Synopsis
Identify a catatonic motor syndrome and dopamine-blocker-associated systemic toxicity, initiate urgent supportive care and distinguish their treatment priorities from ordinary psychotic agitation.
- Catatonia is a syndrome of altered motor activity, speech and behaviour that occurs in mood, psychotic, neurological and general medical conditions.
- Look for combinations of stupor, mutism, posturing, negativism, catalepsy, stereotypy and echo phenomena rather than immobility alone.
- Use a structured catatonia examination and severity scale to document findings and change over time.
- A monitored lorazepam challenge can support diagnosis, but improvement is not completely specific and lack of response does not exclude catatonia.
- NMS is associated with dopamine-blocking exposure and usually features rigidity, fever, altered mental state and autonomic disturbance.
- Stop implicated drugs and provide active medical support; do not respond to suspected NMS by escalating antipsychotics.
- Benzodiazepines and ECT have central roles in catatonia, with urgent specialist escalation for malignant or poorly responsive illness.
Key red flags
Mutism or immobility with inability to eat or drink needs urgent assessment for dehydration, aspiration, thrombosis and an underlying neurological or psychiatric disorder.
Fever, generalised rigidity, tachycardia or blood-pressure instability after an antipsychotic or dopamine-blocking antiemetic requires immediate consideration of NMS.
Investigation priorities
Document the number, nature and severity of catatonic signs before and during treatment.
Management branches
Several catatonic motor or behavioural features are present without immediate malignant instability.
- Record a structured baseline examination and assess hydration, nutrition, swallowing, mobility and pressure or thrombosis risks.
- Obtain urgent psychiatric input while investigating the underlying cause, including neurological assessment when the presentation is new or atypical.
- Consider a monitored lorazepam challenge and arrange continuing benzodiazepine or ECT treatment according to response, severity and individual risk.
Key medicines
Lorazepam challenge for catatoniaBAP describes a single challenge of 1–2 mg intravenously or intramuscularly, or 2 mg orally, after documenting baseline catatonic signs. Reassess after approximately 5 minutes for intravenous, 15 minutes for intramuscular and 30 minutes for oral administration; consider a further challenge only after clinical review.Use a monitored setting with assessment of respiratory reserve, sedative co-exposure and aspiration risk. A substantial score reduction supports catatonia but is not completely specific; absence of improvement does not rule it out.
Continuing lorazepam in malignant catatoniaThe BAP specialist recommendation is 8 mg daily by oral, intramuscular or intravenous routes, divided and titrated to response and tolerability, up to 24 mg daily when required. Partial or absent response within forty-eight to seventy-two hours prompts bilateral ECT; titration and taper require direct specialist supervision.These are specialist high-dose regimens, not routine agitation prescriptions; respiratory disease, frailty, concurrent depressants and sedation may limit dosing. Monitor closely and do not delay ECT or critical-care escalation when deterioration continues.