A detailed medical summary diagram titled "LETHAL CATATONIA (Malignant Catatonia)" for clinical reference. The diagram is organized into clearly labeled sections with color-coded boxes and arrows on a white background. SECTION 1 - DEFINITION (top, blue header): "A life-threatening form of catatonia with clinically significant autonomic dysregulation. NMS is considered an iatrogenically induced form of lethal catatonia." SECTION 2 - SUBTYPES OF CATATONIA (left column, 3 boxes): - Retarded/Stuporous: stupor, mutism, rigidity, waxy flexibility, negativism, posturing - Excited: agitation, combativeness, impulsivity, purposeless overactivity - MALIGNANT (highlighted red): stupor/excitement + autonomic instability + hyperthermia → LETHAL SECTION 3 - PATHOPHYSIOLOGY (center, orange): - Reduced GABA-A activity in substantia nigra → hypodopaminergia (dorsal/ventral striatum) - Increased NMDA receptor activity (dorsal striatum) - Serotonin disequilibrium (↑5-HT1A, ↓5-HT2A) - In NMS: D2 receptor blockade by neuroleptics → bottom-up striatal dysregulation - "Cortical-subcortical gridlock" analogy SECTION 4 - CLINICAL FEATURES of Malignant Catatonia (red box): - Stupor OR extreme excitement - Hyperthermia (high fever) - Autonomic dysregulation: tachycardia, BP changes, diaphoresis, tachypnea - Muscle rigidity (lead-pipe) - Altered/changing consciousness - Rhabdomyolysis → ↑CK → renal failure - Mortality: 75-100% untreated → reduced to 10% with treatment SECTION 5 - CAUSES / ASSOCIATIONS (yellow box, two columns): Psychiatric: Bipolar disorder, Schizophrenia, MDD, Autism spectrum disorder, PTSD Medical: Autoimmune encephalitis (anti-NMDA), CNS infections, Metabolic disorders, Non-convulsive status epilepticus, SLE, Basal ganglia disorders Drug-related: Neuroleptic withdrawal, Benzodiazepine withdrawal, Clozapine withdrawal, Dopamine antagonists (antipsychotics, metoclopramide) SECTION 6 - DIFFERENTIAL DIAGNOSIS (gray box): NMS | Serotonin Syndrome | Malignant Hyperthermia | Heat stroke | Anticholinergic syndrome | Autonomic storm | Pheochromocytoma SECTION 7 - WORKUP (teal box): Labs: CBC, CMP, serum CK (elevated in malignant catatonia), serum iron Imaging: MRI/CT brain EEG: diffuse slowing → delirium LP if encephalitis suspected → CSF autoimmune panel SECTION 8 - TREATMENT (green section, flowchart style): Step 1 - SUPPORTIVE CARE: IV fluids, cooling blanket, anticoagulation, NG/PEG feeds, autonomic control Step 2 - LORAZEPAM (first-line, 70-80% efficacy): 2mg IV challenge (Lazarus response in 30 min), then schedule 2mg q6h; up to 30mg/day; taper 10-25%/day once improved. AVOID antipsychotics alone. Step 3 - ECT (gold standard, 90% efficacy): No absolute contraindications; 2-3 sessions show improvement; maintenance ECT for relapse prevention Step 4 - ALTERNATIVES: Zolpidem 5-10mg; Amantadine 100-600mg/day; Memantine 10-20mg/day; Valproate, Bromocriptine; Aripiprazole (if antipsychotic needed) SECTION 9 - WARNING BOX (red border): "Antipsychotics alone may WORSEN catatonia and increase mortality. Dysautonomia = malignant catatonia. Treat first, ask questions later." Include arrows showing: Untreated → complications (DVT, PE, aspiration pneumonia, renal failure, death). Clean professional medical infographic style with clear typography and color coding.

A clean, professional medical reference diagram titled "LETHAL (MALIGNANT) CATATONIA" on a white background. Organized into 7 clearly labeled rectangular sections with color-coded headers and concise bullet points. Use a structured flowchart-style layout. TOP HEADER (dark red banner, white bold text): "LETHAL CATATONIA = Malignant Catatonia" with subtitle "Life-threatening catatonia + autonomic dysregulation. NMS is its iatrogenic equivalent." ROW 1 — two boxes side by side: LEFT BOX — "SUBTYPES OF CATATONIA" (steel blue header): - Retarded/Stuporous: mutism, rigidity, waxy flexibility, negativism, posturing, catalepsy, psychomotor retardation - Excited: agitation, combativeness, impulsivity, purposeless overactivity - MALIGNANT (red highlight): Either subtype + autonomic instability + hyperthermia → LETHAL RIGHT BOX — "CLINICAL FEATURES of Malignant Form" (dark red header): - Stupor OR extreme excitement - Hyperthermia (high fever) - Autonomic dysregulation: tachycardia, BP instability, diaphoresis, tachypnea - Lead-pipe muscle rigidity - Altered / fluctuating consciousness - Rhabdomyolysis → elevated CK → renal failure - MORTALITY: 75-100% untreated → reduced to 10% with Rx ROW 2 — two boxes side by side: LEFT BOX — "CAUSES / ASSOCIATIONS" (orange header): Psychiatric: Bipolar disorder, Schizophrenia, MDD, Autism spectrum disorder, PTSD, Postpartum psychosis Medical: Anti-NMDA receptor encephalitis, CNS infections, SLE, Non-convulsive status epilepticus, Basal ganglia disorders, Metabolic/endocrine (Wilson's), SAH, Prader-Willi, Antiphospholipid syndrome Drug-related: Dopamine antagonists (antipsychotics, metoclopramide), Dopamine-depleting agents (tetrabenazine), Benzodiazepine/clozapine/zolpidem withdrawal RIGHT BOX — "PATHOPHYSIOLOGY" (purple header): - Reduced GABA-A activity → hypodopaminergia in striatum/paralimbic cortex - Upregulated NMDA receptor activity in dorsal striatum - Serotonin imbalance: ↑5-HT1A, ↓5-HT2A - NMS: D2 receptor blockade by neuroleptics → bottom-up striatal dysregulation - Net effect: cortical-subcortical "gridlock" — loss of inhibitory modulation - GABA-A agonists (lorazepam) → disinhibit dopamine → restore normal flow ROW 3 — full-width box: "DIFFERENTIAL DIAGNOSIS" (gray header): NMS | Serotonin Syndrome | Malignant Hyperthermia | Heat Stroke | Anticholinergic Syndrome | Autonomic Storm | Pheochromocytoma | Thyrotoxicosis | CNS Vasculitis | Status Epilepticus | Tetanus ROW 4 — full-width treatment flowchart box: "TREATMENT" (green header) — horizontal stepped flow with arrows: STEP 1 "SUPPORTIVE CARE" (light green box): IV fluids, cooling blanket, anticoagulation, NG/PEG tube, urinary catheter, autonomic control, nursing care. Stop dopamine antagonists; resume GABAergic/dopamine agonists if withdrawn. → STEP 2 "LORAZEPAM (1st line)" (green box): 70-80% efficacy. 2mg IV challenge ("Lazarus response" in 30 min). If positive → schedule 2mg q6h. Titrate up to 30mg/day. Taper 10-25%/day once improved. Bridge to ECT. → STEP 3 "ECT (Gold Standard)" (dark green box): 90% efficacy. No absolute contraindications. Improvement in 2-3 sessions. Maintenance ECT for relapse prevention. → STEP 4 "ALTERNATIVES" (teal box): Zolpidem 5-10mg | Amantadine 100-600mg/day | Memantine 10-20mg/day | Valproate | Bromocriptine | Aripiprazole (if antipsychotic needed — partial D2 agonist preferred) BOTTOM WARNING BANNER (red border, bold red text): "WARNING: Antipsychotics ALONE may WORSEN catatonia and INCREASE MORTALITY. Dysautonomia = Malignant Catatonia. TREAT FIRST, ask questions later." Style: clean medical infographic, no background images, structured grid layout, readable sans-serif font, bold section headers, white background.