High hopes: catatonia due to medication and substance abuse in two cases

Abstract Background Catatonia due to another general medical condition (CDGMC) is common in consultation-liaison settings. We organize toxic and metabolic etiologies using the MINDSET mnemonic (Miscellaneous; Inflammation of the CNS; Neural injury/Neurodegenerative; Developmental; Structural/space-occupying; Epilepsy; Toxins/Medications), emphasizing the frequently overlooked toxic domain. Methods At our institution, catatonia is assessed by the consultation-liaison psychiatry service using the Bush-Francis Catatonia Rating Scale (BFCRS) and the KANNER Catatonia Rating Scale, alongside focused medical evaluation to identify CDGMC and malignant features. Case 1 A 71-year-old woman with mutism, immobility, and refusal of intake received ceftriaxone (hospital day [HD] 1) for UTI and metoclopramide during endoscopy (HD2). On HD3, BFCRS = 28; KANNER Part I = 3, Part II = 24, Part III = 5. Lorazepam 0.5 mg PO TID was initiated with rapid improvement; both agents were discontinued. Further neurologic testing (EEG/imaging) was deferred given temporal association and recovery. She was discharged on HD9 without benzodiazepines and with sustained resolution. Case 2 A 33-year-old woman presented with stupor, mutism, and immobility in the context of polysubstance use; toxicology was positive for methamphetamine, fentanyl, and benzodiazepines. BFCRS = 7; KANNER Part I = 3, Part II = 28, Part III = 5. Lorazepam 1 mg IM TID produced marked improvement within 24 h. She transferred to a dual-diagnosis facility with no recurrence at short-term follow-up. Key takeaways (1) A MINDSET-guided lens helps clinicians rapidly consider CDGMC, especially toxins/medications; (2) scale-guided bedside assessment supports timely benzodiazepine treatment and discontinuation of potential offending agents; (3) BFCRS and KANNER are feasible and complementary for detection and serial tracking in acute care.