Excited Catatonia in Autism Spectrum Disorder: Two Case Presentations

Out on PubMed, from clinicians in Florida, are these two new cases:

Excited Catatonia in Autism Spectrum Disorder: A Case Series.

Burns NK, Grissett K, Macaluso M, Raza M, Gracious B.Front Psychiatry. 2021 May 11;12:674335. doi: 10.3389/fpsyt.2021.674335. eCollection 2021.PMID: 34045985

The abstract is copied below:

Introduction: Autistic catatonia is an under-recognized debilitating syndrome with long-lasting negative effects for families, healthcare workers, and high-cost to the healthcare system. In this report, we describe two cases of excited catatonia in young men diagnosed with autism. Both endured a delay to diagnosis and difficulty to obtain appropriate treatment. Main concern: Each patient had a change in behavior 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. Yet, despite a confirmed diagnosis, it was difficult to treat as the importance of M-ECT was not recognized by the clinicians. The second patient had been suffering for more than 5 years with a slow progression of worsening aggressive symptoms. The aggression was so uncontrollable that the patient required sedation, intubation and daily ECT. Both suffered from agitation, unprovoked aggression, urinary incontinence, stereotypic, and OCD behaviors and compulsive masturbation. Primary Diagnosis, intervention/outcomes: 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. The first patient's diagnosis of catatonia was only suspected after five psychiatric admissions and more than 20 medication trials. Lorazepam challenge was effective, he was treated with a short series of ECT but each time the treatments were tapered, the aggression returned. Ultimately, stabilized on weekly ECT. The second patient's behavior was escalating over a 5 month period, to the point, the aggression was uncontrollable. He presented to the ED under involuntary hold and the behavior could not be stabilized to the point that emergent ECT was initiated. Conclusion: Two cases of autistic catatonia diagnosed and treated within a year time span at a small community hospital indicates that this diagnosis is more common than previously recognized. We propose screening all patients with neurodevelopmental disorders with the Bush-Francis and Kanner scales to diagnose and treat them appropriately.

Keywords: ECT; autism spectrum disorder; catatonia; excited catatonia; pediatric

The pdf is here.

And a figure:

And from the text:

CONCLUSION 

Patients with autism who present to the ED and psychiatric crisis units commonly do so after episodes of agitation and aggression that are unmanageable in the outpatient setting. We report successful diagnosis and treatment of two cases of excited catatonia comorbid with ASD, presenting within a year to a small community hospital. This indicates that catatonia in ASD may be more common than previously recognized. Both suffered delays in diagnosis and treatment, resulting in burdens to the patient, their families and the healthcare system. Diagnosing catatonia in those with ASD is difficult given the overlaps between catatonic symptoms and behaviors typically seen on the autism spectrum. Screening patients with autism with declines in adaptive functioning with tools such as the Kanner and Bush-Francis Catatonia rating scales may facilitate diagnosis. Clinicians, staff, and caregivers universally struggle with caring for these patients, as they require a different understanding of etiology, more intensive services, greater family involvement, and management of aggression that raises risk for injury. Psychiatric units must increase resources for them. Once diagnosed with catatonia, our patients faced continued barriers to appropriate effective treatments. By improving awareness among the medical community and general public on catatonia and barriers to care, earlier diagnosis and better access to appropriate treatment may occur.

These two cases are worthwhile additions to the literature on catatonia in the context of autism. The clinical presentations are comprehensively described; the cases are typical, rather than novel. That makes it all the more distressing that in 2020 it took so long to correctly  diagnose and treat them.

These patients received the ubiquitous, what I call "kitchen sink" pharmacotherapy before being prescribed ECT. High lorazepam tolerance is noted. The figures (see above) of psychomotor activity are innovative and well done.

The Frontiers in Psychiatry policy of listing the editor and reviewers of the report is quite "open" indeed-this has already been vetted by three of the world's experts in catatonia.

The other catatonia experts and mavens, and most of the rest of us, will want to read it in full, ~15 minutes.