A 27-year-old man with a history of schizophrenia is brought to the emergency department b… — USMLE Step 2 CK

A $27$ -year-old man with a history of schizophrenia is brought to the emergency department by his family because he has been standing completely still in the corner of his room for the past $12$ hours. He does not respond to questions, maintains his arm in a raised position when the physician moves it there, and has not eaten or drank anything all day. His current medications include haloperidol and benztropine. Vital signs are temperature $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure $120/80\text{ mm Hg}$ , pulse $82/\text{min}$ , and respirations $14/\text{min}$ . Arrange the following management steps in the most appropriate chronological order for this patient's current condition.

1Discontinue haloperidol
2Administer an intravenous lorazepam challenge
3Initiate scheduled, continuous benzodiazepine therapy
4Prepare the patient for electroconvulsive therapy (ECT)

Answer

The correct sequence for managing catatonia is to first discontinue the offending antipsychotic, perform a lorazepam challenge, initiate scheduled benzodiazepines, and reserve ECT for refractory cases.

The patient is presenting with catatonia, characterized by immobility, mutism, waxy flexibility (maintaining a posture set by the examiner), and refusal to eat or drink. The management of catatonia follows a specific algorithm. The first step is to discontinue any potentially exacerbating medications, particularly dopamine antagonists (antipsychotics) like haloperidol, which can worsen the condition or trigger neuroleptic malignant syndrome. Once the offending agent is removed, the initial therapeutic and diagnostic step is the lorazepam challenge test (

1

2\text{ mg}

IV), which usually results in marked, rapid, but temporary improvement. Upon a positive challenge, the patient is transitioned to scheduled, standing doses of lorazepam to maintain remission. Electroconvulsive therapy (ECT) is considered the definitive treatment but is generally reserved for patients who fail to respond to a full trial of high-dose benzodiazepines, or for those presenting with malignant catatonia (catatonia accompanied by autonomic instability, fever, and rigidity).

Step-by-Step Solution

Identify the clinical syndrome.

The patient's mutism, immobility, waxy flexibility, and negativism are diagnostic of catatonia.

Accurate diagnosis is required to guide the specific algorithm for psychiatric intervention.

Determine the first step in management.

Discontinue haloperidol.

Dopamine-blocking agents (like haloperidol) can exacerbate catatonia and increase the risk of progression to neuroleptic malignant syndrome (NMS). They must be stopped immediately.

Select the initial pharmacological intervention.

Administer an intravenous lorazepam challenge.

Lorazepam

1

2\text{ mg}

IV is used to confirm the diagnosis and typically provides rapid, temporary relief of catatonic symptoms.

Determine the maintenance strategy.

Initiate scheduled, continuous benzodiazepine therapy.

Because the lorazepam challenge only provides temporary relief, scheduled high-dose benzodiazepines are required to sustain improvement.

Identify the definitive treatment for refractory cases.

Prepare the patient for electroconvulsive therapy (ECT).

If the patient does not respond to benzodiazepines within several days, or if the catatonia becomes malignant (with fever and autonomic instability), ECT is the treatment of choice.

Key Concept

Algorithm for the Management of Catatonia

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