Catatonia in the Context of Emerging Psychosis: Diagnostic and Therapeutic Challenges in Adolescent Psychiatry

Catatonia is a complex neuropsychiatric syndrome that can often be difficult to diagnose in adolescents, particularly when it co-occurs with emerging psychosis. Timely diagnosis is crucial, as delayed treatment may lead to serious complications or delay in treatment. We present the case of a 17-year-old Haitian-American male with no prior medical or psychiatric history who was hospitalized for waxing and waning altered mental status. His presentation included mutism, inappropriate smiling, and posturing. Initial workup was unrevealing, but a lorazepam challenge led to transient improvement, supporting a diagnosis of catatonia. He was treated with lorazepam and antipsychotics, with fluctuating response. Over the following eleven months, he developed persistent psychotic symptoms and was ultimately diagnosed with schizophrenia. Our case illustrates the diagnostic challenges and therapeutic complexities of managing catatonia in the context of emerging psychosis in youth. It highlights the need for high clinical suspicion, multidisciplinary collaboration, and culturally sensitive care. The patient's history of substance use and brief improvement with naloxone during his initial presentation also raises consideration of substance-related contributions. Importantly, this case underscores the necessity of prompt empiric treatment in diagnostically ambiguous presentations, as early intervention can improve outcomes. Further research is warranted to refine diagnostic strategies and treatment protocols for pediatric catatonia, particularly when occurring in the setting of first-episode psychosis.