A 34-year-old man with schizophrenia is found mute, immobile, and resisting passive movement of his limbs. He holds awkward postures for hours and shows waxy flexibility. He has not eaten for two days. Which of the following is the most appropriate initial treatment?

• A Intramuscular haloperidol
• B Electroconvulsive therapy after failure of medication
• C Intravenous lorazepam ✓
• D Switching to clozapine

Explanation

Catatonia, whether occurring in schizophrenia, mood disorder, or medical illness, responds rapidly to benzodiazepines, and intravenous or oral lorazepam is the accepted first-line agent, often producing improvement within hours. Antipsychotics can worsen catatonia and precipitate malignant catatonia, so haloperidol is inappropriate initially. Electroconvulsive therapy is highly effective but is reserved for lorazepam-refractory cases or malignant catatonia. Clozapine has no role in acute catatonia management.

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

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