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Clinical Atlas Prestige · Evidence-first

Psych VivasGeneral adult psychiatry

Psych Vivas · General adult psychiatry

Catatonia — structured clinical viva

Fellowship viva on catatonia criteria, malignant features, NMS overlap, lorazepam challenge, and ECT.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. ED refers a 27-year-old with first-episode psychosis who is mute, postures, and grimaces. Temperature 38.4 C, diaphoretic, BP labile, CK 1,200 U/L (ULN 200). He received IM zuclopenthixol acetate and oral risperidone over the last 72 hours. Staff ask for more IM olanzapine. Discuss diagnosis, differential, immediate management, lorazepam/ECT pathway, and NMS overlap.

Interpretation

Reveal interpretation

Reject more IM olanzapine. This is a malignant catatonia / NMS overlap emergency after multiple dopamine antagonists. Further antipsychotic is a fail.[3][4]

Diagnosis language. Catatonic signs (mutism, posturing, grimacing) plus fever, autonomic instability, and raised CK after neuroleptics. Keep both malignant catatonia and NMS active; map NMS thinking to Gurrera IEC elements (exposure, fever, rigidity if present, MS change, CK ≥4× ULN, autonomic/hypermetabolic features).[3][4][1]

Immediate care. Stop all dopamine antagonists; ABCDE; cool; IV fluids; monitored bed/ICU; serial CK/renal function; infection/encephalitis work-up as indicated; benzodiazepines now (lorazepam challenge/treatment); early ECT planning.[2][5][3]

Pathway honesty. BAP supports benzos first-line for catatonia and ECT for non-response or life-threatening illness; malignant features push ECT earlier. Supportive care is not optional.[2][6]

Key points

Stop dopamine antagonists

Never treat this picture with more antipsychotic.

Name the tools

Bush-Francis exam language; DSM ≥3/12 signs; lorazepam 1–2 mg challenge.

Malignant = urgency

Fever + autonomic instability → medical emergency and early ECT pathway.
[1] [2] [3] [5]

References

  1. [1]Bush G, Fink M, Petrides G, et al. Catatonia. I. Rating scale and standardized examination Acta Psychiatr Scand, 1996.PMID 8686483
  2. [2]Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2023.PMID 37039129
  3. [3]Connell J, Oldham M, Pandharipande P, et al. Malignant Catatonia: A Review for the Intensivist J Intensive Care Med, 2023.PMID 35861966
  4. [4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
  5. [5]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
  6. [6]Rosebush PI, Mazurek MF Catatonia and its treatment Schizophr Bull, 2010.PMID 19969591