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Many faces of catatonia in autism

Updated: Nov 16, 2021

Thomas, a 12-year-old autistic boy has a long history of some features of anxiety and depression. For the past several months, he has been more anxious, sad, and easily overwhelmed. He seems irritable at home and school and cries often. He responds very slowly to the questions and often says "I don't know, I don't know," almost in an automatic way and he is now engaging in some repetitive hand movements which he had not done previously. He is no longer able to shower independently (Irwin et al. 2019).

Catatonia is a psychomotor syndrome that affects a person’s ability to move, to talk and react to external stimuli. Catatonia may affect an individual for a few hours in isolation or may recur periodically over weeks, months or even years (Hervey et al 2013).

For a long time, catatonia was considered a marker of schizophrenia, thus limiting the possibility of diagnosis and treatment. In 2013, things changed with the publication of DSM-5). Now catatonia may be considered either a separate syndrome or a specifier for other psychotic disorders.

The most common symptoms of catatonia

  • Stupor – a person cannot move or speak

  • Immobility - an individual displays lack of reaction to stimuli

  • Waxy flexibility - resistance to bodily manipulation

  • Mutism – an individual is verbally unresponsive

  • Posturing - the individual maintains bodily for long periods of time

  • Fixed facial expression or grimacing

  • Negativism - bodily manipulations are resisted

  • Stereotypy - repetitive motor or verbal behaviour

  • Echophenomena (echolalia & echopraxia) - individuals may repeat other people’s speech or movements

Other signs include: withdrawal, staring, agitation and verbigeration (the compulsive repetition of seemingly meaningless words, phrases, or sentences, without regard to stimulus; oral stereotypy).

Catatonia occurs in more than 10% of patients with acute psychiatric illnesses (Rasmussen et al 2016).

What causes catatonia

The causes are unknown, however, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism (Ghaziuddin, Andersen, Ghaziuddin 2020). Sometimes catatonia can occur as a side effect of medication or have an altogether unknown cause.

Catatonia differential diagnosis and comorbidity

Catatonia may co-occur with other psychiatric disorders (e.g., schizophrenia or bipolar disorder), neurodevelopmental disorders (including ASD) and general medical conditions (e.g., encephalitis neurodegenerative disease or infections).

Catatonia in autism

Up to 20.2% of young people with autism have a diagnosis of catatonia (Breen, Hare 2017).

Catatonia in autism was originally described by Lorna Wing and Amitta Shah (2006). They reported that the catatonic-like states seen in people with autism seem to be distinct from those observed in people with schizophrenia and other psychiatric conditions.

Wachtel LE. (2019) reveals the “multiple faces of catatonia" in 22 autistic patients over 12 years. Stereotypy, posturing, negativism, mutism and stupor were the most common catatonic symptoms in autism, each present in more than half of the study patients. One patient had abnormal vital signs indicative of malignant catatonia. 20 patients had concomitant repetitive self-injurious behaviors that had led to significant tissue injury. The author suggests that repetitive self-injury is an under-recognized motor symptom of catatonia.

The importance of recognizing catatonia is that this comorbidity to autism is treatable and may offer a way of increasing the quality of life for affected patients (Psychiatric Times, 2008). Catatonia left untreated tends to get worse and in some cases may be life threatening.

Although diagnostic criteria for children and adolescent do not differ from those for adults, the clinical presentation and course may not be the same. (For example, in children and adolescents, relatively common are somatic conditions taking the form of catatonia.) The diagnosis and treatment of catatonia is of great practical importance (Remberk et al. 2020).

These are just a few examples:

Case studies with ASD and catatonia in children and adolescents:

Riccio MP. et al. (2020) report the case of a 7-year-old boy diagnosed with ASD with low cognitive functioning, who presented a complex symptomatology, characterized by progressive regression with loss of autonomy and involuntary movements that assume "dystonic" features. Catatonia, with peculiar dystonic characteristics, was diagnosed. An intervention based on elimination of stressful factors, resumption of routines, and support for parents led to the resolution of catatonic symptoms.

Faisal, Pradeep, O'Hanrahan (2021) describe a case of paediatric catatonia in a 13-year-old girl with moderate intellectual disability and ASD. Her symptoms (negativism, grimacing, automatic obedience, waxy flexibility and ambitendency) emerged following shortly after discontinuation of risperidone (an atypical antipsychotic) previously prescribed to manage disruptive behaviour associated with ASD. This case presents challenges of accurately diagnosing and managing catatonic symptoms in adolescent patients with ASD and the potential risk of precipitating catatonia following the discontinuation of antipsychotic treatment that has been prescribed for a prolonged duration.

and in adults:

Hefter D et al. (2019) give an example of diagnostic and therapeutic challenges of catatonic schizophrenia in high functioning autism due to clinical and neurobiological overlaps of these conditions. They presented a case study of a severe catatonic syndrome in a 31-year-old man with HFA without history of psychiatric disease. After the treatment with high-dose lorazepam and intramuscular olanzapine, catatonic symptoms largely remitted, but autistic traits persisted. Following a thorough neuropsychological testing, the man was diagnosed with high functioning autism and catatonic schizophrenia.

Burns et al. (2021) describe two cases of excited catatonia in young men diagnosed with autism. Both patients were diagnosed with autism, one high-functioning, attending high school and working a part-time job, the second – low-functioning, nearly non-verbal, isolated to home and ABA school. Each man had a change in behaviour from their baseline but with differences in severity and onset. The diagnosis in the first patient was made after only 3 months as the change was dramatic and sudden. The second patient had been suffering for more than 5 years with a slow progression of worsening aggressive symptoms. Both suffered from agitation, unprovoked aggression, urinary incontinence, stereotypic, and OCD behaviors and compulsive masturbation.

and in old age:

Bean et al. (2921) describe a 73-year-old man with ASD with symptoms of depression. Following a period of diagnostic uncertainty and failure to improve with antidepressant medication, a lorazepam challenge yielded an abrupt improvement in presentation. The patient was treated extensively with lorazepam, zolpidem, and electroconvulsive therapy during his 16-month hospital admission, but his catatonia ultimately proved refractory to treatment.

Treatment for catatonia

Benzodiazepines and brain stimulation therapy / electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications (Ghaziuddin, Andersen, Ghaziuddin 2020; Wachtel 2019; Withane & Dhossche 2018; Park et al. 2021).

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