None of those under the age of 15 years had full catatonic syndrome, although isolated catatonic symptoms were often observed. In the majority of cases, catatonic symptoms started between the ages of 10 and 19 years. Five individuals had brief episodes of slowness and freezing during childhood, before 10 years of age. Schizophrenia was not diagnosed in any of the patients.
In a report based on a population study, 13 (11%) of 120 autistic persons aged 17 to 40 years (mean age 25.5 years) had clinically diagnosed catatonia with severe motor initiation problems.4 Another 4 had several catatonic symptoms but not the full syndrome. Autistic disorder was diagnosed in 8 of the 13 persons with catatonia; atypical autism was diagnosed in the remaining 5. The proportion of those with autistic disorder in whom catatonia was diagnosed was 11% (8 of 73); 14% of those with atypical autism (5 of 35) had catatonia.
An increasing number of case reports and case series on catatonia in autism that satisfy DSM-IVcriteria for catatonia have been published in the past 15 years.5-15 There is considerable overlap of psychomotor symptoms between the 2 disorders (eg, muteness, echolalia, stereotypical movements, and other psychomotor peculiarities).16 The diagnosis of catatonia in publishedcases was based on significant worsening of these symptoms and emergence of other catatonic symptoms. Some of the authors report that patients responded to treatment with lorazepam(Drug information on lorazepam) (the benzodiazepine most often used) and/or ECT. It should be noted that none of these studies were controlled and the number of cases was very small.
Case 1: Catatonia in an autistic adolescent
A boy in whom Asperger disorderhad been diagnosed showed a decline in function at the age of 15 years when he stopped speaking except to family members. His posture deteriorated. He began to slump and would complain of back pain. At school, he refused to enter classrooms and would walk slowly through corridors with his head down. He was unable to retain food in his mouth. Eventually, he required support in order to stand. He showed poor fine and gross motor skills, with difficulty in holding and using implements (such as a knife to butter bread). His speech slowed excessively at home. He would not engage in activities other than those associated with his specific interest in transport, mostly aircraft. By the age of 17 years, it was very difficult to get him to leave the family home. He required assistance washing and dressing and stopped using the toilet. The psychiatrist considered a diagnosis of catatonia but demurred because of the seemingly selective occurrence of symptoms. During medical examinations, the patient was often uncooperative and unresponsive. He refused to take the prescribed diazepam and fluoxetine(Drug information on fluoxetine).
An intensive behavioral intervention was started using the framework set out by Shah and Wing15 for the treatment of catatonia in patients with autism. On evaluation 9 months later, he showed improvement, speaking more and walking almost everywhere independently. He was able to express a wider range of emotion verbally and nonverbally. Recent testing revealed an IQ of 89. Despite the progress made, he continues to show various motility problems across all circumstances, mainly slowness of movement, clumsiness, inability to control movement, poor coordination, freezing of movement, and awkward posture. The parents are pursuing other treatments for his condition.
A diagnosis of catatonia in this patient is likely. An algorithm for the assessment of catatonia in autism is shown in Figure 1.17 From the age of 15, the patient showed various catatonic symptoms, including mutism, stupor, and posturing, that have remained present although his level of function has recently improved. His symptoms satisfy criteria for catatonia in autism shown in the Table.17
Diagnostic criteria for catatonia in autism
|Immobility, drastically decreased speech, or stupor of at least 1 day’s duration, associated with at least 1 of the following: catalepsy, automatic obedience, or posturing|
|In the absence of from baseline, for slowness of movement prompted, freezing stereotypy, echophenomena, ambitendency|
The severity of catatonia should be determined by assessing the degree to which activities of daily living, occupational activities, and physiologic necessities (eating, drinking, and excretion) are affected. Definitions of mild, moderate, and severe catatonia can be found elsewhere.17 The level of impairment should guide the need for services and staffing levels, as well as the choice of available anticatatonic treatments. At his worst, the patient described above seemed to have severe catatonia--stupor, immobility for most of the day, and need of assistance with food intake--constituting a medical emergency. Patients with features of malignant catatonia (fever, altered consciousness, stupor, and autonomic instability as evidenced by lability of blood pressure, tachycardia, vasoconstriction, and diaphoresis) also fall in this category. Severe and malignant catatonia are indications for administration of lorazepam and ECT.
Does catatonia in autism respond to treatment?
An algorithm for the treatment of moderate catatonia in autism, as in the patient presented in the first case vignette, is shown in Figure 2.17 The proposed schedule relies on the recommendations of some catatonia researchers18,19 and some published case reports and case series.5-15 The psychological approach to treatment outlined below should be available for use in combination with medication or alone if medication fails.