Catatonia is a neuropsychiatric syndrome affecting movement, speech, and behavior. Historically linked to schizophrenia, it is now known to occur across many disorders. Autistic catatonia describes this syndrome specifically in individuals with autism spectrum disorder. Recognizing this distinct presentation is important for addressing the unique needs of autistic individuals.
What is Autistic Catatonia
Autistic catatonia is a neuropsychiatric syndrome characterized by abnormalities in movement, volition, speech, and behavior in individuals with autism spectrum disorder. It is distinct from general catatonia because its symptoms can overlap with existing autistic traits, making it harder to identify. This condition is a significant co-occurring condition within the autistic population.
Prevalence estimates of catatonia in autistic individuals vary, with some studies suggesting it affects between 6% and 20.2% of this population, with a mean estimate around 9-10.4%. Some researchers believe the true number may be even higher, as many cases might go undiagnosed due to the subtle presentation or misinterpretation of symptoms as typical autistic behaviors. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), acknowledges catatonia in autistic people, allowing for diagnoses such as “Catatonia–Not Otherwise Specified” or “Autism–With Catatonia”.
Recognizing the Signs
Identifying autistic catatonia involves observing specific behavioral and physical changes that represent a noticeable deterioration from an individual’s baseline functioning. Motor disturbances are common, including increased slowness in movement, difficulty initiating or completing actions, and “freezing” during activities. Individuals may exhibit immobility, known as stupor, or maintain unusual postures for extended periods, a sign called posturing. Waxy flexibility, where a limb can be moved and remains in the new position, can also be present.
Repetitive movements, known as stereotypies, may increase in frequency or change in nature, sometimes appearing as unusual mannerisms. Agitation can also occur, characterized by purposeless restlessness. Speech disturbances include mutism, a significant reduction or complete absence of speech, or echolalia, the involuntary repetition of others’ words. Behavioral changes might involve increased withdrawal, heightened reliance on physical or verbal prompts for daily tasks, or a regression in self-care skills.
Why it Occurs
The underlying factors contributing to autistic catatonia are complex and likely multifactorial. Neurological mechanisms are thought to play a role, with some studies suggesting dysfunction in the gamma-aminobutyric acid (GABA) system and its receptors. Imbalances in neurotransmitters like dopamine may also be involved in the development of catatonic symptoms. Additionally, neuroimaging studies have indicated that autistic individuals with catatonia may have abnormally small cerebellar structures, and genetic studies point to potential alterations on chromosome 15.
Psychological stressors are also recognized as contributing factors. Autistic individuals can be more susceptible to anxiety, sensory overload, and difficulties with transitions, which may precipitate catatonic episodes. Severe stress, trauma, or significant life changes can trigger catatonia in vulnerable individuals. Co-occurring medical conditions can also influence its onset. For example, epilepsy and certain autoimmune disorders have been associated with catatonia, and a thorough medical evaluation is often necessary to rule out such underlying causes.
Diagnosis and Assessment
Diagnosing autistic catatonia often involves a comprehensive process that begins with detailed clinical observation and a thorough review of the individual’s medical history. Challenges arise because many catatonic symptoms, such as repetitive behaviors, mutism, and reliance on prompting, can overlap with existing autistic traits, making it difficult to differentiate between the two. Therefore, a change in the individual’s baseline functioning or the emergence of new symptoms is a key indicator.
Professionals experienced in both autism and catatonia conduct the evaluation. They may utilize specific assessment scales designed for catatonia, such as the Bush-Francis Catatonia Rating Scale (BFCRS), to assess the severity of symptoms. The “lorazepam challenge test,” where a small dose of lorazepam is administered to observe a temporary improvement in catatonic symptoms, can also aid in diagnosis, particularly in more severe cases. A multidisciplinary approach involving various specialists helps ensure an accurate diagnosis and appropriate intervention.
Treatment and Support Strategies
Managing autistic catatonia involves a combination of pharmacological and non-pharmacological interventions, tailored to individual needs. Benzodiazepines, such as lorazepam, are a first-line pharmacological treatment due to their effectiveness in rapidly reducing catatonic symptoms. The dosage and duration of treatment are carefully monitored, and other medications may be used to address co-occurring conditions or specific symptoms. If benzodiazepines are ineffective, electroconvulsive therapy (ECT) may be considered in severe or life-threatening cases, though it is generally reserved as a last resort.
Non-pharmacological strategies are equally important and aim to create a supportive environment and improve functional abilities. Environmental modifications, such as reducing sensory overload and maintaining predictable routines, can lessen anxiety and potential triggers. Behavioral therapies, occupational therapy, and physical therapy can help improve motor skills, communication, and daily living activities. A multidisciplinary team, including medical doctors, psychiatrists, psychologists, and therapists, collaborates with caregivers to implement these strategies, ensuring ongoing support and proactive measures to prevent relapse.