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The patient has a history of depression and is presenting with decreased motor activity, waxy flexibility, lack of response to external stimuli, and mutism, suggesting the diagnosis of catatonia. Catatonia should initially be treated with benzodiazepines like lorazepam.Catatonia is a state of psychomotor immobility and apathy that is associated with a mood disorder or psychosis. The diagnosis is made clinically by having at least 3 of the following symptoms: stupor (no psychomotor activity), negativism (no response to external stimuli), catalepsy (muscle rigidity in a position against gravity), waxy flexibility (maintaining positioning placed by the examiner), mutism, echolalia (mimicking speech), echopraxia (mimicking movements), stereotypy, grimacing, and non-purposeful agitation or mannerisms. Initial treatment involves benzodiazepines for symptomatic relief. If the patient is unresponsive to benzodiazepines, electroconvulsive therapy (ECT) can be used.Francis reviews the evidence regarding the treatment of patients with catatonia. He discusses how benzodiazepines can be used with rapid improvement in symptoms. He recommends electroconvulsive therapy in refractory cases.Incorrect Answers:Answer 1: Benztropine and IV diphenhydramine can be used to treat an acute dystonic reaction. Dystonic reactions present as involuntary spasms or sustained contractions of the face, neck, torso, pelvis, extremities, and larynx. Medications that block dopamine D2 receptors, such as neuroleptics and antiemetics, carry the greatest risk.Answer 2: Cyproheptadine is a serotonin antagonist that may be part of the treatment for serotonin syndrome. Serotonin syndrome may occur as a result of the simultaneous use of monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), or serotonin-norepinephrine reuptake inhibitors (SNRIs). It presents with myoclonus, hyperthermia, flushing, tachycardia, and delirium.Answer 3: Electroconvulsive therapy is an effective treatment for catatonia but would be considered 2nd line to benzodiazepines for refractory cases.Answer 4: Haloperidol is an antipsychotic, which may worsen catatonia. It can cause neuroleptic malignant syndrome, which can mimic catatonia.Bullet Summary:Catatonia can present in patients with a history of mood disorders and psychosis with symptoms of decreased motor activity, rigid posture, and mutism, and should be treated initially with a benzodiazepine.
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