Catatonia and Psychosis in Pediatric Neuropsychiatric Systemic Lupus Erythematosus: A Literature Review and Clinical Insights Introduction

Background Neuropsychiatric systemic lupus erythematosus (NPSLE) is a rare complication that can involve psychosis and catatonia. Treating these syndromes together poses a clinical challenge because antipsychotics may exacerbate catatonia, while delays in appropriate intervention risk malignant progression. Due to the lack of robust evidence-based guidelines, psychiatrists are confronted with a clinical decision-making dilemma when patients present with severe psychosis and medication-refractory catatonia simultaneously, especially where gold-standard electroconvulsive therapy is unavailable. Despite the recent surge of published reports on pediatric NPSLE cases with concurrent psychosis and catatonia, an updated review does not currently exist in the literature. Methods The present study includes a narrative review of published pediatric NPSLE cases with co-occurring psychosis and catatonia to characterize clinical presentations and differential considerations and to delineate treatment sequences associated with outcomes. Results A literature review highlighted that antipsychotic use before catatonia control was associated with clinical deterioration and early discontinuation. However, a single report of continuous antipsychotic use under ongoing immunotherapy documented gradual improvement, suggesting context-dependent feasibility. First-line management emphasized benzodiazepines with early, aggressive control of lupus activity (eg, high-dose corticosteroids, cyclophosphamide, rituximab, and plasmapheresis/IVIG when indicated). For treatment-refractory catatonia, electroconvulsive therapy was consistently associated with rapid resolution of catatonia and concurrent recovery of psychotic features. Taken together, the findings recommended early recognition of catatonia, timely immunotherapy treatment, and cautious antipsychotic introduction after catatonia stabilized for optimal outcomes. Conclusion Pediatric NPSLE complicated by psychosis and catatonia warrants early detection with standardized catatonia screening and a sequenced approach that prioritizes rapid control of lupus activity and catatonia (benzodiazepines and immunotherapy), reserves antipsychotics until stabilization, and employs electroconvulsive therapy early when catatonia is refractory.