What is autistic catatonia?
Catatonia is a
complex neuro-psychological disorder which refers to a cluster of abnormalities
in movement, volition, speech and behavior. In its extreme form, it is
manifested as absence of speech (mutism), absence of movement (akinesia) and
maintenance of imposed postures (catalepsy). Lesser degrees of these
impairments, and various other abnormalities of posture, movement, speech and
behavior, are also considered to be catatonic phenomena.
Historically, the
term catatonia has been associated with schizophrenia and psychoses, but it is
now recognized that it can occur with a range of conditions, including autism
spectrum disorder (ASD). For example, studies suggest that between 12-18% of autistic individuals may present with varying levels of catatonia-like deterioration.
Although overlapping or shared symptoms (e.g., mutism, echolalia, stereotypic
speech and repetitive behavior) can present a diagnostic challenge, differences in
age-of-onset between catatonia and ASD can help to discriminate between the two similar symptom profiles. Specifically, the age-of-onset of catatonic
regression is typically observed at a later age than symptoms of ASD and occurs most often during adolescence and young adulthood. Stressful life
events, loss of routine, interpersonal conflicts, anxiety and depression, and
side effects of psychiatric medication may precipitate catatonia in adolescents
and teens on the spectrum. Researchers have posited that some
individuals may have an inherent vulnerability to developing catatonia, which
becomes overt in response to stress.
Although the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
does not recognize catatonia as a separate disorder, it is included as a
specifier for ASD to indicate the presence of comorbid (co-occurring)
catatonia. The DSM-5 recognizes that it is possible for individuals with ASD to
experience a marked deterioration in motor symptoms and display a catatonic
episode with symptoms such as mutism, posturing, grimacing, and motoric immobility.
Symptoms of catatonia in autism
Early
identification and diagnosis is critically important as autism-related catatonia can result in marked stress to families and can have a deleterious
effect on the quality of life of the individual. Symptoms can progress to acute
catatonia which is extremely difficult to treat and lead to total immobility,
dependence on all aspects of daily living, and become life-threatening.
Unfortunately, autistic catatonia is infrequently identified at an
early stage, and often misdiagnosed and mistreated. Clinicians may not
recognize the onset and gradual presentation of catatonic-like deterioration rather than the full-scale catatonic stupor state which is more easily
identified and familiar to most mental health practitioners. Co-morbid
catatonia should be considered as a possible diagnosis for an individual on the autism spectrum who who
shows a change in pre-existing symptoms and a marked and obvious deterioration in: (a) movement; (b) volition; (c)
level of activity; (d) speech; and (e) a regression in self-care, practical
skills and independence compared to previous levels.
Specific
indicators of an onset of autism-related catatonia may include any of the
following:
- increased slowness and freezing during actions
- increase in repetitive movements and hesitations
- difficulty in crossing thresholds and completing
movements
- marked reduction in speech or complete mutism
- aggression, extreme negativity, and difficulty initiating actions
- increased reliance on physical or verbal prompts for
functioning
- increase in repetitive and ritualistic behaviors
- grimacing, odd gait, and stiff, locked postures
- impulsivity, bizarre behavior, excitement, and purposeless agitation
Treatment
There is little
research evidence to guide medical treatment of autism-related catatonia. The
current medical treatment algorithm for catatonia-like deterioration in ASD recommends the use of
benzodiazepines, commonly lorazepam, and electroconvulsive therapy (ECT)
for cases with acute catatonic stupor or cases where other approaches have been ineffective. Unfortunately, there is a lack of
controlled studies examining the medical treatment of catatonic symptoms in
ASD. The existing literature is limited to single-case designs and reflects
serious methodological limitations. Likewise, studies have not examined the
side-effects of these treatments and infrequently report long term follow-up of
effects. As a result, there is little
robust evidence to support any specific treatment.
There is some
evidence that when catatonic symptoms in ASD become chronic a psychological
treatment approach, co-occurring with medical treatments, is useful to support
the management of the individual, particularly for parents and caregivers. This
non-medical treatment paradigm is based on a comprehensive psychological assessment
which focuses on identifying stressful life event(s), locating and
eliminating any potential causes such as psychiatric medications, and restructuring
the environment to effectively reduce the source(s) of the stressors. This
approach is also designed to help parents and caregivers understand and
conceptualize the catatonic syndrome and to work with caregivers and
multi-disciplinary teams to implement a treatment/intervention plan. In
addition, the use of prompts as external stimuli and physical activities,
especially routine and structure are emphasized. This psychological approach
can be helpful whether used together with or independently of medical treatments.
Implications
Given the paucity
of information in the literature, it is important to recognize and diagnose
autism-related catatonia as early as possible so that treatment and symptom
management can be implemented. Thus, it is critically important for clinicians, autism
professionals, educators, parents and caregivers to be aware of the symptoms of catatonia-like deterioration in teens and adults on
the autistic spectrum. Catatonia should be assessed in any individual with ASD
when there is a change in pre-existing symptoms and an obvious and marked deterioration in movement, pattern of
activities, self-care, and practical skills, compared with previous levels,
through a comprehensive diagnostic evaluation of medical and psychiatric
symptoms. Possible physical or psychological causes should be investigated, and
treated. There is some indication that screening for catatonic features and
providing early support might reduce later incidence of catatonic deterioration
in people with ASD. Lastly, there is an urgent need for controlled, high-quality studies
examining the potential causes and treatment protocols for this underidentified and misunderstood autism-related condition.
Key References & Further Reading
http://network.autism.org.uk/good-practice/evidence-base/catatonia-and-catatonia-type-breakdown-autism
https://www.autismspeaks.org/blog/2014/01/03/does-our-teen-have-autism-related-catatonia
DeJong, H., Bunton,
P., & Hare, D. (2014). A Systematic
Review of Interventions Used to Treat Catatonic Symptoms in People with
Autistic Spectrum Disorders. Journal of
Autism & Developmental Disorders. Vol 44: 2127-2136.
Dhossche, D., Shah,
A., & Wing, L. (2006). Blueprints for the Assessment, Treatment, and Future
Study of Catatonia in Autism Spectrum Disorders. Catatonia in Autism Spectrum
Disorders. International Review of Neurobiology Vol 72 P.268-283. Elsevier
Inc. USA.
Ghaziuddin, N.,
Dhossche, D., & Marcotte, K. (2012). Retrospective Chart Review of Catatonia in Child and Adolescent Psychiatric Patients. Acta Psychiatrica
Scandinavic, a, 125(1), 33-38.
Shah, A. & Wing, L. (2006). Psychological
Approaches to Chronic Catatonia-Like Deterioration in Autism Spectrum
Disorders. Catatonia in Autism Spectrum Disorders. International Review of
Neurobiology Vol 72 P.245-260. Elsevier Inc.
Wing, L. & Shah, A. (2000) Catatonia in
autistic spectrum disorders. British Journal of Psychiatry. Vol. 176,
357-362.
Lee A. Wilkinson,
PhD, NCSP is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist.
He is author of the award-winning books, A
Best Practice Guide to Assessment and Intervention for Autism and Asperger
Syndrome in Schools and Overcoming
Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT.
He is also editor of a text in the APA School Psychology Book Series, Autism
Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and
Intervention in Schools. His latest book is A
Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder
in Schools (2nd Edition).
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