A 38-year-old man with a history of schizophrenia is brought to the emergency department by police for a court-ordered evaluation. His mother requested that the patient be involuntarily committed after he refused voluntary hospitalization. She says that his illness was controlled with an injectable antipsychotic. She does not remember the name of the medication, but he received it once a month. Four months ago, the patient stopped going to his psychiatrist to receive the injection. His mother has seen a continuous deterioration in his overall functioning, especially within the last few weeks. Temperature is 37 C (98.6 F), blood pressure is 132/80 mm Hg, pulse is 88/min, and respirations are 14/min. Laboratory results are within normal limits, and a urine toxicology screen is negative. During the evaluation, the patient does not respond to any questions. He sits motionless on the edge of the bed, staring at the wall in front of him. During the physical examination, the resident picks up the patient's arm and places it over his head to evaluate range of motion. When the resident releases the arm, the arm stays in place above the patient's head. The resident then purposefully moves it down 30 degrees and the arm, once again, stays in the new location. Which of the following would be the most appropriate next step in management of this patient?

Question

A 38-year-old man with a history of schizophrenia is brought to the emergency department by police for a court-ordered evaluation.  His mother requested that the patient be involuntarily committed after he refused voluntary hospitalization.  She says that his illness was controlled with an injectable antipsychotic.  She does not remember the name of the medication, but he received it once a month.  Four months ago, the patient stopped going to his psychiatrist to receive the injection.  His mother has seen a continuous deterioration in his overall functioning, especially within the last few weeks.  Temperature is 37 C (98.6 F), blood pressure is 132/80 mm Hg, pulse is 88/min, and respirations are 14/min.  Laboratory results are within normal limits, and a urine toxicology screen is negative.  During the evaluation, the patient does not respond to any questions.  He sits motionless on the edge of the bed, staring at the wall in front of him.  During the physical examination, the resident picks up the patient's arm and places it over his head to evaluate range of motion.  When the resident releases the arm, the arm stays in place above the patient's head.  The resident then purposefully moves it down 30 degrees and the arm, once again, stays in the new location.  Which of the following would be the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c04a_c9fe_8f63_e3af0c87876e_MD0005_00 This patient's history of schizophrenia, current unresponsiveness, immobility, and catalepsy (passively allowing the examiner to position him) are all suggestive of catatonia. Catatonia is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with psychotic disorders, bipolar disorder with psychotic features, major depression with psychotic features, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic). Catatonia can range from stupor to marked agitation (catatonic excitement), which contributes to difficulties in recognition. In DSM-5, a single set of criteria is used to diagnose catatonia across diagnostic categories. Characteristic features include decreased motor activity, lack of responsiveness during interview, or excessive and peculiar motor activity. In severe cases, the patient may need close supervision to avoid harm to self or others. The condition should be treated promptly, as potential risks include malnutrition, hyperpyrexia, exhaustion, and self-inflicted injury. The treatment of choice for catatonia is benzodiazepines (especially lorazepam) and/or electroconvulsive therapy (ECT). A lorazepam challenge test (intravenous bolus of lorazepam 1-2 mg) resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis of catatonia. However, a negative response does not rule out catatonia, and patients often need repeated doses. ECT is recommended in urgent clinical situations or when the patient responds poorly to benzodiazepines. Studies indicate that 60%-80% of patients recover with benzodiazepines alone or benzodiazepines followed by ECT. (Choice A) Dantrolene is used to treat muscular rigidity seen in neuroleptic malignant syndrome (NMS). NMS is characterized by recent exposure to antipsychotics, generalized muscular rigidity, high fever, altered sensorium, autonomic instability, and significant laboratory abnormalities (eg, elevated creatine kinase, leukocytosis). NMS is unlikely in this patient who has stable vital signs and normal laboratory results and has not received antipsychotics for 4 months. (Choices C and E) Administering antipsychotics can worsen catatonia. Treatment with lorazepam should precede antipsychotic treatment in this unresponsive patient. He likely will benefit from an antipsychotic to treat his underlying psychosis after his catatonia resolves. (Choice D) Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms (eg, dystonic reactions, parkinsonism) caused by high-potency antipsychotic medications. Educational objective: Catatonia is a syndrome of marked psychomotor disturbance seen in a range of severe psychiatric illnesses. The treatment of choice is benzodiazepines and/or electroconvulsive therapy. A lorazepam challenge test can be used to verify the diagnosis. References: Catatonia. (http://www.ncbi.nlm.nih.gov/pubmed/27255726) Catatonia: our current understanding of its diagnosis, treatment and pathophysiology. (http://www.ncbi.nlm.nih.gov/pubmed/28078203)

A 38-Year-Old Man with a History of Schizophrenia Is Brought