Just when you think you’ve read it all, here comes another condition that is said to be related to autism: catatonia. If you haven’t heard yet, autism and catatonia have been closely studied to understand their comorbid occurrence and, from what we currently know, unfortunately, it does appear to be true that there’s some crossover.
Research into autism-related catatonia has shown the condition to be prevalent within the autism spectrum disorders (ASD) population. Catatonia is an underrecognized debilitating syndrome with long-lasting effects. Its symptoms are diverse and quite challenging depending on the severity and many families face challenges from diagnosis to effective treatments.
If you’re new to this topic or have just learned about catatonia, this article will help to unpack autism and catatonia in depth using a case study published in 2021.
What is catatonia and its subtypes?
Catatonia is a complex neuro psychological disorder characterized by psychomotor disturbances and global symptoms including stupor, waxy flexibility, and mutism lasting more than one hour (Quilliam, et al., 2020). And recently, there’s been more and more research linking catatonia to autism.
The experience of autistic catatonia is ill-understood and not easily diagnosed despite it dating back 20 years (Burns, et al. 2021). The reason being that it is difficult to recognize and its symptoms vary. This is in part due to fluctuations in severity and the features of both autism disorder and catatonia.
Classic (stupor) and excited catatonia are two common forms of the condition:
- Excited or malignant catatonia is identified by motor restlessness and severe psychomotor agitation, potentially leading to life-threatening complications such as hyperthermia, altered consciousness, and autonomic dysfunction, including some symptoms of classic catatonia (Rasmussen, Mazurek, & Rosebush, 2016)
- Classic (stupor) catatonia is characterized by immobility, staring, mutism, rigidity, withdrawal, and refusal to eat, along with more unusual features such as posturing, grimacing, negativism, waxy flexibility, echolalia or echopraxia, stereotypy, verbigeration, and automatic obedience (Rasmussen, Mazurek, & Rosebush, 2016)
It is advised that excited catatonia be considered a medical emergency and a condition called neuroleptic malignant syndrome (NMS) could be considered a form of malignant catatonia. NMS is a life-threatening neurological condition that is linked to the use of antipsychotic agents. Its symptoms are “characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia (disorders of the autonomic nervous system)”. (Wijdicks, E.F.M., 2021)
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Catatonic symptoms of immobility and refusal to eat or drink can cause medical complications such as dehydration, malnutrition, deep vein thrombosis, pulmonary embolism, pneumonia, and others.
The risk factors of developing autistic catatonia are still under investigation. Some hypotheses suggest it could be linked to a “reaction to extreme fear, interpersonal conflict, a tragic event, or following a significant loss” but the direct cause or pathophysiology is unknown (Quilliam, et al., 2020). Some may be predisposed to genes on chromosomes 15 and 22 (Quilliam, et al., 2020).
What does autistic catatonia look like?
Symptoms of autistic catatonia can easily be missed because they’re so similar to symptoms of standard autistic behavior such as repetitive and restrictive behavior, fixation, difficulty making eye contact, to name a few.
While catatonia is found to be related to autism and is termed “autistic catatonia”, the symptoms of autistic catatonia are much more severe. Individuals with autistic catatonia experience symptoms such as obsessive compulsions, repetitive purposeless behaviors, and unresponsiveness to the external world.
Clinicians can detect signs of catatonia by observing symptoms such as psychomotor delay and weight loss, plus many patients show signs of stupor alternating with excitement. Additionally, psychosis is observed in about 75% of patients with catatonia.
When there’s comorbidity with autism, catatonia, and psychosis, this combination is called the “Iron Triangle” and, according to Shorter & Wachtel, (2013), psychosis is strongly linked to autistic catatonia.
The link between catatonia and autism
Currently, the prevalence rate of catatonia in psychiatric units is estimated at five to 20% and the rate of comorbid catatonia in autism or autistic catatonia is 12 to 20% (Burns, et al. 2021).
Unfortunately, it is difficult to recognize catatonic symptoms in individuals with ASD because, firstly, there are 40 different symptoms of catatonia, secondly, the overlap between autism and catatonia creates difficulty for obtaining a diagnosis.
Let’s look at treatment methods for autistic catatonia from the context of two adolescent psychiatric patients: Patient A and Patient B in the case study by Burns, et al, published in 2021.
A case study analysis of autistic catatonia
Burns, et al. (2021) studies two cases of excited catatonia in young men diagnosed with autism. One (Patient A) was an 18-year-old male with high-functioning autism and attention deficit hyperactivity disorder (ADHD). He experienced symptoms such as repetitive behaviors, mutism, disinhibition, and periods of increased psychomotor agitation and aggression. The second male (Patient B) was a 17-year-old with autism and profound intellectual disabilities. Additionally, he experienced symptoms such as increased aggression, urinary incontinence, disinhibited behavior, posturing, grimacing, and running attacks. Both these cases faced delays in diagnosis of catatonia and challenges obtaining appropriate treatment, largely due to their autism.
Patient A was unofficially diagnosed after three months due to a change in sudden and dramatic behavior but unfortunately faced difficulty in receiving help while the other patient (Patient B) had been suffering for more than five years with a slow progression of worsening aggressive symptoms. Patient B’s condition became so severe that the patient required sedation, intubation, and daily electroconvulsive therapy (ECT). “Both suffered from agitation, unprovoked aggression, urinary incontinence, stereotypic, and OCD behaviors and compulsive masturbation” (Burns, et al. 2021).
The study proposes “screening all patients with neurodevelopmental disorders with the Bush-Francis and Kanner scales to diagnose and treat them appropriately” (Burns, et al. 2021).
How to treat catatonic symptoms in autism
The first step to administering any treatment is obtaining a diagnosis. Unfortunately, because autistic catatonia is ill defined and still difficult to diagnose, many individuals go through a series of treatment options to assist with the symptoms.
Let’s look at treatment methods for autistic catatonia from the context of Patient A and Patient B.
Patient A went through a series of symptomatic events and was moved to a psychiatric ward four times while exhibiting severe aggressive behavior to the point of impulsively stabbing a social worker. Eventually, after considering the behaviors, a psychiatrist derived a treatment plan based on a presumptive diagnosis of autistic catatonia at the time. He initially administered a lorazepam challenge of two mg intramuscularly (IM) which was markedly positive.
A lorazepam challenge is a treatment mainly used to determine the likelihood of a catatonia diagnosis (Beach, 2020). It also helps to determine a person’s response to benzodiazepines (type of sedative medication).
After administering the lorazepam challenge, the Bush-Francis Catatonia Rating Scale (BFCRS) was conducted and the score dropped from 27 to 12. The BFCRS is used to diagnose catatonia and monitor response to treatment.
After a series of days of administering lorazepam at different concentrations, improvements such as repetitive behaviors decreased and speech improved. The patient began following instructions, had great spatial orientation (place, space, and time), and many more positives were observed.
Patient A then started a therapy treatment known as electroconvulsive therapy (ECT) which is commonly used for patients with severe depression or bipolar. After a series of trial and error approaches to determine the right frequency for attending ECT and dosage of various medication including antipsychotic medications, some of the staff no longer witnessed catatonic behaviors, and behaviors of catatonia were less noticeable such as motor signs stereotypies, tics, hand-flapping, finger-snapping, and head-turning.
Patient A follows a series of treatment plans which also include cannabidiol for anxiety and sleep.
Patient B at the time was 17-years-old with level three autistic spectrum disorder (ASD), profound intellectual disability, and language impairment. At the time of his admission to the emergency department, he was in a state of excited catatonia.
His symptoms included:
- Decline in psychomotor functioning
- Stereotypical movements such as grimacing, posturing, and muscle tensing
- Refusal to follow instructions without motive
- Agitated and aggressive, scratching and biting his mother and the ABA therapist
- Engaged in inappropriate sexual behaviors
- Compulsive masturbation and refused to wear clothes
- Restricted his diet
- Obsessed with water (he flooded his home and refused to toilet appropriately)
- Slept poorly and showed intermittent behaviors such as tearfulness, wailing, and laughing
He was treated with oral lorazepam which afforded him brief periods of reduced symptoms. When he was taken to the emergency department, he was administered a series of treatments including lorazepam. He underwent ECT treatments along with prescribed doses of sedatives among other treatments to manage symptoms. At the fifth ECT session, Patient B showed significant improvement.
Some notable improvements included: responsiveness to verbal and physical prompts, ability to toilet correctly, body tensing resolved, an ABA therapist noted that his functioning corresponded to when he was eight years old, he laughed, responded to questions, was no longer restrained, sat calmly in bed clothed, inappropriate sexual behavior stopped, and his mother and therapist noted language skills from four years prior.
The overall picture of autistic catatonia treatment
Although lorazepam challenge is a common treatment for catatonia, about 20% of individuals who receive this treatment do not respond positively.
As we know, the earlier a condition is detected, the more effective treatments become but, unfortunately, for conditions such as catatonia, each person’s experiences or symptoms differ.
The behaviors seen in autism overlap very closely with those of catatonia and this makes diagnosing so much more difficult. For this reason, it is recommended that patients with autism who show signs of decline in adaptive functioning are screened against the Kanner and Bush-Francis Catatonia Rating Scales and receive strict maintenance electroconvulsive therapy.
This article used the case study of Patients A and B published by Burns, et al. (2021) to help parents understand autistic catatonia more clearly.
Some key points to close with are as follows. Both these patients had different levels of baseline functioning and their symptoms of excited catatonia were different. Despite Patient A’s dramatic results with ECT treatment, the diagnosis of excitatory catatonia was still questioned. His treatment was even more challenging and he developed resistance to ECT treatment because psychiatrists later realized that ECT treatment is most effective when it is spaced weekly.
Patient A was diagnosed after five psychiatric admissions, while Patient B’s symptoms of catatonia were gradual over a period of more than five years. The lorazepam challenge was most effective for patient B and the inpatient psychiatric team advocated for daily ECT for faster results which were necessary to manage the aggressive behaviors that posed a threat to himself and others.
Overall, due to the trial and error nature of the treatment methods for catatonia, both patients underwent several relapses before the psychiatrist derived a suitable treatment plan.
Additionally, although both patients were positive for excitatory catatonia and autism, their symptoms were different, so not only was diagnosing their condition difficult but their treatment plans were unique to each of them.
A comprehensive psychological assessment that assesses the level of functioning of autistic patients is a great starting point for diagnosing autistic catatonia. This should include assessment of speech, written communication, aggression, ritualistic behaviors, and toileting. It can be topped off with catatonia screening tools.
The challenges that individuals with autism face are vast, and even more so when an individual has autistic catatonia. The challenges are even more overwhelming because of the nature of the condition and, for this reason, we need to raise awareness about the need for research, appropriate effective treatments, and educating the medical community and general public on catatonia.
To learn more about case studies focusing on catatonia and autism, I would encourage reading the articles by Burns, et al., (2021) and Quilliam, et al. (2020) (references below).
American Psychiatric Association, What is Electroconvulsive therapy (ECT)?, https://www.psychiatry.org/patients-families/ect#:~:text=Electroconvulsive%20therapy%20(ECT)%20is%20a,the%20patient%20is%20under%20anesthesia https://www.psychiatry.org/patients-families/ect#:~:text=Electroconvulsive%20therapy%20(ECT)%20is%20a,the%20patient%20is%20under%20anesthesia
Beach, S. R., 2020. Catatonia Diagnosis: The Lorazepam Challenge, https://psychopharmacologyinstitute.com/section/catatonia-diagnosis-the-lorazepam-challenge-2500-4700
Burns, N. K., Grissett, K., Macaluso, M., Raza, M., & Gracious, B. (2021). Excited Catatonia in Autism Spectrum Disorder: A Case Series. Frontiers in psychiatry, 12, 674335. https://doi.org/10.3389/fpsyt.2021.674335
Quilliam, R., Quilliam, S., Turnbull, M., Parkinson, S., & Oligbu, G. (2020). Catatonia as a presentation of autism in a child: a case report. AIMS neuroscience, 7(3), 327–332. https://doi.org/10.3934/Neuroscience.2020019
Shorter, E., & Wachtel, L. E. (2013). Childhood catatonia, autism and psychosis past and present: is there an ‘iron triangle’?. Acta psychiatrica Scandinavica, 128(1), 21–33. https://doi.org/10.1111/acps.12082
Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016). Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World journal of psychiatry, 6(4), 391–398. https://doi.org/10.5498/wjp.v6.i4.391
Wijdicks, E.F.M., 2021. Neuroleptic malignant syndrome. UpToDate, https://www.uptodate.com/contents/neuroleptic-malignant-syndrome#:~:text=INTRODUCTION%20Neuroleptic%20malignant%20syndrome%20(NMS,rigidity%2C%20fever%2C%20and%20dysautonomia.