Catatonia in Autism or the Blind Men and the Elephant

Recent accounts provide empirical evidence that catatonia is diagnosable in 7% to 17% of acute psychiatric inpatients and is treatable.¹⁸ This contradicts earlier comments that catatonia may have disappeared in adult psychiatry.²⁸ Given these conflicting views and the ambiguous nosologic status of catatonia in DSM-IV,one could argue that catatonia has become like the elephant and the blind men. Many aspects of catatonia are described but the syndromal diagnosis is often not made, possibly leading to suboptimal therapy. The emerging evidence that a similar proportion of autistic adolescents and adults also meet criteria for autism has 2 major clinical implications.

First, catatonia should be considered in any autistic patient of any age when there is an obvious and marked deterioration in movement, pattern of activities, self-care, and practical skills. An outline for diagnostic evaluation in such cases is shown in Figure 1 and the Table. Researchers should seek further evidence that catatonia in autism responds to accepted anticatatonic treatments. Treatment responsiveness is key in clarifying the nature of the beast. Clinicians may find the proposed treatment algorithms for catatonia in autism, as in Figure 2, helpful in the treatment of the disorder in these challenging patients.

Second, autism should be considered as the underlying condition in patients presenting with catatonia, especially in those with histories of developmental problems. Psychiatrists working with adults are usually much more familiar with schizophrenia and other psychotic disorders than autism. Therefore, catatonia may be misdiagnosed as a feature of schizophrenia, and any underlying diagnosis of autism may be missed, leading to possible suboptimal treatment of both catatonia and autism.

Limitations

The lack of controlled studies and the very small number of published cases to date must be emphasized. It is not clear from the available evidence whether treatment with lorazepam(Drug information on lorazepam) and/ or ECT is helpful in all cases of autism in which catatonic features become exacerbated or only in those with very severe forms of catatonia. Another consideration is the likelihood that only examples of successful treatments will be published. These problems emphasize the necessity for more research in this field. Cooperation between centers would be particularly valuable because each clinician is likely to see only a few cases.

Acknowledgments

The authors thank the parents of the young man in the first case for allowing publication of details of the illness of their son, and Miss Kathryn M. Darke (BSc psychology, 1-to-1 support worker) for writing up the information they provided.

Dr Dhossche is a professor of psychiatry and medical director of the University Child Psychiatry Unit at the University of Mississippi Medical Center, Jackson. He serves on the board of directors of the American Academy of Clinical Psychiatrists. His recent work includes editing 2 books in the International Review of Neuro- biology series, GABA in Autism and Related Disordersand Catatonia in Autism Spectrum Dis- orders.He reports that he has no conflicts of interest concerning the subject matter of this article.

Dr Wing is a psychiatrist involved in researching developmental disorders, particularly autistic spectrum disorders. She joined with other parents of autistic children to found the National Autistic Society (NAS) in the United Kingdom in 1962. She currently works part-time as a consultant psychiatrist at the NAS Centre for Social and Communication Disorders at Elliot House. Dr Wing lives in England and is the author of many books and academic papers, including Asperger's Syndrome: a Clinical Account,a 1981 academic paper that popularized the research of Hans Asperger and introduced the term Asperger syndrome. She reports that she has no conflicts of interest concerning the subject matter of this article.