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Catatonia is a cluster of affective, behavioral, and motor symptoms. Its causes are multifactorial ranging from severe and untreated psychiatric illnesses to neurological diseases and other general medical conditions. It is estimated that 20% of catatonia causes are due to medical conditions out of which two thirds are due to an underlying neurological condition which might include encephalitis, neural injury, developmental disorders, structural brain pathology, or seizures. Symptoms of catatonia can wax and wane, fluctuating between the retarded and the excited type within hours making it more difficult to identify and diagnose. If left untreated, catatonia can lead to multiple medical complications which can lead to significant long-term morbidity and mortality. The initial complications include dehydration, malnourishment, electrolyte imbalance, deep venous thrombosis, pulmonary embolism, pneumonia, urinary tract infection, and retention. In the long run, patients can have sepsis, rhabdomyolysis, DIC, decubitus ulcers, arrhythmia, renal failure, and liver dysfunction. This article  will describe  three patients (adolescent & adult) that presented to Aga Khan University Hospital (AKUH), Karachi with challenging presentations of catatonia. Their diagnostic and management difficulties will be discussed.