A 34-year-old woman admitted for an acute psychotic episode is found mute, immobile, and resisting passive movement of her limbs. She has not eaten for two days and shows waxy flexibility. Vital signs are stable. What is the immediate next step in management?

• A Intravenous lorazepam challenge test ✓
• B Start haloperidol orally
• C Immediate electroconvulsive therapy without any drug trial
• D Start clozapine under monitoring

Explanation

Catatonia is first treated with a lorazepam challenge, classically 1 to 2 mg intravenous or intramuscular, with dramatic improvement in rigidity, mutism, and posturing within minutes confirming the diagnosis. Antipsychotics such as haloperidol can precipitate or worsen malignant catatonia and neuroleptic malignant syndrome. ECT is reserved for patients who fail benzodiazepines or have life-threatening catatonia, so it is not the immediate first step.

Reference: Kaplan and Sadock's Synopsis of Psychiatry, 12th ed.

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