Prompt

You are the psychiatry registrar. ED refers a 27-year-old with first-episode psychosis who is mute, postures, and grimaces. Temperature 38.4 C, diaphoretic, BP labile, CK 1,200 U/L (ULN 200). He received IM zuclopenthixol acetate and oral risperidone over the last 72 hours. Staff ask for more IM olanzapine. Discuss diagnosis, differential, immediate management, lorazepam/ECT pathway, and NMS overlap.

Interpretation

Reveal interpretationShow

Reject more IM olanzapine. This is a malignant catatonia / NMS overlap emergency after multiple dopamine antagonists. Further antipsychotic is a fail.^[3]^[4]

Diagnosis language. Catatonic signs (mutism, posturing, grimacing) plus fever, autonomic instability, and raised CK after neuroleptics. Keep both malignant catatonia and NMS active; map NMS thinking to Gurrera IEC elements (exposure, fever, rigidity if present, MS change, CK ≥4× ULN, autonomic/hypermetabolic features).^[3]^[4]^[1]

Immediate care. Stop all dopamine antagonists; ABCDE; cool; IV fluids; monitored bed/ICU; serial CK/renal function; infection/encephalitis work-up as indicated; benzodiazepines now (lorazepam challenge/treatment); early ECT planning.^[2]^[5]^[3]

Pathway honesty. BAP supports benzos first-line for catatonia and ECT for non-response or life-threatening illness; malignant features push ECT earlier. Supportive care is not optional.^[2]^[6]

References6Show

[1]Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination Acta Psychiatr Scand, 1996.PMID 8686483
[2]Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2023.PMID 37039129
[3]Connell J, Oldham M, Pandharipande P, et al. Malignant Catatonia: A Review for the Intensivist J Intensive Care Med, 2023.PMID 35861966
[4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
[5]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
[6]Rosebush PI, Mazurek MF Catatonia and its treatment Schizophr Bull, 2010.PMID 19969591

Interpretation

Reveal interpretationShow

Reject more IM olanzapine. This is a malignant catatonia / NMS overlap emergency after multiple dopamine antagonists. Further antipsychotic is a fail.^[3]^[4]

Pathway honesty. BAP supports benzos first-line for catatonia and ECT for non-response or life-threatening illness; malignant features push ECT earlier. Supportive care is not optional.^[2]^[6]

References6Show

[1]Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination Acta Psychiatr Scand, 1996.PMID 8686483
[2]Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2023.PMID 37039129
[3]Connell J, Oldham M, Pandharipande P, et al. Malignant Catatonia: A Review for the Intensivist J Intensive Care Med, 2023.PMID 35861966
[4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
[5]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
[6]Rosebush PI, Mazurek MF Catatonia and its treatment Schizophr Bull, 2010.PMID 19969591

Catatonia — structured clinical viva

Interpretation

Catatonia — structured clinical viva

Interpretation