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Autistic catatonia is a rare type of disorder that affects roughly 10 percent of all adults with autism spectrum disorder. Most are not severely affected but a few exhibit stupor and severe excitement, which is the most extreme form of the disorder. Full expression of excitement could be a sign of comorbid bipolar disorder but more research is needed.

More than 40 symptoms have been identified to be a result of the disorder, but some of the symptoms overlap with those of autism spectrum disorder, making diagnosing difficult even for a seasoned professional. In a few cases stupor and hyperactivity can continue for weeks or even months. During the excitement phase individuals show combativeness and can have delusions and hallucinations and can also pose a danger to themselves or others and can make marked destruction of property. In the later stages of medium and even more in the severe (and, if left untreated, lethal) state they will also experience autonomic instability.

Childhood schizophrenia increases the risk for autistic catatonia later in life dramatically. There seems to be a common font of brain pathology for psychosis, catatonia and autism.

Autistic Catatonia
Catatonia in individuals with autism spectrum disorders (ASDs) is also referred to as "catatonia-like deterioration" or "autistic catatonia."

Catatonia-like deterioration is a neurological complication that can occur in ASDs that affects movement, verbal responses, initiation and completion of actions, motivation, and physiological necessities (e.g. eating, drinking, excretion). This deterioration often results in an increased dependence on others for physical or verbal prompts. Catanonia may be mild, moderate, or severe and may be life-threatening. In its most severe form, these symptoms affect the individual's autonomic system (e.g. heart rate, body temperature, digestion, metabolism, urination and defecation, breathing and swallowing). Mood disorders, anxiety, language impairments, and passivity in social interactions in people with ASDs increase the risk of catatonia-like deterioration in this population.

The reported age of onset varies from as early as 10 years with a typical age range from 15 to 20 years of age. Younger patients presenting isolated symptoms that progress over time.

The prevalence of catatonia-like deterioration in adolescents and young adults with ASDs ranges from 6.5 percent to between 12 and 18 percent.

Symptoms related to catatonia in individuals with ASDs overlap with those found in other psychiatric disorders (e.g., schizophrenia, depression, obsessive-compulsive disorder, Tourette syndrome and Attention-deficit hyperactivity disorder), learning disabilities of an unspecified nature, and Neurodevelopmental disorders (e.g., Prader-Willi syndrome, Parkinsonism), making the condition difficult to diagnose. Researchers have yet to reach agreement on whether catatonia is a comorbid condition or a subtype of autism. The catatonic-like symptoms that occur in ASD (e.g., motor stereotypies, mannerisms, rituals, mutism, echolalia, and negativism) do not always encompass wider definitions of catatonia. Some researchers believe the presence of psychiatric disorders increases "the risk of catatonia emerging in persons with autism." Due to the overlap in symptoms, diagnosis of autistic catatonia is indicated with the emergence of new symptoms or "an obvious and marked deterioration in movement, pattern of activities, self-care and practical skills, compared with previous levels."

Other causes of catatonia that should be ruled out include: antipsychotic medications and illicit drugs (e.g. PCP, mescaline, psilocybin, cocaine, opiates, and opioids), disulfiram, steroids, antibiotic agents (ciprofloxacin), and bupropion), rapid withdrawal of benzodiazepines, gabapentin, and dopaminergic drugs, as well as infectious, metabolic, endocrinological, neurological and autoimmune diseases.

Observation and treatment of autistic catatonia has, to date, been based on clinical reports, but no controlled studies investigating the causes, nature, and treatment of catatonia in individuals with ASDs have been published.

Symptoms
Symptoms of catatonia-like deterioration are generally marked by a loss of language skills, inertia, intellectual decline, and, in some cases, seizures which may affect existing patterns of activities, self-care, and practical skills.

List of symptoms that has been observed in those with individuals with catatonia. Some of these overlap with individuals with ASD that exhibit catatonia-like deterioration. Researchers advise that "studies may need to employ head-to-head comparisons of patients with autism and catatonia in order to substantiate common biological, neuropsychological, or genetic factors."

• Stupor

• Mutism

• Hyperactivity

• Agitation

• Excitement

• Posturing

• Negativism

• Rigidity

• Waxy flexibility, mitmachen, mitgehen – tendency to remain in immobile posture, inability to resist external pressure on posture

• Automatic obedience

• Combativeness (during excitement)

• Aggressivity

• Stereotypies

• Tics

• Grimacing

• Echolalia

• Echopraxia/Echophenomena

• Perseveration

• Verbigeration

• Staring, gaze fixation

• Withdrawal

• Immobility

• Challenging behaviour

• Tremor

• Slowness

• Amotivation

• Grasp reflex

• Choreoathetoid movements of the trunk and extremities

• Autonomic instability (during excitement)

• Inability to start or stop actions (if during excitement episodes needs acute psychiatric care)

• Impulsivity

• Psychotic

• Sleep problems, reversal of day and night

• Urinary or fecal incontinence

• Passivity

• Eyerolling

• Stiff muscles

• Catalepsy

• Gegenhalten

• Ambitendency – contradictory behavior

• Rituals – repetitive behaviors

Treatment
A 2019 report states that "the evidence basis supporting the treatment for catatonia in individuals with ASDs is limited, but growing." However, articles written prior to that year report a "lack of evidence concerning the most appropriate treatments for catatonia in people with ASDs" and an "absence of treatable cause." Single case studies record a variety of medications used as interventions and "no or only short-lived beneficial effects." Wachtel, Hermida, and Dhossche wrote in 2010:

Physical and Verbal Prompts
Physical and verbal prompts may help people with catatonia-like deterioration to move on or complete an action or activity and/or stop a repetitive action once started. The amount, level, and type of prompting is dependent on the individual's needs for any given situation and may vary even with the same individual. Teaching strategies based on the principles of applied behavior analysis (ABA) may provide some benefit to individuals afflicted with this condition.

Activity
Physical activity involving rhythmic, repetitive movements that reduce stress and keep individuals active, mobile, and stimulated may reduce the effects of catatonia-like deterioration.

Electroconvulsive Therapy (ECT)
Electroconvulsive Therapy (ECT) is used in treating severe cases of catatonia, particularly with individuals at risk of starvation and death, or when other approaches have proved ineffective. The use of ECT may result in partial resolution of catatonic symptoms, but effects may be temporary. ECT is often combined with various medication for sustained benefit. Researchers call for "modern studies that meet acceptable scientific standards" to address the treatment needs of people with and without ASDs.

Side effects include headache, confusion, subjective memory loss and prolonged seizures. Repeated administration of ECT over a lengthy period may also have cumulative effects, which are not well documented particularly in pediatric populations.

Lorazepam
The "lorazepam challenge test," the administration of a small dose of the drug, may be conducted to diagnose severe forms of catatonia. A positive response results in rapid resolution of symptoms. Zolpidem has also been used. Individual case studies have reported a positive response to medication and/or ECT for individuals with ASDs and catatonia-like states. However, for individuals with chronic catatonia-like deterioration without stupor, medical interventions sho no or only partial remission of symptoms.

Side effects include allergic reactions to the medication and complications due to sedation.

History
In the 19th century the psychiatrist Karl Ludwig Kahlbaum observed several symptoms of the disorder. Among them were stupor, mutism, excitement, hyperactivity, posing, negativism, rigidity, waxy flexibility and automatic obedience, stereotypies, tics, grimacing, echo-phenomenon, and self-harming.

Also marbling of the skin, profuse sweating, deviation of the pupils and odd reaction to light were considered catatonic phenomenons.

During most of the 20th century catatonia was regarded as schizophrenic in its nature, but towards the end of the century it was more commonly observed in those with bipolar disorder and autism spectrum disorder. Now only 15 percent of those with catatonia are considered to have schizophrenia.