A 39-year-old woman with mutism and poor oral intake
A 39-year-old woman with bipolar I disorder is admitted to the hospital after three weeks of progressive social withdrawal, mutism, and poor oral intake. Her sister notes that she abruptly stopped attending her weekly ceramics workshop and yesterday remained seated on the couch in her winter coat for six hours. Temperature is 36.9 C (98.4 F), blood pressure is 124/78 mmHg, and pulse is 86/min. On examination, she is awake but nonverbal, staring fixedly ahead. When her arm is elevated above her head, she maintains the posture indefinitely without fatigue. Passive flexion of her elbow encounters steady resistance proportional to the applied force. Serum electrolytes, renal function, and non-contrast head CT are normal. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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View on AmazonThe Correct Answer
C
Explanation
Clinical Pearl:
Catatonia is characterized by motor, speech, and behavioral abnormalities such as catalepsy, stupor, mutism, and negativism, frequently complicating mood disorders. Intravenous lorazepam is the first-line diagnostic and therapeutic intervention, whereas dopamine-blocking antipsychotics are contraindicated because they can worsen catatonic symptoms and precipitate neuroleptic malignant syndrome.
Explanation:
This patient presents with acute catatonia secondary to bipolar I disorder, evidenced by mutism, stupor with fixed staring, catalepsy demonstrated by posturing against gravity, and negativism seen as resistance to passive motion proportional to applied force. According to psychiatric clinical guidelines, the definitive initial diagnostic and therapeutic intervention for catatonia is an intravenous lorazepam challenge, which provides rapid symptomatic relief in most cases. Administering intramuscular haloperidol is contraindicated because high-potency dopamine D2 receptor antagonists worsen catatonic rigidity and carry a substantial risk of precipitating neuroleptic malignant syndrome. Administering intravenous benztropine is indicated for acute medication-induced dystonic reactions or parkinsonism rather than catatonia, and anticholinergic agents offer no therapeutic benefit here. Initiating electroconvulsive therapy is reserved for catatonia that is refractory to benzodiazepine trials or complicated by malignant features such as hyperthermia and severe autonomic instability, neither of which is present in this afebrile, hemodynamically stable patient. Administering intravenous methylprednisolone is the appropriate empiric treatment for autoimmune encephalitis, but this patient has an established primary psychiatric diagnosis, normal neuroimaging, and no signs of seizures, autonomic storming, or focal neurological deficits to justify immunosuppression.
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