A 19-year-old man receives his first injection of haloperidol for an acute psychotic episode. Six hours later he develops torticollis, upward deviation of the eyes, and trismus. He is fully conscious and afebrile. What is the most appropriate immediate management?

• A Intravenous dantrolene and oral bromocriptine
• B Parenteral promethazine or diphenhydramine ✓
• C Oral propranolol and reassurance
• D Immediate lumbar puncture and brain MRI

Explanation

This is an acute drug-induced dystonic reaction, common in young males within hours to days of starting a high-potency typical antipsychotic. It responds dramatically to parenteral anticholinergics such as promethazine or diphenhydramine. Dantrolene plus bromocriptine treats neuroleptic malignant syndrome, which is excluded here by the absence of fever, rigidity, and autonomic instability. Propranolol treats akathisia, and imaging is unnecessary when the presentation follows a clear drug trigger.

Reference: Kaplan and Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.