A 19-year-old woman is brought to the emergency department by her father due to bizarre behavior. When the patient did not come down for breakfast this morning, her father went to her room and found her sitting up in bed, staring at the wall. The patient did not respond to questions and was very stiff when her father tried to help her stand. The patient was diagnosed with bipolar disorder last year. She takes lithium, risperidone, and fluoxetine. Her dosages of risperidone and fluoxetine were both increased recently to target residual depressive symptoms. Temperature is 36.6 C (97.9 F), blood pressure is 121/78 mm Hg, pulse is 68/min, and respirations are 14/min. When asked what today's date is, the patient repeats, "Date, date, date," repeatedly. She resists the examiner's movement of her arms, increasing her resistance in proportion to the applied force. Which of the following is the most likely diagnosis for this patient?

Question

A 19-year-old woman is brought to the emergency department by her father due to bizarre behavior.  When the patient did not come down for breakfast this morning, her father went to her room and found her sitting up in bed, staring at the wall.  The patient did not respond to questions and was very stiff when her father tried to help her stand.  The patient was diagnosed with bipolar disorder last year.  She takes lithium, risperidone, and fluoxetine.  Her dosages of risperidone and fluoxetine were both increased recently to target residual depressive symptoms.  Temperature is 36.6 C (97.9 F), blood pressure is 121/78 mm Hg, pulse is 68/min, and respirations are 14/min.  When asked what today's date is, the patient repeats, "Date, date, date," repeatedly.  She resists the examiner's movement of her arms, increasing her resistance in proportion to the applied force.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d75e_493e_bc81_0f39e87603e3_MD0003_00 This patient's acute onset of immobility, mutism, negativism (ie, proportional resistance to passive movement), and echolalia (ie, repeating another's words) are consistent with catatonia. Catatonia is a syndrome characterized by psychomotor signs/symptoms that occur in the context of psychiatric or medical illness. Catatonia most often develops in the context of a mood disorder (eg, bipolar disorder, major depressive disorder); however, it may also occur in psychotic disorders (eg, schizophrenia), autism spectrum disorder, and general medical illness. Catatonia is most often treated with benzodiazepines (eg, lorazepam), but severe or intractable cases can be successfully treated with electroconvulsive therapy. Relief of symptoms in response to a lorazepam challenge test (usually intravenous lorazepam) supports the diagnosis. (Choice A) Akinetic mutism is caused by lesions in the frontal cortex. It may present similarly to catatonia but is not accompanied by echophenomena (eg, echolalia, echopraxia). (Choice C) Delirium is a disorder of acute onset altered attention and arousal that fluctuates in severity across time. It would not explain this patient's motor symptoms or echophenomena. (Choice D) Drug-induced parkinsonism presents with resting tremor, bradykinesia, and rigidity; it is most often caused by dopamine-blocking agents (eg, antipsychotics). This patient's presentation, which includes mutism and echolalia, is better explained by catatonia. (Choice E) Locked-in syndrome is usually caused by a pontine stroke and presents with paralysis, mutism, and a preservation of cognitive abilities. (Choice F) Neuroleptic malignant syndrome presents with autonomic instability (eg, hyperthermia, tachycardia, hypertension), rigidity, and altered mental status in the setting of antipsychotic medication use. This patient is afebrile with normal vital signs. (Choice G) Serotonin syndrome is characterized by autonomic instability (eg, hyperthermia, tachycardia, hypertension), hyperreflexia, and altered mental status in the context of serotonergic medication use. It would not explain this patient's immobility, negativism, and normal vital signs. Educational objective: Catatonia is characterized by immobility, mutism, negativism, and echophenomena. It most often presents in the context of bipolar disorder or major depressive disorder. Catatonia is treated with benzodiazepines (eg, lorazepam). References: A clinical review of the treatment of catatonia. (http://www.ncbi.nlm.nih.gov/pubmed/25538636) Systematic review of catatonia treatment. (http://www.ncbi.nlm.nih.gov/pubmed/29398916) The use of lorazepam and electroconvulsive therapy in the treatment of catatonia: treatment characteristics and outcomes in 60 patients. (http://www.ncbi.nlm.nih.gov/pubmed/28640169)

A 19-Year-Old Woman Is Brought to the Emergency Department by Her