A 46-year-old man is hospitalized due to suicidal ideation and hearing voices. The patient has become increasingly depressed over the past month and has been unable to work. Last week he told his wife that he was "tormented by voices" and that "death would be a relief." She brought him to the hospital after she found him staring at a blank screen on the television and not responding to her questions. The patient was prescribed risperidone, lithium, and escitalopram by his psychiatrist, but his wife is unsure if he takes them regularly. He has a history of bipolar disorder since age 18 with multiple hospitalizations for both manic and depressive episodes. His other medical problems are hypercholesterolemia and seasonal allergies. Temperature is 37 C (98.6 F), blood pressure is 125/80 mm Hg, pulse is 68/min, and respirations are 12/min. Routine laboratory results are within normal limits, lithium level is within therapeutic range, and a toxicology screen is negative. During the evaluation, the patient stares blankly and is mute and motionless. He resists all instructions to move. When the physician lifts the patient's arm, it remains in the exact same position after she lets go. Which of the following is the most appropriate next step in management?

Question

A 46-year-old man is hospitalized due to suicidal ideation and hearing voices.  The patient has become increasingly depressed over the past month and has been unable to work.  Last week he told his wife that he was "tormented by voices" and that "death would be a relief."  She brought him to the hospital after she found him staring at a blank screen on the television and not responding to her questions.  The patient was prescribed risperidone, lithium, and escitalopram by his psychiatrist, but his wife is unsure if he takes them regularly.  He has a history of bipolar disorder since age 18 with multiple hospitalizations for both manic and depressive episodes.  His other medical problems are hypercholesterolemia and seasonal allergies.  Temperature is 37 C (98.6 F), blood pressure is 125/80 mm Hg, pulse is 68/min, and respirations are 12/min.  Routine laboratory results are within normal limits, lithium level is within therapeutic range, and a toxicology screen is negative.  During the evaluation, the patient stares blankly and is mute and motionless.  He resists all instructions to move.  When the physician lifts the patient's arm, it remains in the exact same position after she lets go.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec25c8_d75d_acfd_bc81_b1d3d68be0e6_MD0003_00 This patient's history of severe bipolar disorder and current immobility and mutism are suggestive of catatonia. Catatonia is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with mood disorders with psychotic features, psychotic disorders, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic). Common features include decreased motor activity, lack of responsiveness during interview, posturing, and waxy flexibility (initial resistance to repositioning by the examiner, followed by maintenance of new repositioned posture). Catatonia can range from stupor to marked agitation (catatonic excitement), which contributes to difficulty in recognition. Treatment of catatonia includes benzodiazepines (most commonly lorazepam) and/or electroconvulsive therapy (ECT). A lorazepam challenge test (intravenous lorazepam 1-2 mg) resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis. Catatonia generally responds to lorazepam within a week; ECT is the treatment of choice in patients who do not improve. (Choice A) Benztropine is an anticholinergic medication used to treat extrapyramidal side effects (eg, acute dystonic reaction, parkinsonism) of antipsychotic medications. This patient's complete immobility, mutism with lack of responsiveness, and waxy flexibility are more characteristic of catatonia. (Choices B and E) Antipsychotics can worsen catatonia and should be avoided. Clozapine is generally reserved for treatment-refractory psychosis due to the risk of severe neutropenia. Treatment of this patient's underlying bipolar disorder with risperidone should be deferred until his catatonia resolves with lorazepam. (Choice C) The serotonin antagonist cyproheptadine has been used to treat severe cases of serotonin syndrome, which is characterized by a triad of autonomic instability, altered mental status, and neuromuscular irritability. (Choice D) Dantrolene has been used to treat muscular rigidity associated with severe neuroleptic malignant syndrome that does not respond to discontinuation of antipsychotic medication. This syndrome is characterized by fever, diffuse muscular rigidity, autonomic instability, and significant laboratory abnormalities (eg, elevated creatine kinase). It is unlikely in this patient, who has stable vital signs. Educational objective: Catatonia is a syndrome seen in severe psychiatric and medical illness and is characterized by immobility, mutism, and posturing. Lorazepam and electroconvulsive therapy are the treatments of choice. 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 46-Year-Old Man Is Hospitalized Due to Suicidal Ideation and Hearing