Catatonia in autism: implications across the life span

Catatonia in autism spectrum disorders: Prevalence, functional impact, and diagnostic insights

The current study aimed to evaluate subtle catatonia behaviors and functionality in adolescents with autism spectrum disorders (ASD). The sample consisted of 48 patients (11 female, 37 male) aged 12-18 (13.77 ± 2.01). DSM-5 catatonia criteria and Bush-Francis Catatonia Rating Scale (BCRS) was utilized to assess catatonia, while the impairment in functionality was appraised using the Global Assessment Scale. Parents fulfilled the Revised Child Anxiety and Depression Scale-Parent version (RCADS-PV) and Repetitive Behavior Scale-Revised (RBS-R). The presence of catatonia was detected in 18 out of 48 (37.5 %) participants according to BCRS, and in 16 cases (35.4 %) according to DSM-5 criteria. A significant association between two diagnostic tools was observed (p < 0.001). In the group with mild impairment in functionality, 2 cases had catatonia (12.5 %), while in the group with more impaired functionality, 16 cases (50 %) had catatonia (p = 0.011) according to BCRS. Major depressive disorder subscale scores of RCADS-PV and stereotypic movements (RBS-R) were correlated with the presence of catatonia (p < 0.05). The findings suggest a higher prevalence of catatonia in ASD, and a potential correlation between the presence of catatonia and functionality. More research is warranted to highlight the presence and course of catatonia beginning from the early years of ASD.

[Electroconvulsive therapy in people with intellectual disability]

Electroconvulsive therapy (ECT) is a highly effective treatment option for severe mental illness. Although people with intellectual disability (ID) have similar prevalence rates of mental disorders in comparison to the general population their access to ECT remains challenging. A systematic literature review was carried out on treatment with ECT in patients with ID and a case report on a patient with ID who underwent ECT is presented, to highlight a typical clinical routine. A total of 100 articles with 208 different case reports were retrieved. In summary, the results underline the effectiveness of ECT in people with ID, with side effects comparable to those in the general population. The ECT is effective in the treatment of severe affective and psychotic disorders and particularly in people with catatonia. The use of ECT can improve the patient's mental health and quality of life and is often a life-saving treatment option. The prophylaxis of relapses should be included as early as possible in the planning process. Providing an easy access to ECT treatment for people with ID is corroborated by its effectiveness and is in line with the right to equal treatment in accordance with article 25 of the United Nations Convention on the Rights of Persons with Disabilities.

Major Depressive Disorder with Catatonia: A Phenotype Related to Autistic Traits and High Suicidality

Background: Major Depressive Disorder (MDD) represents a significant global health concern, often complicated by comorbidities such as catatonia and autism spectrum disorder (ASD). Recognizing the interplay among these conditions and their impact on suicidal tendencies is crucial for effective clinical management. Methods: A total sample of 147 subjects with MDD was divided into Significant Catatonia (SC) and Non-Significant Catatonia (NSC) groups based on Catatonia Spectrum (CS) scores. Participants were evaluated through the Structured Clinical Interview for DSM-5, Research Version (SCID-5-RV), the Adult Autism Subtreshold Spectrum (AdAS Spectrum), and the Mood Spectrum-Self Report questionnaires. Statistical analyses included Mann-Whitney U test, Chi-square test, logistic regression analyses, and a decision tree model. Results: The SC group exhibited higher CS, AdAS Spectrum, and MOODS-SR total and domain scores compared to the NSC group. Individuals with significant autistic traits were over-represented in the SC group, as well as participants with higher suicidality, suicidal ideation, and a history of suicide attempts. The total AdAS Spectrum and MOOD-SR score, the AdAS domain "Hyper-hypo reactivity to sensory input", and the "Cognitive depressive" MOOD-SR domain were predictive of belonging to the SC group. Suicidality levels appeared to be higher in clinically significant ASD, intermediate in subjects with autistic traits (AT), and low in the absence of AT. Conclusions: the study suggests the existence of a specific phenotype of MDD associated with catatonia, characterized by elevated autistic traits and suicide risk.

Exploring genetic risk for catatonia in a genome wide association study and polygenic risk score analysis

BACKGROUND

Catatonia is an under-recognized disorder characterized by psychomotor (increased, decreased, or abnormal) changes, affective symptoms, and disturbance of volition, which may arise in the setting of decompensated psychiatric or non-psychiatric medical disorders. Genetic studies of catatonia are limited, and to the best of our knowledge no prior genome wide association studies of catatonia have been performed to date.

METHODS

First we performed a genome wide association study of catatonia regardless of etiology (psychiatric or non-psychiatric). Secondarily we evaluated whether there was an elevated genetic risk profile for predisposing psychiatric disorders (schizophrenia spectrum disorder, bipolar affective disorder, etc.) in patients with catatonia. We used a matched case control design and applied polygenic risk scores to evaluate for a shared polygenetic contribution to catatonia from common psychiatric phenotypes that show a high prevalence of catatonia in their decompensated states.

RESULTS

Anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorder polygenic risk scores were significantly associated with catatonia case status in both unadjusted and adjusted logistic regression models for the European Ancestry set even after correcting for multiple comparisons. Depression, Alzheimer's, Autism Spectrum Disorder and Obsessive Disorder polygenic risk scores were not significantly associated with catatonia status in participants of European Ancestry. In the African Ancestry set, no psychiatric polygenic risk scores were significantly associated with catatonia status in either the unadjusted or adjusted regression models.

CONCLUSIONS

Even after controlling for relevant covariates, anxiety, bipolar affective disorder, schizophrenia spectrum disorder and cross disorders were significantly associated with catatonia status suggesting that there might be a shared genetic risk for those disorders amongst patients with catatonia.

Diagnostic overshadowing clouding the efficient recognition of pediatric catatonia: a case series

Catatonia is a neuropsychiatric condition that causes disruption of movement, emotion, and behaviors. Children and adults with underlying psychiatric conditions are particularly susceptible to developing catatonia, which may result in medical and psychiatric complications. Although catatonia research has been growing at a rapid rate in the last 20 years, it continues to be met with inefficiencies in its diagnosis and incertitude in its treatment. In the pediatric population, catatonia is plagued by diagnostic overshadowing, where the catatonia is erroneously attributed to existing pathologies that lead to a prolonged disease state. This paper describes three pediatric patients with catatonia that fell victim to diagnostic overshadowing. More rigorous training and education are imperative to improve the efficient recognition and treatment of children with catatonia.

The mediating effect of mood spectrum on the relationship between autistic traits and catatonia spectrum

Background

In the recent years, several studies have shown a correlation between autism spectrum disorder (ASD) and catatonia. It is also known that both conditions are found to be associated with mood disorders. This study aimed to investigate the relationship between autistic traits and catatonic symptoms, as well as the potential mediating role of mood disorder spectrum in the relationship between them.

Methods

The total sample of 514 subjects was composed by four diagnostic groups, composed by patients affected by catatonia (CTN), borderline personality disorder (BPD), major depressive disorder (MDD) and healthy controls (HC). Subjects were assessed with the SCID-5-RV, the Adult Autism Subthreshold Spectrum (AdAS Spectrum) and the Catatonia Spectrum (CS) and the Mood Spectrum Self-Report (MOODS-SR). Statistical analyses included Pearson's coefficient calculation, multiple linear regression, and mediation analysis.

Results

all the correlations appear to be strongly positive and significant with the strongest coefficient emerging between AdAS Spectrum total score and CS total score (r = 0.762, p < 0.001). The Mediation Analysis showed that AdAS Spectrum total score showed a significant indirect effect on CS total score through MOODS-SR total score (b = 0.168, 95% bootstrapped CI [0.127:0.207]).

Conclusion

The present study highlights the presence of a mediating role of the mood disorder spectrum in the relationship between autistic traits and the catatonia spectrum.

Autism Spectrum Disorder in a Patient with Bipolar Disorder and Its Relationship with Catatonia Spectrum: A Case Study

According to several studies, the prevalence of Autism Spectrum Disorder (ASD) ranges from 2.4 to 9.9 percent among adult mental inpatients. However, subjects with forms of ASD that fit in the high functioning spectrum may remain undiagnosed during childhood and adolescence without reaching clinical attention until they develop in adult life other psychiatric disorders, often characterized by treatment resistance and poor outcomes. The aim of this case report was to evaluate the role of an undiagnosed ASD in the mental illness trajectory and discuss the diagnostic and therapeutic implications. We reported a case of a young man with an undiagnosed ASD that came to clinical attention only after the development of a severe manic episode with mixed and psychotic features and with catatonia in adulthood, despite meeting DSM-5-TR (APA, 2022) diagnostic criteria for ASD since early childhood. This case confirms the need of a timely identification of ASD in order to prevent the development of a mental illness trajectory and to improve the prognosis and the outcome. Moreover, on the heuristic level, this case seems to support the presence of a continuum between ASD and catatonia. In this framework, the use of a questionnaire based on a spectrum model, such as the AdAS Spectrum, could be useful in early diagnosis of ASD without intellectual or language impairment as well as in early detection of subthreshold conditions (broad autism spectrum phenotype or autistic traits), which represents a vulnerability factor for the development of various mental disorders.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

The Autism Spectrum: Behavioral, Psychiatric and Genetic Associations

Autism spectrum disorder (ASD) consists of a group of heterogeneous genetic neurobehavioral disorders associated with developmental impairments in social communication skills and stereotypic, rigid or repetitive behaviors. We review common behavioral, psychiatric and genetic associations related to ASD. Autism affects about 2% of children with 4:1 male-to-female ratio and a heritability estimate between 70 and 90%. The etiology of ASD involves a complex interplay between inheritance and environmental factors influenced by epigenetics. Over 800 genes and dozens of genetic syndromes are associated with ASD. Novel gene–protein interactions with pathway and molecular function analyses have identified at least three functional pathways including chromatin modeling, Wnt, Notch and other signaling pathways and metabolic disturbances involving neuronal growth and dendritic spine profiles. An estimated 50% of individuals with ASD are diagnosed with chromosome deletions or duplications (e.g., 15q11.2, BP1-BP2, 16p11.2 and 15q13.3), identified syndromes (e.g., Williams, Phelan-McDermid and Shprintzen velocardiofacial) or single gene disorders. Behavioral and psychiatric conditions in autism impacted by genetics influence clinical evaluations, counseling, diagnoses, therapeutic interventions and treatment approaches. Pharmacogenetics testing is now possible to help guide the selection of psychotropic medications to treat challenging behaviors or co-occurring psychiatric conditions commonly seen in ASD. In this review of the autism spectrum disorder, behavioral, psychiatric and genetic observations and associations relevant to the evaluation and treatment of individuals with ASD are discussed.

Catatonia in neurodevelopmental disorders: assessing catatonic deterioration from baseline

Despite the inclusion of catatonia as a specifier of autism spectrum disorder in DSM-5, we-a team of child and adolescent neuropsychiatrists who specialise in paediatric catatonia and neurodevelopmental disorders-have identified a number of issues with the diagnosis and clinical management of catatonia in our patients. In this Personal View, we summarise the literature regarding catatonia in people with neurodevelopmental disorders, including autism spectrum disorder, describe our concerns, and offer a novel approach to addressing important issues with current diagnostic and treatment paradigms. We emphasise the need for a measure to diagnose and monitor people with catatonia and their history of neurodevelopmental disorders. This measure should consider previous complex and underlying motor, medical, functional, and neurobehavioural symptoms. We propose two concepts for understanding catatonia that relate to the baseline status of an individual: the personalised score at baseline, an estimate of premorbid neurobehavioral and motor symptoms, and the catatonic deterioration from baseline, an estimate of current features that are due to catatonia rather than an underlying neurodevelopmental disorder. We hope this measure will provide a practical tool for clinicians and researchers working with this underserved and high-risk population.

Electroconvulsive Treatment Utilization for Inpatient Management of Catatonia in Adolescents With Schizophrenia Spectrum Disorders

OBJECTIVE

The aim of this study was to determine rates of electroconvulsive therapy (ECT) use for catatonia in schizophrenia spectrum disorders, stratified by patient demographics and hospital characteristics, and its impact on inpatient length of stay and cost.

METHODS

We found 155 adolescents (aged 12-18 years) with principal discharge diagnosis of schizophrenia spectrum disorders with catatonia from the National Inpatient Sample. They were subgrouped into ECT (n = 20) and non-ECT (n = 135) groups. We used descriptive statistics to evaluate the utilization of ECT for catatonia and independent-sample t test for continuous variables with statistical significance at P ≤ 0.05.

RESULTS

The overall utilization rate of ECT in adolescents for catatonia was 12.9%. A high rate of ECT use was evident for Whites (30.8%) compared with the other race/ethnicities and also was seen in private health insurance beneficiaries (20%). The rate of ECT use varied by the region, with highest for the Northeast (20%), followed by the South (18.2%), and the West (14.3%). Adolescent inpatients with catatonia in public and teaching type, and large bed-size hospitals were more likely to receive ECT than their counterparts. The mean number of ECT sessions required during the inpatient stay was 5.2 (range, 1-15), and the mean number of days from admission to initial ECT was 2.5 (range, 0-6).

CONCLUSIONS

Electroconvulsive therapy is used for approximately only 13% of adolescents with catatonia when comorbid schizophrenia spectrum disorders are present, suggesting that many patients may not get evidence-based treatment. Future studies in this area are needed.

Benzodiazepines Remain Important Therapeutic Options in Psychiatric Practice

Benzodiazepines and medications acting on benzodiazepine receptors that do not have a benzodiazepine structure (z-drugs) have been viewed by some experts and regulatory bodies as having limited benefit and significant risks. Data presented in this article support the use of these medications as treatments of choice for acute situational anxiety, chronic anxiety disorders, insomnia, alcohol withdrawal syndromes, and catatonia. They may also be useful adjuncts in the treatment of anxious depression and mania, and for medically ill patients. Tolerance develops to sedation and possibly psychomotor impairment, but not to the anxiolytic effect of benzodiazepines. Sedation can impair cognitive function in some patients, but assertions that benzodiazepines increase the risk of dementia are not supported by recent data. Contrary to popular opinion, benzodiazepines are not frequently misused or conduits to misuse of other substances in patients without substance use disorders who are prescribed these medications for appropriate indications; most benzodiazepine misuse involves medications that are obtained from other people. Benzodiazepines are usually not lethal in overdose except when ingested with other substances, especially alcohol and opioids. Benzodiazepines comprise one of the few classes of psychotropic medication the mechanisms of action of which are clearly delineated, allowing for greater precision in their clinical use. These medications, therefore, belong in the therapeutic armamentarium of the knowledgeable clinician.

Catatonia in autism spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Catatonic features can appear in autism spectrum disorders (ASDs). There can be overlap in symptoms across catatonia and ASD. The overall aim of this review is to provide evidence for the presence of catatonic features in subjects with ASD.

METHODS

A systematic literature search using the Web of Science database from inception to July 10, 2021 was conducted following PRISMA, MOOSE guidelines and the PROSPERO protocol. (CRD42021248615). Twelve studies with information about catatonia and ASD were reviewed. Data from a subset was used to conduct meta-analyses of the presence of catatonia in ASD.

RESULTS

The systematic review included 12 studies, seven of which were used for the meta-analysis, comprising 969 individuals. The mean age was 21.25 (7.5) years. Two studies (16.6%) included only children and adolescents. A total of 70-100% were males. Our meta-analysis showed that 10.4% (5.8-18.0 95%CI) of individuals with ASD have catatonia. Motor disturbances were common in ASD subjects with catatonia. No differences were found in comorbidity. Several treatments have been used in ASD with catatonic features, including benzodiazepines, antipsychotics, and electroconvulsive therapy (ECT). The findings of the systematic review showed that ECT might help manage catatonic symptoms.

CONCLUSIONS

Different features of catatonia can exist in individuals with ASD and core symptoms of catatonia are reported in ASD. Longitudinal and longer-term studies are required to understand the relationship between catatonia and ASD, and the response of catatonic symptoms to treatment.

Refractory catatonia in old age: a case report

BACKGROUND

Catatonia is a clinical syndrome characterized by psychomotor disruption, which often goes undiagnosed. Most reports have focused on interventions and outcomes for catatonia in younger people and those with schizophrenia. The clinical characteristics and course of catatonia in old age are poorly understood. We present a report of an older person whose catatonia was refractory to extensive treatment, and we identify important implications for the management of catatonia in old age.

CASE PRESENTATION

We describe a 73-year-old white man with longstanding autistic spectrum disorder who presented 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.

CONCLUSIONS

Catatonia should be considered promptly as a differential diagnosis in older people presenting with atypical features of functional mental illness. Although partial improvement of catatonic features was achieved using benzodiazepines and electroconvulsive therapy, these were not sustained in our patient. We identified comorbid autistic spectrum disorder, prolonged duration of catatonia, and sensitivity to benzodiazepines as important factors in prognostication in old age.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Prevention in Autism Spectrum Disorder: A Lifelong Focused Approach

Autism Spectrum Disorder (ASD) is a complex highly heritable disorder, in which multiple environmental factors interact with the genes to increase its risk and lead to variable clinical presentations and outcomes. Furthermore, the inherent fundamental deficits of ASD in social attention and interaction critically diverge children from the typical pathways of learning, "creating" what we perceive as autism syndrome during the first three years of life. Later in life, training and education, the presence and management of comorbidities, as well as social and vocational support throughout the lifespan, will define the quality of life and the adaptation of an individual with ASD. Given the overall burden of ASD, prevention strategies seem like a cost-effective endeavour that we have to explore. In this paper, we take a life course approach to prevention. We will review the possibilities of the management of risk factors from preconception until the perinatal period, that of early intervention in the first three years of life and that of effective training and support from childhood until adulthood.

Catatonia in Patients with Autism Spectrum Disorder

Catatonia was first described by Karl Ludwig Kahlbaum in 1874, occurring in association with other psychiatric and medical disorders. However, in the nineteenth century the disorder was incorrectly classified as a subtype of schizophrenia. This misclassification persisted until the publication of DSM-5 in 2013 when important changes were incorporated. Although the etiology is unknown, disrupted gamma-aminobutyric acid has been proposed as the underlying pathophysiological mechanism. Key symptoms can be identified under 3 clinical domains: motor, speech, and behavioral. Benzodiazepines and electroconvulsive therapy are the only known effective treatments. Timely recognition and treatment have important outcome, and sometimes lifesaving, implications.

Catatonia in Down syndrome: systematic approach to diagnosis, treatment and outcome assessment based on a case series of seven patients

OBJECTIVE

The goal is to expand our knowledge of catatonia occurring in adolescents and young adults with Down syndrome (DS) by describing the first prospective, consecutive, well-characterized cohort of seven young people with DS diagnosed with catatonia and treated between 2013 and 2018, and to assess each patient's treatment responses. Longitudinal assessment of each patient's response to treatment is intended to provide clinicians and psychiatrists a firm foundation from which assess treatment efficacy.

STUDY DESIGN

Young adults with Down syndrome were consecutively enrolled in the study as they were diagnosed with catatonia. A comprehensive data set included medical, laboratory, developmental, demographic, family, social and genetic data, including query into disorders for which individuals with DS are at risk. Catatonia was diagnosed based on an unequivocal history of regression, positive Bush-Francis Catatonia Rating Scale and positive response to intravenous lorazepam. Patients' longitudinal progress was monitored using the Catatonia Impact Scale (CIS) developed for this purpose.

RESULTS

Seven consecutive DS patients, who presented with unequivocal regression were diagnosed with catatonia and treated for 2.7-6 years using standard-of-care therapies; primarily GABA agonist, lorazepam, electroconvulsive therapy (ECT) and glutamate antagonists (dextromethorphan/quinidine, memantine, minocycline). Responses to each treatment modality were assessed at clinic visits and through weekly electronic CIS reports.

CONCLUSION

Seven young adults with DS were diagnosed with catatonia; all responded to Lorazepam and/or ECT therapy with good to very good results. Though ECT most dramatically returned patients to baseline, symptoms often returned requiring additional ECT. Dextromethorphan/quinidine, not used until mid-2017, appeared to reduce the reoccurrence of symptoms following ECT. Though all seven patients improved significantly, each continues to require some form of treatment to maintain a good level of functioning. Findings of a significant number of autoimmune disorders and laboratory markers of immune activation in this population may guide new diagnostic and treatment opportunities.

Personalized and precision medicine as informants for treatment management of bipolar disorder

DSM-5 diagnostic categories, defined by a set of psychopathological symptoms are heterogeneous conditions that may include different biological entities, with distinct etiopathogenesis, different courses and requiring different treatment management. For bipolar disorder the major evidences for this lack of validity are the long paths before a proper diagnosis, the inconsistence of treatment guidelines, the long phases of pharmacological adjustment and the low average of long-term treatment response rates. Personalized medicine for mental disorders aims to couple established clinical-pathological indexes with new molecular profiling to create diagnostic, prognostic and therapeutic strategies precisely tailored to each patient. Regarding bipolar disorder, the clinical history and presentation are still the most reliable markers in stratifying patients and guiding therapeutic management, despite the research goes to great lengths to develop new neuropsychological or biological markers that can reliably predict individual therapy effectiveness. We provide an overview of the advancements in personalized medicine in bipolar disorder, with particular attention to how psychopathology, age at onset, comorbidity, course and staging, genetic and epigenetic, imaging and biomarkers can influence treatment management and provide an integration to the conventional treatment guidelines. This approach may offer a new and rational path for the development of treatments for targeted subgroups of patients with bipolar disorder.

Two Sides of the Same Coin: A Case Report of First-Episode Catatonic Syndrome in a High-Functioning Autism Patient

Background: Catatonic phenomena such as stupor, mutism, stereotypy, echolalia, echopraxia, affective flattening, psychomotor deficits, and social withdrawal are characteristic symptoms of both schizophrenia and autism spectrum disorders (ASD), suggesting overlapping pathophysiological similarities such as altered glutamatergic and dopaminergic synaptic transmission and common genetic mutations. In daily clinical practice, ASD can be masked by manifest catatonic or psychotic symptoms and represent a diagnostic challenge, especially in patients with unknown or empty medical history. Unclear diagnosis is one of the main factors for delayed treatment. However, we are still missing diagnostic recommendations when dealing with ASD patients suffering from catatonic syndrome. Case presentation: A 31-year-old male patient without history of psychiatric disease presented with a severe catatonic syndrome and was admitted to our closed psychiatric ward. After the treatment with high-dose lorazepam and intramuscular olanzapine, catatonic symptoms largely remitted, but autistic traits persisted. Following a detailed anamnesis and a thorough neuropsychological testing, we diagnosed the patient with high-functioning autism and catatonic schizophrenia. The patient was discharged in a remitted state with long-acting injectable olanzapine. Conclusion: This case represents an example of diagnostic and therapeutic challenges of catatonic schizophrenia in high-functioning autism due to clinical and neurobiological overlaps of these conditions. We discuss clinical features together with pathophysiological concepts of both conditions. Furthermore, we tackle social and legal hurdles in Germany that naturally arise in these patients. Finally, we present diagnostic "red flags" that can be used to rationally select and conduct current recommended diagnostic assessments if there is a suspicion of ASD in patients with catatonic syndrome in order to provide them with the most appropriate treatment.

The multiple faces of catatonia in autism spectrum disorders: descriptive clinical experience of 22 patients over 12 years

A retrospective review was conducted from the inpatient and outpatient records of twenty-two autistic youth presenting to a neurobehavioral service over a twelve-year period for combined psychiatric and behavioral pathology who also met DSM5 criteria for catatonia. Six autistic girls and 16 autistic boys ranging from ages eight to 26 years old were identified, and their variegated symptoms evaluated. Stereotypy, posturing, negativism, mutism and stupor were the most common catatonic symptoms, each present in more than half of the study patients. One patient had abnormal vital signs indicative of malignant catatonia. Twenty patients had concomitant repetitive self-injurious behaviors that had led to significant tissue injury and were refractory to psychotropic and behavioral interventions. The sample was weighted towards patients with severe self-injurious behavior, which often was the reason for admission. The many "faces" of catatonia in autism spectrum disorders are seen in this sample, and the novel recognition of repetitive self-injury as an under-recognized motor symptom of catatonia is highlighted. The preliminary findings in this study open many important future vistas for ongoing research regarding catatonia in ASDs.

Electroconvulsive Treatment for Catatonia in Autism Spectrum Disorders

Catatonia has been increasingly recognized in people with autism spectrum disorders (ASD). Assessment, diagnosis, and treatments are reviewed and illustrated with 2 new case vignettes. The use of electroconvulsive treatment (ECT) is recommended in patients who fail to respond to medical treatments, including a trial of lorazepam or another benzodiazepine. The importance of maintenance ECT is discussed. There is an urgent need for prospective studies of catatonia in ASD and for controlled treatment trials.

Neuromodulation and a Reconceptualization of Autism Spectrum Disorders: Using the Locus Coeruleus Functioning as an Exemplar

The Autism Spectrum Disorders (ASD) are a heterogeneous group of developmental disorders. Although, ASD can be reliably diagnosed, the etiology, pathophysiology, and treatment targets remain poorly characterized. While there are many atypical findings in anatomy, genetics, connectivity, and other biologic parameters, there remains no discreet hypothesis to explain the core signs as well as the very frequent comorbidities. Due to this, designing targets for treatments can only be done by assuming each symptom is a result of a discreet abnormality which is likely not the case. Neuronal circuity remains a major focus of research but rarely taking into account the functioning of the brain is highly dependent on various systems, including the neuromodulatory substances originating in the midbrain. A hypothesis is presented which explores the possibility of explaining many of the symptoms found in ASD in terms of inefficient neuromodulation using the functioning of the locus coeruleus and norepinephrine (LC/NE) as exemplars. The basic science of LC/NE is reviewed. Several functions found to be impaired in ASD including learning, attention, sensory processing, emotional regulation, autonomic functioning, adaptive and repetitive behaviors, sleep, language acquisition, initiation, and prompt dependency are examined in terms of the functioning of the LC/NE system. Suggestions about possible treatment directions are explored.

Catatonia in children and adolescents: New perspectives

INTRODUCTION

Catatonia is a rare and severe psychomotor condition in children and adolescents. In the current report, we aimed to review the recent literature.

METHOD

Using a PRISMA approach, we searched MEDLINE between 1982 and 2017 using the keywords 'CATATONIA' and 'CHILD' or 'ADOLESCENT'. In total, we reviewed 130 reports (controlled study, N=4; clinical chart, N=23; case report, N=54; and editorial/review, N=42).

RESULTS

Several aspects seem to be age specific: (1) although the clinical presentation resembles that in adults, some symptoms are important in children and adolescents (e.g., psychomotor regression). (2) Associated disorders are similar to that found in adults; however, schizophrenia is more frequently observed than mood disorder. Additionally, a history of neurodevelopmental disorders maybe encountered. (3) Morbidity and mortality are among the worst in child psychiatry. (4) Underlying organic conditions are highly prevalent (>20% of the cases), and their search is warranted because some diagnoses may result in specific treatments (e.g., immune-suppressor therapy for autoimmune conditions). (5) Symptomatic approaches - high dose of benzodiazepines and electroconvulsive therapy (ECT) - are as efficient in children or adolescents as they are in adults, but this finding needs to be acknowledged because a resistance against the use of ECT or high-dose medication exists among child psychiatrists.

DISCUSSION

Recent advances in child and adolescent catatonia research have offered major improvements in understanding catatonia and in new therapeutic opportunities. The syndrome is rare, but these advances need to be acknowledged in order to direct patients to centers that have developed a specific expertise.

The nature and prevalence of catatonic symptoms in young people with autism

BACKGROUND

A proportion of young people with autism are reported to show catatonic-like symptoms in adolescence. The aetiology and prevalence of such presentations is unknown but include a set of behaviours that can best be described as attenuated.

METHOD

The current study empirically investigated the presence and nature of such attenuated behaviours in children and adolescents with autism using a newly developed 34-item third party report measure, the Attenuated Behaviour Questionnaire. Caregivers or parents of young people with autism reported on the presentation of symptoms via the online completion of the Attenuated Behaviour Questionnaire and two established clinical measures of repetitive behaviour and depression.

RESULTS

Initial results indicate that the Attenuated Behaviour Questionnaire is a workable clinical measure in this population with a degree of discriminant validity with regard to catatonia. Attenuated behaviour indicative of catatonia was relatively common in young people with autism with up to 20.2% having an existing diagnosis of catatonia and evidence of a relationship between attenuated behaviours and measures of depression and repetitive and restricted behaviours.

CONCLUSION

Catatonic symptoms are more prevalent in young people with autism than previously thought, and the Attenuated Behaviour Questionnaire has potential as a clinical and research tool.

Treatment of Severe Self-Injurious Behavior in Autism Spectrum Disorder by Neuromodulation

An increasing number of case reports and series document the safe and effective use of electroconvulsive therapy (ECT) in children, adolescents, and young adults with autism spectrum disorder who engage in severe, intractable, repetitive self-injurious behavior (SIB) without environmental or operant function. Although the treatment is very effective for such patients, they typically remain highly dependent on frequent maintenance ECT (M-ECT) to maintain suppression of the SIB achieved during the acute course. Some patients receive M-ECT as frequently as once every 5 days. Such a regimen is quite burdensome for the patient and the patient's family, and the long-term effects of such regimens, starting as early as childhood, are unknown. In this review, we explore the expanding literature supporting the use of ECT for suppressing severe SIB associated with autism spectrum disorder. We also focus on the possible development of alternate nonconvulsive focal forms of brain stimulation, which might replace frequent M-ECT or reduce how frequently a patient needs to receive it. Although there are scarce clinical data currently available supporting these latter treatments, future studies are clearly indicated.

Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology

Catatonia is a psychomotor syndrome that has been reported to occur in more than 10% of patients with acute psychiatric illnesses. Two subtypes of the syndrome have been identified. Catatonia of the retarded type is characterized by immobility, mutism, staring, rigidity, and a host of other clinical signs. Excited catatonia is a less common presentation in which patients develop prolonged periods of psychomotor agitation. Once thought to be a subtype of schizophrenia, catatonia is now recognized to occur with a broad spectrum of medical and psychiatric illnesses, particularly affective disorders. In many cases, the catatonia must be treated before any underlying conditions can be accurately diagnosed. Most patients with the syndrome respond rapidly to low-dose benzodiazepines, but electroconvulsive therapy is occasionally required. Patients with longstanding catatonia or a diagnosis of schizophrenia may be less likely to respond. The pathobiology of catatonia is poorly understood, although abnormalities in gamma-aminobutyric acid and glutamate signaling have been suggested as causative factors. Because catatonia is common, highly treatable, and associated with significant morbidity and mortality if left untreated, physicians should maintain a high level of suspicion for this complex clinical syndrome. Since 1989, we have systematically assessed patients presenting to our psychiatry service with signs of retarded catatonia. In this paper, we present a review of the current literature on catatonia along with findings from the 220 cases we have assessed and treated.

Catatonia in Ugandan children with nodding syndrome and effects of treatment with lorazepam: a pilot study

Background

Nodding syndrome (NS) is a severe neuropsychiatric syndrome of an unknown etiology affecting children and adolescents mostly in Eastern Africa. Symptoms of NS and catatonia seem to overlap. We investigated the presence and types of catatonic symptoms in NS and their response to one or two doses of lorazepam, the first-line treatment for catatonia.

Methods

A cross-sectional descriptive study with systematic assessment of catatonia in 33 patients with NS using a modified version of the Bush Francis Catatonia Rating Scale. Sixteen patients met criteria for catatonia and were observed in an open and uncontrolled study to examine the effects of one or two doses of lorazepam in them.

Results

Sixteen of 33 patients with NS had an average of 5 catatonia symptoms and met criteria for catatonia. The highest scores were found for mutism, staring, poor eating/drinking, stupor, and grimacing. Excitement, rigidity, negativism and impulsivity had lower scores. None of the children had echolalia or echopraxia. In 6 children, there was a reduction of more than 50 % in catatonia ratings, representing a positive response to lorazepam. Three out of six children whose catatonia ratings did not change after the first dose, responded after administration of a second double dose. There were no unusual or critical side-effects.

Conclusions

About half of a selected sample of children with NS met criteria for catatonia. Catatonia scores decreased in most patients after one or two doses of lorazepam. Larger, longer, and controlled studies are warranted to assess the prevalence of catatonia in NS and to assess the use of lorazepam in NS through its effects on catatonia.

Trial Registration: ClinicalTrials.gov NCT02462109

Date of formal registration: June 2, 2015

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1805-5) contains supplementary material, which is available to authorized users.

Quetiapine responsive catatonia in an autistic patient with comorbid bipolar disorder and idiopathic basal ganglia calcification

BACKGROUND

Bipolar disorder (BD) has been linked with the manifestation of catatonia in subjects with autism spectrum disorders (ASD). Idiopathic basal ganglia calcification (IBGC) is characterized by movement disorders and various neuropsychiatric disturbances including mood disorder.

CASE

We present a patient with ASD and IBGC who developed catatonia presenting with prominent dystonic feature caused by comorbid BD, which was treated effectively with quetiapine.

CONCLUSION

In addition to considering the possibility of neurodegenerative disease, careful psychiatric interventions are important to avoid overlooking treatable catatonia associated with BD in cases of ASD presenting with both prominent dystonic features and apparent fluctuation of the mood state.

Bipolar disorder in adults with Asperger׳s Syndrome: a systematic review

BACKGROUND

Asperger׳s Syndrome (AS) is a neurodevelopmental disorder included in the Autism Spectrum (ASD). The current literature shows growing evidence of a high rate of comorbidity between AS and other psychiatric disorders, particularly Bipolar Disorder (BD). We reviewed available epidemiological and clinical data on BD-AS comorbidity and its diagnostic and therapeutic implications

METHODS

A systematic review of the literature was conducted through PubMed, Scopus and Psych-Info using combinations of the following search terms: Asperger׳s Syndrome, Bipolar Disorder, depression, mood disorder, psychiatric comorbidity, treatment, mood stabilizers, anticonvulsants, antipsychotics, and antidepressants.

RESULTS

BD prevalence in adults with AS ranges from 6% to 21.4% of the cases. Relatives of patients with AS showed a doubled risk of being affected by BD and a BD prevalence near to 10%. When comorbid with AS, BD assumes peculiar features which might shape its under-recognition or misdiagnosis (especially schizophrenia when psychotic symptoms are prominent). Although controlled data on pharmacological treatments in BD-AS comorbidity are substantially lacking, information is derived by open observations, case series and chart reviews. Mood stabilizers should be considered the first choice, and antipsychotics, especially second generation drugs (SGA) with 5-HT2a antagonism, have been shown useful in controlling psychotic and behavioral symptoms and improving social withdrawal. Some evidence of efficacy for the treatment of anxiety, obsessive-compulsive symptoms and depression is reported for SSRI antidepressants. The use of these drugs should be carefully monitored, because activation with hypomanic or manic switches is reported up to 54% of the treated subjects.

CONCLUSION

BD in AS patients is frequent, usually it onsets during adolescence and is often characterized by atypical presentation, making its correct identification particularly difficult. A correct diagnosis of BD in AS individuals has relevant implications on the choice of adequate psychopharmacological, psycho-social and rehabilitative treatments.

[Autism Spectrum Disorder in DSM-5 - concept, validity, and reliability, impact on clinical care and future research]

Autism Spectrum Disorder (ASD) in DSM-5 comprises the former DSM-IV-TR diagnoses of Autistic Disorder, Asperger's Disorder and PDD-nos. The criteria for ASD in DSM-5 were considerably revised from those of ICD-10 and DSM-IV-TR. The present article compares the diagnostic criteria, presents studies on the validity and reliability of ASD, and discusses open questions. It ends with a clinical and research perspective.

Catatonic features in adolescents with schizophrenia with and without a comorbid pervasive developmental disorder

BACKGROUND

Catatonia has been associated with both schizophrenia and pervasive developmental disorders. The aim of this study was to evaluate catatonic features among adolescents suffering from schizophrenia. Further, we compared these features between adolescents with a comorbid pervasive developmental disorder and those without one. Finally, we wanted to compare the profile of catatonia-like features of our schizophrenia patients to that described earlier among persons with autism spectrum disorders.

METHODS

The study comprised a consecutive sample of 18 adolescents with schizophrenia (mean age 15.6 years, SD 1.4) and their families. Diagnosis of schizophrenia was assessed with the Schedule for Affective Disorders and Schizophrenia for School-Aged Children - Present and Life-Time (K-SADS-PL) for the DSM-IV. The Diagnostic Interview for Social and Communication Disorders version 11 was used to assess catatonic features.

RESULTS

All adolescents with schizophrenia had showed some lifetime catatonic features. Approximately 78% of them had already expressed these features before the age of 10. The number of catatonic features before the age of 10 was significantly higher among the adolescents with a comorbid pervasive developmental disorder compared to those without one. The numbers of catatonic features after the age of 10 did not significantly differ between the two groups. Over three-quarters of schizophrenia patients shared four lifetime catatonic features: "lacks facial expression", "odd intonation", "poor eye contact" and "lack of cooperation".

CONCLUSIONS

Adolescent schizophrenia patients with a comorbid pervasive developmental disorder show many catatonic features in childhood whereas those without one seem to develop these features first in adolescence. Catatonic features exhibited by adolescents with schizophrenia resemble those described among persons with pervasive developmental disorders without schizophrenia.

Autism Spectrum Disorder: Defining Dimensions and Subgroups

Autism spectrum disorder (ASD) is a behaviorally defined neurodevelopmental disorder associated with the presence of social-communication deficits and restricted and repetitive behaviors. In the latest conceptualization of ASD, these two behavioral dimensions represent the core defining features of ASD, whereas associated dimensions, such as intellectual and language ability, provide a means for describing the ASD heterogeneity. In addition, the characterization of ASD subgroups, defined by the presence of known medical, genetic, or other psychiatric disorders, furthers our understanding of ASD heterogeneity. This paper reviews the history of autism, describes its core defining features, and provides an overview of the clinically and etiologically relevant subgroups that add to the complexity of this condition.

Catatonia in patients with autism: prevalence and management

Although recent studies have shown that catatonia can occur in patients with autism spectrum disorders (ASDs), the overlap of the behavioral features between these disorders raises many diagnostic challenges. In fact, in clinical practice it is common to misinterpret catatonic symptoms, including mutism, stereotypic speech, repetitive behaviors, echolalia, posturing, mannerisms, purposeless agitation and rigidity, as features of ASDs. The current medical treatment algorithm for catatonia in ASDs recommends the use of benzodiazepines. Electroconvulsive therapy (ECT) is indicated when patients are unresponsive, or insufficiently responsive, to benzodiazepines. Other pharmacological options are also described for the treatment of catatonic patients resistant to benzodiazepines and ECT, and there is evidence for the effectiveness of a psychological treatment, co-occurring with medical treatments, in order to support the management of these patients. In this article we provide a summary of studies exploring catatonia in ASDs and our clinical experience in the management and treatment of this syndrome through the presentation of three brief case studies. Moreover, we review the mechanisms underlying symptoms of catatonia in ASDs, as well as the diagnostic challenges, providing an outline for the management and treatment of this syndrome in this clinical population.

Revisiting the relationship between autism and schizophrenia: toward an integrated neurobiology

Schizophrenia and autism have been linked since their earliest descriptions. Both are disorders of cerebral specialization originating in the embryonic period. Genetic, molecular, and cytologic research highlights a variety of shared contributory mechanisms that may lead to patterns of abnormal connectivity arising from altered development and topology. Overt behavioral pathology likely emerges during or after neurosensitive periods in which resource demands overwhelm system resources and the individual's ability to compensate using interregional activation fails. We are at the threshold of being able to chart autism and schizophrenia from the inside out. In so doing, the door is opened to the consideration of new therapeutics that are developed based upon molecular, synaptic, and systems targets common to both disorders.

Modulation of ion channels in clinical psychopharmacology: adults and younger people

This review focuses on the use of Na(+), Ca(2+) and Cl(-) channel modulators in psychiatric disease. Drugs that modulate ion channels have been used in psychiatry for more than a century, and in this review we critically evaluate clinical research that reports the therapeutic effects of drugs acting on GABA(A), voltage-gated Na(+) and voltage-gated Ca(2+) channels in pediatric and adult patients. As in other fields, the evidence underpinning the use of medicines in younger people is far less robust than for adults. In addition, we discuss some current developments and highlight clinical disorders in which current molecules could be further tested. Notable success stories, such as benzodiazepines (in sleep and anxiety disorders) and antiepileptics (in bipolar disorder), have been the result of serendipitous discoveries or refinements of serendipitous discoveries, as in all other major treatments in psychiatry. Genomic, high-throughput screening and molecular pharmacology discoveries may, however, guide further developments in the future. This could include increased research in promising targets that have been perceived as commercially risky, such as selective α-subunit GABA(A) receptors.

Autism spectrum disorders--a genetics review

Autism is an etiologically and clinically heterogeneous group of disorders, diagnosed solely by the complex behavioral phenotype. On the basis of the high-heritability index, geneticists are confident that autism will be the first behavioral disorder for which the genetic basis can be well established. Although it was initially assumed that major genome-wide and candidate gene association studies would lead most directly to common autism genes, progress has been slow. Rather, most discoveries have come from studies of known genetic disorders associated with the behavioral phenotype. New technology, especially array chromosomal genomic hybridization, has both increased the identification of putative autism genes and raised to approximately 25%, the percentage of children for whom an autism-related genetic change can be identified. Incorporating clinical geneticists into the diagnostic and autism research arenas is vital to the field. Interpreting this new technology and deciphering autism's genetic montage require the skill set of the clinical geneticist including knowing how to acquire and interpret family pedigrees, how to analyze complex morphologic, neurologic, and medical phenotypes, sorting out heterogeneity, developing rational genetic models, and designing studies. The current emphasis on deciphering autism spectrum disorders has accelerated the field of neuroscience and demonstrated the necessity of multidisciplinary research that must include clinical geneticists both in the clinics and in the design and implementation of basic, clinical, and translational research.

Electroconvulsive therapy in adolescents with the catatonia syndrome: efficacy and ethics

OBJECTIVES

In child and adolescent psychiatry, catatonia is infrequent, but it is one of the most severe syndromes, characterized by the coexistence of psychic and motor symptoms. In this report, we explore the therapeutic experience with electroconvulsive therapy (ECT) in adolescents with catatonia.

METHODS

We review the literature (1985-2009) to clarify issues related to the use of ECT in child and adolescent patients with catatonia.

RESULTS

Electroconvulsive therapy is used as second-line management after high-dose benzodiazepine trials. Electroconvulsive therapy is an effective, safe, and useful procedure in the treatment of catatonic youngsters as reported in 59 patients. Ethical issues regarding the use of ECT are analyzed and their implications briefly discussed in the light of general medical ethics.

CONCLUSIONS

Electroconvulsive therapy is a safe and effective treatment for catatonia in children and adolescents.

Tics as signs of catatonia: electroconvulsive therapy response in 2 men

OBJECTIVES

Tics have rarely been described in catatonia although tics are sudden and nonrhythmic variants of stereotypic or repetitive movement abnormalities that are considered cardinal symptoms of catatonia. We describe 2 men with tics and self-injurious behavior, who met criteria for catatonia. One patient met criteria for autism.

CASE REPORTS

We reported 2 new cases and performed a literature review using PubMed to identify other cases of tics that were treated with electroconvulsive therapy. Tics along with other catatonic symptoms and self-injurious behavior responded to electroconvulsive therapy in 2 men. Eight other patients with tics that were treated with electroconvulsive therapy were found in the literature. Catatonia was recognized in 4 of the 8 patients. Two patients met criteria for autism.

CONCLUSIONS

Tics, with or without self-injurious behavior, may be signs of catatonia. Patients with tics or Tourette syndrome warrant assessment for catatonia. If catatonia is present, electroconvulsive therapy provides a safe but rarely used alternative to pharmacotherapy, psychosurgery, or invasive brain stimulation in the treatment of tics and Tourette syndrome.

Onset of catatonia at puberty: electroconvulsive therapy response in two autistic adolescents

Catatonia is a syndrome of motor and behavioral disturbance. It is a poorly understood condition, which is underrecognized and may go untreated despite intensive medical workup and numerous unsuccessful medication trials. However, with treatments known to be effective, such as benzodiazepines and/or electroconvulsive therapy, patients may return to their baseline functioning. Autism and catatonia have been previously reported together. We report 2 patients with autism and mental retardation who developed catatonic symptoms at the onset of puberty. Both patients experienced persistent symptoms over several years and presented with a history of motor disturbance, functional decline, and episodic aggression. Both patients were treated with electroconvulsive therapy resulting in a positive response and functional improvement. Catatonia may persist as a chronic condition, lasting over several months or years, if not recognized and treated.

Catatonia is hidden in plain sight among different pediatric disorders: a review article

Over the past two decades, catatonia has been better demarcated in adult psychiatry as a unique syndrome that consists of specific motor signs with a characteristic response to benzodiazepines and electroconvulsive therapy. Pediatric catatonia is considered rare, but may be underdiagnosed, and hence undertreated. Discussed here are the current diagnostic criteria of catatonia in individual cases of children and adolescents diagnosed with childhood disintegrative disorder, Kleine-Levin syndrome, Prader-Willi syndrome, tic disorder, and autoimmune encephalitis, and the effects of benzodiazepines and electroconvulsive therapy. In these cases, catatonia resolved safely once it was recognized and treated properly. Children and adolescents presenting with these disorders should be systematically assessed for catatonia; when the presence of catatonia is confirmed, the use of benzodiazepines and electroconvulsive therapy should be considered. The occurrence of catatonia in such a wide range of child and adolescent disorders supports the view that pediatric catatonia is not so rare, that there are shared elements in the etiology, psychopathology, and pathophysiology of these disorders, and that catatonia is best classified as a unique neurobiologic syndrome.

Lorazepam, fluoxetine and packing therapy in an adolescent with pervasive developmental disorder and catatonia

Packing therapy is an adjunct symptomatic treatment used for autism and/or catatonia. Here, we report the case of a 15-year-old boy with pervasive developmental disorder who developed catatonia. At admission, catatonic symptoms were severe and the patient required a feeding tube. Lorazepam up to 15 mg/day moderately improved the catatonic symptoms. On day 36 we added fluoxetine and on day 62 we added packing therapy (twice per week, 10 sessions). After three packing sessions, the patient showed a significant clinical improvement (P<0.001). At discharge (day 96), he was able to return to his special education program. Although we do not consider packing as a psychodynamic treatment, this case challenges the concept of embodied self that has opened new perspectives on a dialogue between psychoanalysis and neuroscience. Indeed, better body representation following packing sessions, as shown in patient's drawing, paralleled clinical improvement, and supports the concept of embodied self. This concept may serve as a link between psychoanalysis and attachment theory, developmental psychology with the early description of "sense of self", and cognitive neurosciences that more and more support the concept of embodied cognition. Further clinical studies are necessary to clarify the efficacy and underlying mechanism of packing treatment and to understand how patient's experience may illustrate the concept of embodied self.

Catatonia: diagnosis, classification, and treatment

Catatonia is a distinct neuropsychiatric syndrome that is becoming more recognized clinically and in ongoing research. It occurs with psychiatric, metabolic, or neurologic conditions. It may occur in many forms, including neuroleptic malignant syndrome. Treatment with benzodiazepines or electroconvulsive therapy leads to a dramatic and rapid response, although systematic, randomized trials are lacking. An important unresolved question is the role of antipsychotic agents in treatment and their potential adverse effects.

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.