# Autistic catatonia

Autistic catatonia is a term used to describe the occurrence of catatonia in autistic people. Catatonia is a complex behavioral syndrome typically characterized by immobility, withdrawal, abnormal movements, and abnormal behaviors. 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".
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. 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%; 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. 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."
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". 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.
Autistic catatonia is an understudied and underrecognized condition. Catatonia of all kinds is frequently missed by clinicians. 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. 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. 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.
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.$^{:60}$

## 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. Also, neuroimaging studies have indicated that autistic catatonic patients have abnormally small cerebellar structures. Furthermore, genetic studies have implied that alterations on chromosome 15 may underpin the disease.
Alternatively, catatonia has been frequently observed in patients with severe anxiety. Because autism can cause individuals to be susceptible to anxiety, the prevalence of catatonia in autism may be attributable to anxiety.

## 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. In the table below, each of these features of catatonia is first defined in technical language, and then illustrated by means of an example:
| Feature | Definition | Examples |
| Catalepsy | "passive induction of a posture held against gravity" | 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. |
| Waxy flexibility | "slight and even resistance to positioning by examiner" | 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. |
| Posturing | "spontaneous and active maintenance of a posture against gravity" | 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. |
| Grimacing | "any stereotypy, mannerism, or posturing of facial muscles" | 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. |
| Mutism | "no, or very little, verbal response [Note: not applicable if there is an established aphasia]" | A catatonic patient might speak only in monosyllables, or stop speaking altogether. This loss of speech is called mutism. |
| Negativism | "opposing or not responding to instructions or external stimuli" | 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. |
| Stupor | "no psychomotor activity; not actively relating to environment" | 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. |
| Mannerisms | "odd caricature of normal actions" | A catatonic patient might perform odd, purposeful movements, such as hopping, walking tiptoe, or saluting passers-by. These odd movements are called mannerisms. |
| Stereotypies | "repetitive, abnormally frequent, non-goal directed movements" | 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. |
| Echolalia | "mimicking another’s speech" | A catatonic patient may find themselves echoing other people's speech. This kind of echoing is called echolalia. |
| Echopraxia | "mimicking another’s movements" | A catatonic patient may find themselves repeating other people's movements. This kind of repetition is called echopraxia. |
| Agitation | excited or impulsive behavior | A 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. |
An even fuller list of symptoms may be found in the Bush-Francis Catatonia Scale, 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). Each letter in this acronym can be said to stand for one of the characteristic traits of catatonia:
* L: Lethargy or lethargic stupor (seeming or feeling extremely fatigued; seeming or feeling sedated)
* I: Immobility (loss of movement; seeming or feeling "frozen")
* M: Mutism (loss of speech or minimal speech)
* P: Positioning (odd stiffness, rigidity, or "posing", including symptoms like catalepsy, posturing, or waxy flexibility)
* M: Movement abnormalities (including symptoms like grimacing, agitation, and mannered movement/mannerisms)
* E: Echolalia/echopraxia (echoing words or movements)
* N: Negativism (saying "no" to commands or requests, or passively refusing to comply)
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". 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. During excitement, individuals show combativeness, can have delusions and hallucinations, and can also pose a danger to themselves and others. In the medium, severe, and lethal states, they will also experience autonomic instability.
Symptoms overlap with autism spectrum disorder. Thus, diagnosis of catatonic breakdown can be difficult. 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.

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

## History

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