A 34-year-old woman with an acute psychotic illness becomes mute, maintains her limbs in positions placed by the examiner, resists passive movement, and refuses to eat. She is afebrile with stable vitals. What is the most appropriate first-line treatment?

• A High-dose intramuscular haloperidol
• B Supportive nursing care alone while awaiting spontaneous remission
• C Clozapine initiation after baseline neutrophil count
• D Lorazepam, with consideration of electroconvulsive therapy if unresponsive ✓

Explanation

The picture is catatonia: mutism, waxy flexibility, negativism, and refusal to eat. Benzodiazepines, classically lorazepam, are the established first-line treatment, often producing dramatic improvement within hours to days; electroconvulsive therapy is indicated for benzodiazepine-refractory or life-threatening catatonia. High-potency typical antipsychotics can precipitate or worsen catatonia into malignant catatonia resembling neuroleptic malignant syndrome, so option A is actively dangerous. Clozapine is not first-line, and waiting risks dehydration and thromboembolism.

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

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Written and medically reviewed by the StethoPrep medical team.