Recognizing Catatonia Beyond Hypokinesis: Features Linked to Underdiagnosis and Training Targets

Objective: To estimate how clinical signs shape whether catatonia is recorded during routine inpatient care and to identify training targets that reduce missed cases. Methods: We conducted a retrospective chart review at a tertiary psychiatric hospital (July 2019-July 2024). Of 14,907 admissions, 87 had a formal catatonia diagnosis. We screened discharge summaries with 24 terms; 697 encounters with ≥3 terms underwent independent ICD-11 review by two clinicians (third reviewer as needed), yielding 194 additional encounters meeting criteria. We compared patients with a recorded diagnosis with those meeting criteria without a diagnosis and fitted logistic models for diagnostic assignment. Results: At the patient level (first admission), 54 diagnosed and 183 underdiagnosed individuals were included. Hypokinetic signs-negativism, mutism, rigidity, and posturing-were more frequent in diagnosed cases, while grimacing and mannerisms were more frequent among underdiagnosed cases. In adjusted analyses, rigidity and negativism were linked to a higher likelihood of a recorded diagnosis, whereas grimacing signaled missed recognition. Medical complication rates did not differ. The longer unadjusted length of stay in diagnosed patients was not significant after adjustment for age and symptom burden. Conclusions: Clinicians tend to identify hypokinetic catatonia and overlook movement-rich presentations. A one-minute ICD-11 screen and documentation prompts for parakinetic/hyperkinetic signs are pragmatic steps for training programs.