European Child & Adolescent Psychiatry

, Volume 28, Issue 4, pp 471–480 | Cite as

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

  • Lee Elizabeth WachtelEmail author
Original Contribution


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.


Catatonia Autism Self-injury Benzodiazepines Electroconvulsive therapy 



The author would like to thank Max Fink, MD and Edward Shorter, PhD for their invaluable and extensive mentorship, and the patients and their families who have so generously shared their stories.

Compliance with ethical standards

Conflict of interest

The author hereby declares no conflicts of interest or necessary disclosures.


  1. 1.
    Kahlbaum K (1874) Die Katatonie oder das Spannungsirresein. Verlag August Hirshwald, BerlinGoogle Scholar
  2. 2.
    American Psychiatric Association (2014) Diagnostic and statistical manual of mental disorders: DSM 5, 5th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  3. 3.
    Morrison J (1973) Catatonia: retarded and excited types. Arch Gen Psychiatry 28:39–41CrossRefGoogle Scholar
  4. 4.
    Bush G, Fink M, Petrides G, Dowling F, Francis A (1996) Catatonia: I. Rating scale and standardized examination. Acta Psychiatr Scand 93:129–136CrossRefGoogle Scholar
  5. 5.
    Bush G, Fink M, Petrides G, Dowling F, Francis A (1996) Catatonia. II. Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand 93:137–143CrossRefGoogle Scholar
  6. 6.
    Fink M, Taylor A (2006) Catatonia: a clinician’s guide to diagnosis and treatment. Cambridge University Press, CambridgeGoogle Scholar
  7. 7.
    Caroff S, Mann S, Francis A, Fricchione G (2004) Catatonia: from psychopathology to neurobiology. American Psychiatric Publishing Inc, WashingtonGoogle Scholar
  8. 8.
    Ghaziuddin N, Marcotte K, Dhossche D (2012) Retrospective chart review of catatonia in child and adolescent psychiatric patients. Acta Psychiatr Scand 125(1):33–38CrossRefGoogle Scholar
  9. 9.
    Wing L, Shah A (2000) Catatonia in autistic spectrum disorders. Br J Psychiatry 176:357–362CrossRefGoogle Scholar
  10. 10.
    Billstedt E, Gilberg C, Gilberg C (2005) Autism after adolescence: population-based 13- to 22-year follow-up study of 120 individuals with autism diagnosed in childhood. J Autism Dev Disord 35:351–360CrossRefGoogle Scholar
  11. 11.
    Breen J, Hare D (2017) The nature and prevalence of catatonic symptoms in young people with autism. J Intellect Disabil Res 61(6):580–593CrossRefGoogle Scholar
  12. 12.
    Dhossche D, Wing L, Ohta M, Neumarker K-J (eds) (2006) Catatonia in Autism spectrum disorders, vol 72. International Review of Neurobiology. Elsevier Academic Press, San Diego, USAGoogle Scholar
  13. 13.
    Wachtel L, Contrucci-Kuhn S, Griffin M, Thompson A, Dhossche D, Reti I (2009) ECT for self-injury in an autistic boy. Eur Child Adolesc Psychiatry 18(7):458–463. CrossRefGoogle Scholar
  14. 14.
    Wachtel L, Dhossche D (2010) Self-injury in autism as an alternate sign of catatonia: implications for electroconvulsive therapy. Med Hypotheses 75(1):111–114. CrossRefGoogle Scholar
  15. 15.
    Wachtel L, Jaffe R, Kellner C (2011) Electroconvulsive therapy for psychotropic-refractory bipolar affective disorder and severe self-injury and aggression in an 11-year-old autistic boy. Eur Child Adolesc Psychiatry 20(3):147–152. CrossRefGoogle Scholar
  16. 16.
    Wachtel L, Kahng S, Dhossche D, Cascella N, Reti I (2008) Electroconvulsive therapy for catatonia in an autistic girl. Am J Psychiatry 165:329–333CrossRefGoogle Scholar
  17. 17.
    Wachtel L, Shorter E (2013) Self-injurious behaviour in children: a treatable catatonic syndrome. Aust N Z J Psychiatry 47(12):1113–1115. CrossRefGoogle Scholar
  18. 18.
    Paclawskyj TR, Kurtz PF, O’Connor JT (2004) Functional assessment of problem behaviors in adults with mental retardation. Behav Modif 28(5):649–667CrossRefGoogle Scholar
  19. 19.
    Soke GN, Rosenberg SA, Hamman RF, Fingerlin T, Robinson C, Carpenter L, Giarelli E, Lee LC, Wiggins LD, Durkin MS, DiGuiseppi C (2016) Brief report: prevalence of self-injurious behaviors among children with autism spectrum disorder-a population-based study. J Autism Dev Disord 46(11):3607–3614. CrossRefGoogle Scholar
  20. 20.
    Folch A, Cortes MJ, Salvador-Carulla L, Vicens P, Irazabal M, Munoz S, Rovira L, Orejuela C, Haro JM, Vilella E, Martinez-Leal R (2018) Risk factors and topographies for self-injurious behaviour in a sample of adults with intellectual developmental disorders. J Intellect Disabil Res. Google Scholar
  21. 21.
    Wachtel L, Dhossche D (2010) Self-injury in autism as an alternative sign of catatonia. Med Hypotheses 75(1):111–114CrossRefGoogle Scholar
  22. 22.
    Shorter E, Fink M (2018) The madness of fear: a history of catatonia. Oxford University Press, New YorkCrossRefGoogle Scholar
  23. 23.
    Wachtel LE, Kahng S, Dhossche DM, Cascella N, Reti IM (2008) ECT for catatonia in an autistic girl. Am J Psychiatry 165(3):329–333. CrossRefGoogle Scholar
  24. 24.
    Zaw F, Bates G, Murali V, Bentham P (1999) Catatonia, autism, and ECT. Dev Med Child Neurol 41:843–845CrossRefGoogle Scholar
  25. 25.
    Ohta M, Kano Y, Nagai Y (2006) Catatonia in individuals with autism spectrum disorders in adolescence and early adulthood: a long-term prospective study. Int Rev Neurobiol 72:41–54CrossRefGoogle Scholar
  26. 26.
    Hare D, Malone C (2004) Catatonia and autism spectrum disorders. Autism 8:183–195CrossRefGoogle Scholar
  27. 27.
    Dhossche D (1998) Brief report: catatonia in autistic disorders. J Autism Dev Disord 28(4):329–331CrossRefGoogle Scholar
  28. 28.
    Kakooza-Mwesige A, Wachtel L, Dhossche D (2008) Catatonia in autism: implications across the life span. Eur Child Adolesc Psychiatry 17(6):327–335CrossRefGoogle Scholar
  29. 29.
    Wachtel L, Commins E, Park M, Rolider N, Stephens R, Reti I (2015) Neuroleptic malignant syndrome and delirious mania as malignant catatonia in autism: prompt relief with electroconvulsive therapy. Acta Psychiatr Scand 132(4):319–320. CrossRefGoogle Scholar
  30. 30.
    Wachtel L, Griffin M, Dhossche D, Reti I (2010) Brief report: electroconvulsive therapy for malignant catatonia in an autistic adolescent. Autism 14(4):349–358. CrossRefGoogle Scholar
  31. 31.
    Wachtel L, Griffin M, Reti I (2009) Electroconvulsive therapy in a man with autism experiencing severe depression, catatonia and self-injury. J ECT 26(1):70–73CrossRefGoogle Scholar
  32. 32.
    Wachtel L, Reti I, Ying H (2013) Stability of intraocular pressure after retinal reattachment surgery during electroconvulsive therapy for intractable self-injury in a 12-year-old autistic boy. J ECT 30(1):73–76CrossRefGoogle Scholar
  33. 33.
    Wachtel L, Schuldt S, Ghaziuddin N, Shorter E (2013) The potential role of electroconvulsive therapy in the ‘Iron Triangle’ of pediatric catatonia, autism, and psychosis. Acta Psychiatr Scand 128(5):408–409CrossRefGoogle Scholar
  34. 34.
    Dhossche D, Shah A, Wing L (2006) Blueprints for the assessment, treatment, and future study of catatonia in autism spectrum disorders. Int Rev Neurobiol 72:267–284CrossRefGoogle Scholar
  35. 35.
    Fink M, Taylor M, Ghaziuddin N (2006) Catatonia in autistic spectrum disorders: a medical treatment algorithm. Int Rev Neurobiol 72:233–244CrossRefGoogle Scholar
  36. 36.
    Dhossche D (2004) Autism as early expression of catatonia. Med Sci Monit 10:RA31–RA39Google Scholar
  37. 37.
    Dhossche D, Rout U (2006) Are autistic and catatonic regression related? A few working hypotheses involving GABA, Purkinje cell survival, neurogenesis, and ECT. Int Rev Neurobiol 72:55–79CrossRefGoogle Scholar
  38. 38.
    Dhossche D, Song Y, Liu Y-M (2005) Is there a connection between autism, Prader-Willi syndrome, catatonia, and GABA? Int Rev Neurobiol 71:189–216CrossRefGoogle Scholar
  39. 39.
    Dhossche DM, Bouman NH (1997) Catatonia in an adolescent with Prader-Willi syndrome. Ann Clin Psychiatry 9(4):247–253CrossRefGoogle Scholar
  40. 40.
    Faedda G, Wachtel L, Higgins AM, Shprintzen R (2015) Catatonia in an adolescent with velo-cardio-facial syndrome. Am J Med Genet A 167A(9):2150–2153CrossRefGoogle Scholar
  41. 41.
    Winarni T, Schneider A, Ghaziuddin N, Seritan A, Hagerman R (2015) Psychosis and catatonia in fragile X: case report and literature review. Intractable Rare Dis Res 4(5):139–146CrossRefGoogle Scholar
  42. 42.
    Shorter E, Wachtel L (2013) Childhood catatonia, autism and psychosis past and present: is there an ‘iron triangle’? Acta Psychiatr Scand 128(1):21–33. CrossRefGoogle Scholar
  43. 43.
    Stauder K (1934) Die todliche Katatonie. Arch Psychiatr Nervenkrank 102:614–634CrossRefGoogle Scholar
  44. 44.
    Dhossche D, Shettar S, Kumar T, Burt L (2009) Electroconvulsive therapy for malignant catatonia in adolescence. South Med J 102(11):1170–1172CrossRefGoogle Scholar
  45. 45.
    Wachtel L, Crawford T, Dhossche D, Reti I (2010) Electroconvulsive therapy for pediatric malignant catatonia with cerebellar dysgenesis. Pediatr Neurol 43(6):427–430. CrossRefGoogle Scholar
  46. 46.
    Ghaziuddin N, Hendriks M, Patel P, Wachtel LE, Dhossche DM (2017) Neuroleptic malignant syndrome/malignant catatonia in child psychiatry: literature review and a case series. J Child Adolesc Psychopharmacol 27(4):359–365. CrossRefGoogle Scholar
  47. 47.
    Handen BL, Mazefsky CA, Gabriels RL, Pedersen KA, Wallace M, Siegel M, Autism, Developmental Disorders Inpatient Research C (2018) Risk factors for self-injurious behavior in an inpatient psychiatric sample of children with autism spectrum disorder: a naturalistic observation study. J Autism Dev Disord. Google Scholar
  48. 48.
    Kahng S, Iwata B, Lewin A (2002) Behavioral treatment of self-injury, 1964–2000. Am J Ment Retard 107(3):212–221CrossRefGoogle Scholar
  49. 49.
    Hanley G, Iwata B, McCord B (2003) Functional analysis of problem behavior: a review. J Appl Behav Anal 36(2):147–185CrossRefGoogle Scholar
  50. 50.
    Mace F, Mauk J (1995) Bio-behavioral diagnosis and treatment of self-injury. Ment Retard Dev Disabil 1:104–110CrossRefGoogle Scholar
  51. 51.
    Wachtel L, Hagopian L (2006) Psychopharmacology and applied behavioral analysis: tandem treatment of severe problem behaviors in intellectual disability and a case series. Isr J Psychiatry Relat Sci 43(4):265–274Google Scholar
  52. 52.
    Bates W, Smeltzer D (1982) Electroconvulsive treatment of psychotic self-injurious behavior in a patient with severe mental retardation. Am J Psychiatry 139:1355–1356CrossRefGoogle Scholar
  53. 53.
    Fink M (1999) Electroshock: healing mental illness. Oxford University Press, LondonGoogle Scholar
  54. 54.
    Carr V, Dorrington C, Schrader G, Wale J (1983) The use of ECT for mania in childhood bipolar disorder. Br J Psychiatry 143:411–415CrossRefGoogle Scholar
  55. 55.
    Black D, Wilcox J, Stewart M (1985) The use of ECT in children: case-report. J Clin Psychiatry 46:98–99Google Scholar
  56. 56.
    Cizadlo B, Wheaton A (1995) Case study: ECT treatment of a young girl with catatonia. J Am Acad Child Adolesc Psychiatry 34:332–335CrossRefGoogle Scholar
  57. 57.
    Chung A, Varghese J (2008) Treatment of catatonia with electroconvulsive therapy in an 11 year-old girl. Aust NZJ Psychiatry 42:251–253CrossRefGoogle Scholar
  58. 58.
    Arora M, Praharaj S, Prakash R (2008) Electroconvulsive therapy for multiple major self-mutilations in bipolar psychotic depression. Turk J Psychiatry 19(2):1–4Google Scholar
  59. 59.
    Wachtel LE, Shorter E, Fink M (2018) Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key. Curr Opin Psychiatry 31(2):116–122. CrossRefGoogle Scholar
  60. 60.
    DeJong H, Bunton P, Hare DJ (2014) A systematic review of interventions used to treat catatonic symptoms in people with autistic spectrum disorders. J Autism Dev Disord 44(9):2127–2136. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Kennedy Krieger InstituteBaltimoreUSA

Personalised recommendations