Catatonia recognition and management (MEQ)

(i) Diagnosis. Working diagnosis: catatonia associated with bipolar mania (DSM-5-TR specifier context) — retarded (stuporous) phenotype. He has ≥3 of 12 psychomotor features (mutism, staring, posturing, and implied negativism/withdrawal with food refusal). Not currently febrile or autonomically unstable, so not malignant at this snapshot, but risk can evolve. Not NMS without recent dopamine antagonist exposure and rigidity/fever/autonomic storm pattern.[5][1][4]

(ii) Assessment and investigations. Structured Bush-Francis exam and severity rating; full MSE, capacity, legal basis under local law; vital signs each shift; hydration and VTE/aspiration risk. Labs: FBC, U&E, LFT, glucose, CRP, CK, ECG; infection screen if indicated; consider imaging/EEG/autoimmune panel if atypical, first-episode, seizures, or medical red flags. Collateral for mood course and substances.[1][3]

(iii) Lorazepam plan. Challenge: lorazepam 1–2 mg IV/IM (or oral if safe swallowing); reassess motor signs within minutes to about half an hour. If positive, schedule lorazepam and titrate to motor response with airway/sedation monitoring (daily multi-mg divided regimens under specialist supervision are often required). Taper slowly after resolution. Treat mania once motor syndrome improving (mood stabiliser pathway; cautious antipsychotics only after benzos and NMS exclusion).[2][4][3]

(iv) ECT and complications. Escalate to ECT if inadequate benzodiazepine response, evolution to malignant features (fever, autonomic instability), or life-threatening food/fluid refusal. Series show high ECT response rates in catatonia. Untreated complications: dehydration, aspiration, PE from immobility, pressure injury, rhabdomyolysis if excited, multi-organ failure if malignant.[6][3][4]