Malignant Catatonia From Paliperidone Withdrawal With Successful Pharmacological Treatment: A Diagnostic and Therapeutic Challenge

Catatonia is a neuropsychiatric syndrome of psychomotor disturbances occurring in various psychiatric and medical conditions, as well as from adverse effects of antipsychotics. Malignant catatonia is a severe, life-threatening subtype characterized by autonomic instability along with typical catatonia features. It requires immediate treatment with electroconvulsive therapy (ECT) in critical care settings. While oral antipsychotics are well-recognized causes of withdrawal catatonia, cases related to long-acting injectable antipsychotic drugs causing withdrawal catatonia occur less commonly. We present a case of a 43-year-old man with schizophrenia, major depressive disorder, and generalized anxiety disorder who had been on paliperidone. The patient presented to the hospital after missing a dose of paliperidone with symptoms consistent with catatonia. His condition rapidly deteriorated, leading to malignant catatonia. The ECT plan was deferred due to non-availability at the facility and the family’s wishes. The patient was treated with high-dose benzodiazepines, which successfully improved his symptoms. He had a prolonged hospital stay due to slow recovery and was discharged on a long taper of benzodiazepines. Paliperidone was resumed as an outpatient because of concerns about rebound catatonia following immediate resumption during hospitalization. This case highlights several atypical features related to catatonia and long-acting injectable antipsychotic medications. It also emphasizes the importance of potential adverse effects from medication nonadherence, especially with long-acting injectable antipsychotics, which can pose diagnostic challenges. Early recognition of malignant hyperthermia, aggressive benzodiazepine dose escalation, and ECT remain cornerstones of successful management. The case further highlights therapeutic challenges in psychiatric emergencies due to patient and system factors.