Psychiatric emergencies — structured clinical viva

This is a catatonic emergency with malignant features (fever, autonomic instability, not eating/drinking). Differential must explicitly include malignant catatonia, NMS (recent antipsychotic), encephalitis, and other medical catatonia mimics. Do not park her on a psychiatric ward without medical work-up capacity.^[2]

Examination. Bush-Francis style motor signs (mutism, posturing, negativism, waxy flexibility), full neurology, vitals, hydration, CK, FBC, U&E, infection screen, consider imaging/LP if encephalitis suspected, ECG. Stop or hold dopamine antagonists if NMS remains live.^[2]

Treatment. Supportive medical care (fluids, cooling, VTE prophylaxis thinking, airway). Lorazepam challenge 1–2 mg (IV/IM/oral as available) with reassessment; if responsive, scheduled lorazepam. If non-responsive or deteriorating malignant picture, escalate early to ECT — this is disease-modifying, not last-ditch folklore.^[1]

Legal/ethics. She likely lacks capacity for treatment decisions while mute and severely ill; use emergency treatment principles and local Mental Health Act for ongoing care, documenting least-restrictive rationale and involving family appropriately under privacy law. Capacity is decision-specific — reassess as she improves.^[3]