From time to time, as a doctor, I am asked to see a completely silent patient in the emergency room of a hospital.

He sits still, looking around the room. I raise his arm and he stays in that position. Someone is giving him a blood test and he’s not even responding. He hasn’t eaten or drank anything for a day or two.

Questions begin to form in your mind. What’s happening? Can you answer someone else? Do you have a brain injury? Are you pretending? And the hardest part is, how do I know what’s wrong with her if she can’t tell me?

I am a psychiatrist and researcher who specializes in a rare condition known as catatonia, a serious type of mental illness in which people have problems with movement and speech.

Catatonia can last from a few hours to weeks, months, or even years. Some people have recurrent attacks.

I have spoken to doctors, nurses, academics, patients and caregivers about this disease. And one of the most frequently asked questions is: What do people with catatonia think? Do they think too?

If a person can barely move or speak, it is easy to assume that they are not conscious.

However, research in recent years has shown that this is not the case. Actually, it’s the opposite.

People with catatonia often express intense anxiety and say they are overwhelmed by their emotions. People with catatonia may have too many thoughts, not just because they have no thoughts.

But what are these thoughts? What could cause a person to “freeze” in their mind?

In a new study, my colleagues and I tried to shed some light on these questions.

hundreds of patients

When we looked at the case notes of hundreds of patients suffering from catatonia, we found that some spoke of their experiences either then or later. Others didn’t know or remember what it was.

Some patients reported experiencing overwhelming fear. Although they were aware of the pain of being rigid for so long, they could not move.

However, what we found most interesting was the case of people who had a logical explanation for some level of catatonia.

One patient’s notes were:

“He was kneeling with his forehead on the floor when I saw him. He said he was in this position to save his life and wanted to be seen by a neck specialist… He kept repeating that his head had fallen from his neck.”

If you really think your head is in danger of falling, it might not be such a bad idea to put it down.

Some patients have reported hearing voices telling them to do certain things. The voices warned a person that his head would explode if he moved, a pretty compelling reason to stay still.

Another patient thought that God had told him not to eat or drink.

fake death

One theory is that catatonia resembles some animals’ strategy of playing dead.

When faced with a predator of overwhelming size or strength, some animals “freeze” to avoid detection by potential aggressors.

One patient in the study vividly described seeing a snake (which also spoke to him).

We cannot tell from a single instance that it adopted a primitive defense against a predator, but it is certainly a possibility.

Catatonia remains an enigma, between neurology and psychiatry.

By better understanding what patients are going through, we can at least comfort and empathize with them.