Autistic catatonia

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Autistic catatonia is a term used to describe the occurrence of catatonia in autistic people. [1] Catatonia is a complex behavioral syndrome typically characterized by immobility, withdrawal, abnormal movements, and abnormal behaviors. [2] [3] According to current diagnostic guidelines, its primary feature is that it causes patients to demonstrate one or more of the following: 1) decreased movement; 2) "decreased engagement during an interview or physical examination", and/or 3) "excessive and peculiar movement". [4]

Contents

Most researchers believe that at least 1 in 10 autistic people has catatonia, while some have suggested that the true number may be as high as 1 in 5. [1] More specifically, prevalence estimates of catatonia among people with neurodevelopmental disorders (of which autism is one) have ranged from 6-20.2%, with the mean estimate falling at 9%; [1] similarly, in a recent meta-analysis of 12 studies of autistic catatonia, Vaquerizo-Serrano et al. suggest that catatonia is found in 10.4% of autistic people. [5] At the same time, as Shah suggests, the real number of sufferers may be much higher, as "there are probably a lot more people with autism and catatonia who do not have a diagnosis and are not known to services." [6]

Autistic catatonia is currently recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is the major taxonomic and diagnostic tool published by the American Psychiatric Association. The DSM does not currently treat autistic catatonia as a separate disorder. However, as of the fifth edition, it allows for the diagnosis of catatonia in autistic people by means of the designations "Catatonia--Not Otherwise Specified" and "Autism--With Catatonia". [7] In 2013, the editors of the DSM-5 published an explicit justification for this new formulation of catatonia, saying, in part, that this change would make it more possible to diagnose the presence of catatonia in autism. [8]

Autistic catatonia is an understudied and underrecognized condition. Catatonia of all kinds is frequently missed by clinicians. [8] Studies have found that it is frequently overlooked in a wide range of contexts: among patients with schizophrenia, with major mood disorders, and with general medical conditions; among autistic people; and among people in the ICU. [8] Catatonia in autistic people is especially hard to recognize because many of the symptoms of catatonia (such as mutism, withdrawal, stereotypy, and echolalia, among others) overlap with the symptoms of autism. [9] For this reason, it is often the case that

clinicians will not recognise and diagnose the most commonly seen manifestation of catatonia in autism, which is a gradual deterioration/breakdown in functioning and difficulty with voluntary movements. [9]

In addition to the common sign of catatonia (posturing, negativism, mutism, and stupor), autistic people with catatonia are more likely to stim and self-harm. [7] : 60 

Pathology

There exists debate over the biological origins of autistic catatonia. Some studies have suggested that dysfunction of GABA and its receptors are primary causes for autistic catatonia. [5] Also, neuroimaging studies have indicated that autistic catatonic patients have abnormally small cerebellar structures. [5] Furthermore, genetic studies have implied that alterations on chromosome 15 may underpin the disease. [5]

Alternatively, catatonia has been frequently observed in patients with severe anxiety. [5] Because autism can cause individuals to be susceptible to anxiety, the prevalence of catatonia in autism may be attributable to anxiety. [5]

Symptoms

Catatonia is defined as the presence of at least three of the following twelve traits: catalepsy, waxy flexibility, posturing, grimacing, mutism, negativism, stupor, mannerism, stereotypy, echolalia, echopraxia, and agitation. [8] [7] In the table below, each of these features of catatonia is first defined in technical language, and then illustrated by means of an example:

FeatureDefinitionExamples
Catalepsy"passive induction of a posture held against gravity" [8] A catatonic patient might hold part of their body in a raised or lifted position, instead of relaxing or lowering it as expected. For instance, they might lift their head off the bed, and then, instead of allowing the head to relax back onto the pillow, hold it in a lifted position for an unusually long time. These kinds of raised or lifted poses are called catalepsy. [10]
Waxy flexibility"slight and even resistance to positioning by examiner" [8] When asked to move or bend a joint, like an elbow or a wrist, a catatonic person might first seem to resist or stiffen the joint, but then gradually relax and loosen up, so that the joint bends easily. This kind of initial stiffness, giving way to flexibility, is called waxy flexibility. [11]
Posturing"spontaneous and active maintenance of a posture against gravity" [8] Sometimes a catatonic patient may hold themself in a very stiff position, almost as if they have frozen in place, for no apparent reason. This behavior is called posturing. [10]
Grimacing"any stereotypy, mannerism, or posturing of facial muscles" [12] A catatonic patient might make odd or exaggerated facial expressions: for instance, they might squint their eyes tightly shut, scrunch up their face, or form an exaggerated pout. They might hold these odd expressions for an unusually long time, as if frozen, or repeat them in an unusual way. These facial behaviors are called grimacing. [12]
Mutism"no, or very little, verbal response [Note: not applicable if there is an established aphasia]" [8] A catatonic patient might speak only in monosyllables, or stop speaking altogether. This loss of speech is called mutism. [13]
Negativism"opposing or not responding to instructions or external stimuli" [8] A catatonic patient might refuse to move or respond to instructions, either by passively resisting them, or by speaking out in a seemingly defiant way ("I won't!"). This rejection of requests and commands (whether passive or active) is called negativism. [14]
Stupor"no psychomotor activity; not actively relating to environment" [8] A catatonic patient might stop responding to their environment altogether, and stare into space as if in a dream or a daze. This loss of responsiveness is called stupor. [15]
Mannerisms"odd caricature of normal actions" [8] A catatonic patient might perform odd, purposeful movements, such as hopping, walking tiptoe, or saluting passers-by. These odd movements are called mannerisms. [16]
Stereotypies"repetitive, abnormally frequent, non-goal directed movements" [8] A catatonic patient may find themselves stimming a lot: for instance, by rocking back and forth or spinning. If they are autistic, they might find themselves stimming even more than is usual, or in new ways than are usual. This kind of stimming behavior is called stereotypy. [17]
Echolalia"mimicking another’s speech" [8] A catatonic patient may find themselves echoing other people's speech. This kind of echoing is called echolalia. [18]
Echopraxia"mimicking another’s movements" [8] A catatonic patient may find themselves repeating other people's movements. This kind of repetition is called echopraxia. [18]
Agitationexcited or impulsive behaviorA catatonic patient might perform lots of excited or sudden movements, without a clear motive for their behavior. They might act out impulsively or take seemingly random, dramatic action, like taking all their clothes off, or running screaming down a hallway. In extreme cases, they may experience truly frenzied activity that might pose a risk to themself or to others. [19] [20]

An even fuller list of symptoms may be found in the Bush-Francis Catatonia Scale, [21] a rating instrument for physicians which lists a total of 23 possible features of catatonia that may be useful in diagnosing the condition.

One memory aid useful for remembering the features of catatonia is the acronym LIMP MEN. (Multiple variations of this mnemonic exist). [22] [23] Each letter in this acronym can be said to stand for one of the characteristic traits of catatonia:

This acronym is especially notable because it draws attention to the seeming lethargy which is characteristic of catatonia (a feature which is not marked in many other accounts). Due to the onset of stupor, many patients with catatonia may "appear sedated or even comatose". [22] This feeling or appearance of sedation may be an important indicator of catatonia in autistic people in particular, given that it is not a typical feature of autism as a baseline or underlying condition.The most severe cases of autistic catatonia display fully developed stupor, hyperactivity, or severe excitement, which can sometimes continue for weeks or even months. [24] During excitement, individuals show combativeness, can have delusions and hallucinations, and can also pose a danger to themselves and others.[ citation needed ] In the medium, severe, and lethal states, they will also experience autonomic instability. [25]

Symptoms overlap with autism spectrum disorder. Thus, diagnosis of catatonic breakdown can be difficult. [25] Childhood schizophrenia increases the risk for autistic catatonia later in life dramatically. Also, it seems that the processes that give rise to psychosis, catatonia, and autism are similar. [26] [27]

Treatment

There exists great diversity in treatments for autistic catatonia. The psycho-ecological approach considers the individual's profile of autism, identifies the underlying causes behind their catatonia, and formulates support strategies. These strategies vary depending on the individual and their difficulties. [9]

It has also been shown that benzodiazapines are effective for some patients. [28] More recently, electroconvulsive therapy (ECT) has been trialed, with mixed effect. [28] Several patients have responded well to intensive, multi-month ECT regimens after other treatments failed. [28] Furthermore, ECT was successfully used to treat symptoms in patients prone to self-injury and compulsive behavior. [28] However, it seems that ECT must be continued for long periods of time to prevent re-onset of autistic catatonic symptoms. [28] Furthermore, there is popular resistance to the idea of inducing seizures as treatment - which ECT relies on - especially in pediatric patients. [28]

History

Karl Ludwig Kahlbaum was among the first to systematically describe catatonia, which in 1874 he documented as a separate brain disorder. [28] The phenomenon was later described by Emil Kraepelin as a precursor disease that led to dementia. [28] It was not until the 1970s that catatonia was recognized as a feature of other affective psychiatric disorders in adults, especially manias. [28]

Related Research Articles

<span class="mw-page-title-main">Catatonia</span> Psychiatric behavioural syndrome

Catatonia is a complex syndrome, most commonly seen in people with underlying mood or psychotic disorders. People with catatonia have abnormal movement and behaviors, which vary from person to person and fluctuate in intensity within a single episode. People with catatonia appear withdrawn, meaning that they do not interact with the outside world and have difficulty processing information. They may be nearly motionless for days on end or perform repetitive purposeless movements. Two people may exhibit very different sets of behaviors and both still be diagnosed with catatonia. Treatment with benzodiazepines or ECT are most effective and lead to remission of symptoms in most cases.

<span class="mw-page-title-main">Asperger syndrome</span> Formerly recognized subtype of autism

Asperger syndrome (AS), also known as Asperger's syndrome or Asperger's, was a diagnosis used to describe a neurodevelopmental disorder characterized by significant difficulties in social interaction and nonverbal communication, along with restricted, repetitive patterns of behavior and interests. Asperger syndrome has been merged with other conditions into autism spectrum disorder (ASD) and is no longer a diagnosis in the WHO's ICD-11 or the APA's DSM-5-TR. It was considered milder than other diagnoses which were merged into ASD due to relatively unimpaired spoken language and intelligence.

<span class="mw-page-title-main">Electroconvulsive therapy</span> Medical procedure in which electrical current is passed through the brain

Electroconvulsive therapy (ECT) or electroshock therapy (EST) is a psychiatric treatment during which a generalized seizure is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple or from front to back of one side of the head. However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

In psychology, schizotypy is a theoretical concept that posits a continuum of personality characteristics and experiences, ranging from normal dissociative, imaginative states to extreme states of mind related to psychosis, especially schizophrenia. The continuum of personality proposed in schizotypy is in contrast to a categorical view of psychosis, wherein psychosis is considered a particular state of mind, which the person either has or does not have.

<span class="mw-page-title-main">Conditions comorbid to autism</span> Medical conditions more common in autistic people

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that begins in early childhood, persists throughout adulthood, and is characterized by difficulties in social communication and restricted, repetitive patterns of behavior. There are many conditions comorbid to autism spectrum disorder, such as attention deficit hyperactivity disorder, anxiety disorders, and epilepsy.

<span class="mw-page-title-main">Echolalia</span> Speech disorder

Echolalia is the unsolicited repetition of vocalizations made by another person; when repeated by the same person, it is called palilalia. In its profound form it is automatic and effortless. It is one of the echophenomena, closely related to echopraxia, the automatic repetition of movements made by another person; both are "subsets of imitative behavior" whereby sounds or actions are imitated "without explicit awareness". Echolalia may be an immediate reaction to a stimulus or may be delayed.

This glossary covers terms found in the psychiatric literature; the word origins are primarily Greek, but there are also Latin, French, German, and English terms. Many of these terms refer to expressions dating from the early days of psychiatry in Europe; some are deprecated, and thus are of historic interest.

Echopraxia is the involuntary repetition or imitation of another person's actions. Similar to echolalia, the involuntary repetition of sounds and language, it is one of the echophenomena. It has long been recognized as a core feature of Tourette syndrome, and is considered a complex tic, but it also occurs in autism spectrum disorders, schizophrenia and catatonia, aphasia, and disorders involving the startle reflex such as latah. Echopraxia has also been observed in individuals with epilepsy, dementia and autoimmune disorders; the causes of and the link between echopraxia and these disorders is undetermined.

Oneiroid syndrome (OS) is a condition involving dream-like disturbances of one's consciousness by vivid scenic hallucinations, accompanied by catatonic symptoms (either catatonic stupor or excitement), delusions, or psychopathological experiences of a kaleidoscopic nature. The term is from Ancient Greek "ὄνειρος" (óneiros, meaning "dream") and "εἶδος" (eîdos, meaning "form, likeness"; literally dream-like / oneiric or oniric, sometimes called "nightmare-like"). It is a common complication of catatonic schizophrenia, although it can also be caused by other mental disorders. The dream-like experiences are vivid enough to seem real to the patient. OS is distinguished from delirium by the fact that the imaginative experiences of patients always have an internal projection. This syndrome is hardly mentioned in standard psychiatric textbooks, possibly because it is not listed in DSM.

<span class="mw-page-title-main">Muteness</span> Medical condition

In human development, muteness or mutism is defined as an absence of speech, with or without an ability to hear the speech of others. Mutism is typically understood as a person's inability to speak, and commonly observed by their family members, caregivers, teachers, doctors or speech and language pathologists. It may not be a permanent condition, as muteness can be caused or manifest due to several different phenomena, such as physiological injury, illness, medical side effects, psychological trauma, developmental disorders, or neurological disorders. A specific physical disability or communication disorder can be more easily diagnosed. Loss of previously normal speech (aphasia) can be due to accidents, disease, or surgical complication; it is rarely for psychological reasons.

<span class="mw-page-title-main">Waxy flexibility</span> Catatonia psychomotor symptom

Waxy flexibility is one of the twelve symptoms that can lead to the diagnosis of catatonia. It is a psychomotor symptom that results in a decreased response to stimuli and a tendency to remain in an immobile posture. If one were to move the arm of someone with waxy flexibility, the patient would keep that arm where it had been positioned until moved again as if positioning malleable wax. Attempts to reposition the patient are met by "slight, even resistance".

Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.

<span class="mw-page-title-main">Classic autism</span> Former neurodevelopmental disorder now classified under autism spectrum disorder

Classic autism, also known as childhood autism, autistic disorder, or Kanner's syndrome, is a formerly diagnosed neurodevelopmental disorder first described by Leo Kanner in 1943. It is characterized by atypical and impaired development in social interaction and communication as well as restricted, repetitive behaviors, activities, and interests. These symptoms first appear in early childhood and persist throughout life.

Autism spectrum disorder (ASD), or simply autism, is a neurodevelopmental disorder characterized by repetitive, restricted, and inflexible patterns of behavior, interests, and activities; deficits in social communication and social interaction; and the presence of high or low sensory sensitivity. A formal diagnosis requires that symptoms cause significant impairment in multiple functional domains, in addition to being atypical or excessive for the person's age and sociocultural context.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

In psychiatry, stilted speech or pedantic speech is communication characterized by situationally inappropriate formality. This formality can be expressed both through abnormal prosody as well as speech content that is "inappropriately pompous, legalistic, philosophical, or quaint". Often, such speech can act as evidence for autism spectrum disorder (ASD) or a thought disorder, a common symptom in schizophrenia or schizoid personality disorder.

The Ritvo Autism & Asperger Diagnostic Scale (RAADS) is a psychological self-rating scale developed by Riva Ariella Ritvo. An abridged and translated 14 question version was then developed at the Department of Clinical Neuroscience at the Karolinska Institute, to aid in the identification of patients who may have undiagnosed ASD.

<span class="mw-page-title-main">Bell's mania</span> Medical condition

Bell's mania, also known as delirious mania, refers to an acute neurobehavioral syndrome. This is usually characterized by an expeditious onset of delirium, mania, psychosis, followed by grandiosity, emotional lability, altered consciousness, hyperthermia, and in extreme cases, death. It is sometimes misdiagnosed as excited delirium (EXD) or catatonia due to the presence of overlapping symptoms. Pathophysiology studies reveal elevated dopamine levels in the neural circuit as the underlying mechanism. Psychostimulant users as well as individuals experiencing severe manic episodes are more prone to the manifestation of this condition. Management solutions such as sedation and ketamine injections have been discussed for medical professionals and individuals with the condition. Bell's mania cases are commonly reported in countries like the United States and Canada and are commonly associated with psychostimulant use and abuse.

<span class="mw-page-title-main">Catatonic depression</span> Spectrum of mood disorders

Catatonic depression is characterized as a spectrum of mood disorders and is distinguished by the co-occurrence of catatonia and major depressive disorder (MDD). Catatonic symptoms involve a variety of motor abnormalities and behavioral disturbances, such as stupor, immobility, mutism, negativism, posturing, rigidity, and repetitive or purposeless movements. Individuals suffering from catatonic depression frequently demonstrate a significant decline in their capacity to engage in voluntary behaviors and communicate effectively. These symptoms can significantly impair daily functioning and pose challenges in their personal and professional lives.

References

  1. 1 2 3 Moore, Shavon; Amatya, Debha N.; Chu, Michael M.; Besterman, Aaron D. (2022). "Catatonia in autism and other neurodevelopmental disabilities: a state-of-the-art review". npj Mental Health Research. 1 (1): 12. doi: 10.1038/s44184-022-00012-9 . PMC   10955936 . PMID   38609506.
  2. ↑ Fink, Max; Taylor, Michael Alan (1 November 2009). "The Catatonia Syndrome: Forgotten but Not Gone". Archives of General Psychiatry. 66 (11): 1173–1177. doi:10.1001/archgenpsychiatry.2009.141. PMID   19884605.
  3. ↑ Burrow, Jeffrey P.; Spurling, Benjamin C.; Marwaha, Raman (2022). "Catatonia". StatPearls. StatPearls Publishing. PMID   28613592.
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  5. 1 2 3 4 5 6 Vaquerizo-Serrano, J.; Pablo, G. Salazar De; Singh, J.; Santosh, P. (2022). "Catatonia in autism spectrum disorders: A systematic review and meta-analysis". European Psychiatry. 65 (1): e4, 1–10. doi:10.1192/j.eurpsy.2021.2259. PMC   8792870 . PMID   34906264.
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  9. 1 2 3 Shah, Amitta Catatonia, Shutdown and Breakdown in Autism: A Psycho-Ecological Approach. Jessica Kingsley Publishers, 2019, p. 20, 21-22, 97.
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  11. ↑ URMC Department of Psychiatry (2022-06-06). Waxy Flexibility | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  12. 1 2 URMC Department of Psychiatry (2022-06-06). Grimacing | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  13. ↑ URMC Department of Psychiatry (2022-06-06). Mutism | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  14. ↑ URMC Department of Psychiatry (2022-06-06). Negativism | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  15. ↑ URMC Department of Psychiatry (2022-06-06). Immobility / Stupor | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  16. ↑ URMC Department of Psychiatry (2022-06-06). Mannerisms | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  17. ↑ URMC Department of Psychiatry (2022-06-06). Stereotypy | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
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  19. ↑ URMC Department of Psychiatry (2022-06-06). Excitement | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  20. ↑ URMC Department of Psychiatry (2022-06-06). Impulsivity | Bush-Francis Catatonia Rating Scale . Retrieved 2024-10-07– via YouTube.
  21. ↑ "BFCRS - Bush-Francis Catatonia Rating Scale -Collaborative Care and Wellness - Department of Psychiatry - University of Rochester Medical Center". www.urmc.rochester.edu. Retrieved 2024-10-09.
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  24. ↑ Wijemanne, Subhashie; Jankovic, Joseph (2015-08-01). "Movement disorders in catatonia". Journal of Neurology, Neurosurgery & Psychiatry. 86 (8): 825–832. doi: 10.1136/jnnp-2014-309098 . ISSN   0022-3050. PMID   25411548. S2CID   5925700.
  25. 1 2 Wilcox, James Allen; Reid Duffy, Pam (2015-12-09). "The Syndrome of Catatonia". Behavioral Sciences. 5 (4): 576–588. doi: 10.3390/bs5040576 . ISSN   2076-328X. PMC   4695780 . PMID   26690229.
  26. ↑ 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. doi:10.1111/acps.12082. PMC   3714300 . PMID   23350770.
  27. ↑ Dhossche, Dirk Marcel; Carroll, Brendan T.; Carroll, Tressa D. (2006). "Is There a Common Neuronal Basis for Autism and Catatonia?". In Dhossche, Dirk Marcel; Wing, Lorna; Ohta, Masataka; et al. (eds.). Catatonia in Autism Spectrum Disorders. International Review of Neurobiology. Vol. 72. pp. 151–64. doi:10.1016/S0074-7742(05)72009-2. ISBN   978-0-12-366873-8. PMID   16697296.
  28. 1 2 3 4 5 6 7 8 9 Dhossche, Dirk M.; Reti, Irving M.; Wachtel, Lee E. (March 2009). "Catatonia and Autism". The Journal of ECT. 25 (1): 19–22. doi:10.1097/yct.0b013e3181957363. ISSN   1095-0680. PMID   19190507.

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