How to manage a patient with auditory hallucinations (AH) and delusions who developed catatonia on Seroquel (quetiapine) but responded to Ativan (lorazepam) 2mg, and what to add if AH and delusions return?

Management of Neuroleptic-Induced Catatonia with Lorazepam and Treatment of Recurrent Psychosis

Continue lorazepam at the effective dose (2mg) for maintenance treatment of catatonia, and if auditory hallucinations and delusions return, add aripiprazole rather than restarting quetiapine, as the patient has demonstrated neuroleptic-induced catatonia.

Immediate Management: Lorazepam Continuation

Maintain lorazepam at the dose that achieved response (2mg) and continue indefinitely as maintenance therapy for catatonia. 1, 2

• Lorazepam is the first-line treatment for catatonia and should be continued at the lowest effective dose that maintains symptom control 3
• The patient's dramatic response to 2mg lorazepam confirms the diagnosis of catatonia and indicates this is an effective therapeutic dose 1, 4
• Benzodiazepines should be used in the lowest effective dose for catatonia management, but unlike delirium, catatonia often requires prolonged maintenance treatment 3, 2

Dosing Strategy for Lorazepam Maintenance

• Start with the effective dose of 2mg and monitor for recurrence of catatonic symptoms 2
• If catatonia symptoms re-emerge, increase lorazepam in 0.5-1mg increments rather than switching medications 2
• Some patients require indefinite benzodiazepine maintenance following catatonia, particularly when associated with psychotic disorders 2
• Critical pitfall: Sudden discontinuation or non-adherence to lorazepam can lead to catatonia relapse or loss of benzodiazepine response requiring higher doses 2

Management of Returning Auditory Hallucinations and Delusions

If psychotic symptoms (auditory hallucinations and delusions) return, add aripiprazole as the antipsychotic of choice rather than restarting quetiapine. 5

Rationale for Aripiprazole Selection

• The patient developed catatonia on quetiapine (Seroquel), indicating neuroleptic sensitivity 6
• Aripiprazole has a lower risk of extrapyramidal symptoms and catatonia induction compared to other antipsychotics 3
• Aripiprazole is specifically recommended for delusional symptoms and has third-generation antipsychotic properties with reduced motor side effects 3, 5

Aripiprazole Dosing Protocol

• Start aripiprazole at 5mg daily (lower dose given the patient's demonstrated neuroleptic sensitivity) 3
• Titrate gradually based on response to psychotic symptoms while monitoring closely for any re-emergence of catatonic features 3
• Do not discontinue or taper lorazepam when adding aripiprazole—maintain benzodiazepine coverage to prevent catatonia recurrence 5, 2

Alternative Antipsychotic if Aripiprazole Fails or Is Not Tolerated

Consider clozapine as a second-line option if aripiprazole is ineffective or causes catatonic symptoms. 7

• Clozapine has demonstrated efficacy in preventing recurrent catatonia in schizophrenia patients 7
• Two case reports showed complete resolution of recurrent catatonia with continuous clozapine therapy over 2-year follow-up 7
• Clozapine may be particularly useful if the patient has a pattern of recurrent catatonia with other antipsychotics 7

Critical Monitoring Parameters

For Catatonia Recurrence

• Monitor for mutism, rigidity, negativism, posturing, and stupor 1, 4
• Assess for autonomic instability (hyperthermia, tachycardia, hypertension, excessive sweating) which may indicate progression to malignant catatonia 1
• Check CPK levels if catatonic symptoms re-emerge 1

For Benzodiazepine Tolerance

• Approximately 44% of patients (4 of 9 in one series) developed chronic tolerance requiring higher lorazepam doses over time 2
• If the patient requires progressively higher doses to maintain response, this indicates tolerance development 2
• Consider cross-taper to clonazepam if tolerance develops, though this is challenging and may result in relapse 2

What NOT to Do

Do not restart quetiapine or use other typical/atypical antipsychotics that caused the initial catatonia. 6

• Antipsychotics are not effective for relieving catatonia and may induce neuroleptic malignant syndrome 1
• Haloperidol specifically worsened catatonic and psychotic symptoms in documented cases despite normalized CPK 1
• Benzodiazepines are contraindicated as treatment for delusions alone, but in this case, the primary indication is catatonia, not delusional symptoms 5

Long-Term Management Strategy

• Continue lorazepam indefinitely as maintenance for catatonia prevention 2
• Add aripiprazole specifically to target auditory hallucinations and delusions if they return 5
• Consider tapering benzodiazepines only after aripiprazole is optimized and catatonia has been stable for an extended period, though many patients require indefinite benzodiazepine maintenance 5, 2
• Monitor for fall risk, cognitive impairment, and paradoxical agitation with chronic benzodiazepine use 5