]. This intense anxiety may be observable and accompanied by a sense of impending doom with the patient feeling that they will die. Some patients may even believe that they are already dead [8, 9].
Based on the limited studies available on patient reports about the catatonic episode, the main psychological drivers and subjective experiences of catatonia have been around intense negative emotions like fear and heightened anxiety. Novak et al. , postulate that one may look at catatonia from an evolutionary perspective, meaning, this is a survival mechanism, applied when there is perceived impending danger. This is similar to what Northoff , Shorter and Fink , Rosebush and Mazurek , and Moskowitz  also postulate. So, although there is still scanty literature on the psychological impact of catatonia and the subjective experience as described by patients, what is available does seem to implicate fear circuits and somehow involves the perception of immediate danger or threat that the patient perceives.
To understand this better, and also how catatonia might fit into this theory of being fear- and danger-driven, one can compare the response to fear in humans to the response seen in animals. Whether in humans or animals, it may manifest as the fight-flight-freeze response that has been described as a built-in defense mechanism triggered by fear or trauma, whether physical or psychological. Walter Cannon, a medical doctor and physiologist who studied the stress response, first described this observation back in 1915, as quoted by Quick and Spielberger .
Cannon’s research and pioneering work on stress and how it affects the human psyche and physical state, served to advance the study of psychosomatic medicine, highlighting how a persons’ psychological state could affect their physical health . He also highlighted the response to stress and how it can drive behavior, including how danger, or conditions that generate a stress response, can evoke heightened feelings of anxiety and anger accompanied by an autonomic nervous system reaction with all its involuntary bodily changes . This then drives the fight-or-flight response. Cannon’s work has been studied and expanded upon over the years and this reaction is now recognized to potentially also include the freeze-and-fawn responses, which are also linked to the same defense system against fear- or anxiety-inducing stimuli . This fear reaction is explained below:
Fight – this entails facing the danger and fighting the threat aggressively.
Flight – this implies running away from the threat to try and save yourself.
Freeze – this is equivalent to playing dead through immobility until the threat passes.
Fawn – This is the submissive response which serves to avoid conflict [12, 13].
Relevance of catatonia to psychology
The medical approach to treatment emphasizes biopsychosocial interventions. Interventions for catatonia, however, are solely biological until the acute catatonic episode has settled. Psychological interventions are usually reserved for intervention until after the acute catatonic episode. Interventions like specific psychotherapies are then tailored to the underlying condition driving the catatonia.
If one accepts that the drivers of the catatonic response include fear or extreme anxiety, then the signs of catatonia may be recognized as the range of responses one gets in response to danger, as described by Cannon and expanded on by others [12, 13, 14]. Signs of catatonia, like withdrawal, immobility, and stupor, may be equivalent to the freezing aspect of the stress response; negativism and combativeness to the fight response; and automatic and passive obedience to the fawn reaction.
Having laid out the drivers of catatonia and the psychological impacts of intense emotions like fear and anxiety, one can anticipate the role that psychological interventions might play in the management of acute catatonia and in the prevention of catatonia, especially in vulnerable or at-risk individuals. By combining this knowledge with the risk profile that one could build based on the findings earlier studies conducted at the site on prevalence and risk factors of catatonia, one might be able to find applicability for psychological interventions that target the management of stress, anxiety, and fear. Catatonia responds to specific biological treatments like benzodiazepines and ECT, irrespective of the underlying cause. Similarly, one could use psychological interventions in acute catatonia to help patients manage the intense negative emotions that accompany catatonia, irrespective of the cause.
If one looks at the available evidence, one can conclude that an acute episode of catatonia is possibly the ideal time to offer psychological interventions because this is the point at which the patient may be experiencing their most intense negative emotions. This may be the ideal time to support patients with anxiety and fear management techniques to help them gain control over their reactions.
Based on the evidence by Northoff , Fink and Taylor [4, 15], Rosebush and Mazurek , and Moskowitz , one expects reports of fear and anxiety with different aspects that fit into the fight, flight, freeze, or fawn response to be at the forefront of participants’ self-report. The design of the enquiry undertaken in this part of the thesis was qualitative and exploratory so as not to lead participants but to rather let them set the themes for the emotive, cognitive, and behavioral experiences and responses during the catatonic episode.
Based on data from previous studies that indicate that patients are aware of their emotive and cognitive experiences during the non-communicative stage of acute catatonia, one could assume that they would be able to understand and engage with supportive interventions targeted at re-assurance and focused on helping them to manage overwhelming fear and anxiety.
This study was conducted as a complementary part of an overall study on prevalence of catatonia and aimed at researching the psychological experience of participants who had screened positive for catatonia during the prevalence study.