Case Presentation: A twenty-two-year-old male with unknown history was brought in with altered mental status (AMS). On exam he was lying in bed, clutching a taco sauce packet mid-air as if perpetually about to pour; he remained immobile for 10 minutes, exhibited waxy flexibility, and did not respond to questions or commands. Bush-Francis Catatonia score was 24. He was given 1mg of lorazepam intravenously (IV) and began to sway his fist side to side. Another 2mg of lorazepam was given and he began speaking in short phrases, demonstrating poverty of content and thought blocking. Lorazepam was gradually increased but with diminishing improvements. He became increasingly psychotic, disorganized and sexually inappropriate as his altered mental status resolved. He was started on olanzapine in addition to benzodiazepines and improved.

Discussion: Catatonia is a state of immobility and stupor derived from an altered mental state which can be difficult to recognize and distinguish from other conditions due to its multifaceted presentation. Initial treatment typically involves a trial of benzodiazepines in addition to treating the underlying cause; however, this can be problematic when the underlying cause is psychosis rather than a medical disorder as benzodiazepines can worsen many altered states and antipsychotics can precipitate catatonia. Treating catatonia therefore requires complex decision-making. While consultation with psychiatry may be the most appropriate course of action, it is important for internists to be familiar with the presentation and treatment of catatonia.

Conclusions: While benzodiazepines are a recognized treatment in catatonia, there are many cases in which they are not sufficient. Particularly problematic is the psychotic patient with catatonia as antipsychotics are known to precipitate catatonia; however some limited data suggest that second-generation antipsychotics might be helpful rather than harmful in treatment. A delicate balance must be struck when weighing the need to treat psychosis with the desire to relieve a patient’s catatonia. Alternative treatments such as electroconvulsive therapy should be considered, as well as possibly amantadine and valproic acid. Further research must be undertaken to better understand the pathophysiology of catatonia due to underlying psychosis.