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Clinical Atlas Prestige · Evidence-first

Psych VivasEmergency psychiatry

Psych Vivas · Emergency psychiatry

Psychiatric emergencies — structured clinical viva

Fellowship viva covering catatonic emergency versus NMS, lorazepam challenge and ECT pathway, medical resuscitation, and capacity/least-restrictive care.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the on-call psychiatry registrar. ED calls about a 26-year-old woman with mutism, posturing and refusal of food for 36 hours. Temperature has risen to 38.6 C with tachycardia. Family says she had a puerperal psychosis 2 years ago and recently restarted an antipsychotic. Discuss your differential, examination, immediate management including drug doses, and legal/ethical approach if she cannot consent.

Interpretation

Reveal interpretation

This is a catatonic emergency with malignant features (fever, autonomic instability, not eating/drinking). Differential must explicitly include malignant catatonia, NMS (recent antipsychotic), encephalitis, and other medical catatonia mimics. Do not park her on a psychiatric ward without medical work-up capacity.[2]

Examination. Bush-Francis style motor signs (mutism, posturing, negativism, waxy flexibility), full neurology, vitals, hydration, CK, FBC, U&E, infection screen, consider imaging/LP if encephalitis suspected, ECG. Stop or hold dopamine antagonists if NMS remains live.[2]

Treatment. Supportive medical care (fluids, cooling, VTE prophylaxis thinking, airway). Lorazepam challenge 1–2 mg (IV/IM/oral as available) with reassessment; if responsive, scheduled lorazepam. If non-responsive or deteriorating malignant picture, escalate early to ECT — this is disease-modifying, not last-ditch folklore.[1]

Legal/ethics. She likely lacks capacity for treatment decisions while mute and severely ill; use emergency treatment principles and local Mental Health Act for ongoing care, documenting least-restrictive rationale and involving family appropriately under privacy law. Capacity is decision-specific — reassess as she improves.[3]

Key points

Malignant catatonia is a medical emergency

Fever and autonomic instability move the case from “interesting MSE” to resuscitation plus ECT pathway thinking.

NMS and malignant catatonia overlap

Both may need stop-dopamine-antagonist logic and intensive support; lorazepam/ECT remain central for catatonia.

Name doses

Lorazepam challenge 1–2 mg is the expected viva number.
[1]

References

  1. [1]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
  2. [2]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
  3. [3]Spencer BWJ, Gergel T, Hotopf M, et al. Unwell in hospital but not incapable: cross-sectional study on the dissociation of decision-making capacity for treatment and research in in-patients with schizophrenia and related psychoses. Br J Psychiatry, 2018.PMID 29909778