OBJECTIVE: The case of a schizoaffective patient suffering from a malignant catatonic syndrome following combined lithium-risperidone therapy is explored. METHOD: A case report and relevant deliberations regarding pathophysiology of the catatonic dilemma are discussed. CONCLUSIONS: There are two critical transitions in the development of a malignant catatonic syndrome. Dopaminergic system and psychopharmacological factors are supposed to play a key role. However, other neurotransmitter systems and the individual predisposition must be considered.