Case Presentation: A 15-year-old male with autism spectrum disorder (ASD), depression, and anxiety presented to the emergency department (ED) with aphasia, agitation, and unusual gait. His mother reported stuttering, decreased oral intake, and difficulty with daily activities. He visited the ED for similar symptoms over the past few months. His outpatient provider trialed lorazepam, which improved symptoms. Within a few weeks, he returned to the ED with increasing agitation. He was prescribed lorazepam for anxiety related to a recent move and school change. Following a brief improvement, he returned with slowed speech and functional decline. On exam, he was alert with minimal movement, shuffling gait, and word-finding difficulty. Labs and head imaging were normal, and he was admitted for evaluation and ultimately diagnosed with catatonia.
Discussion: Catatonia is a neuropsychiatric syndrome characterized by a range of psychomotor abnormalities. The DSM-5 diagnostic criteria require the presence of at least 3 of the following symptoms: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, or echopraxia. Catatonia can be diagnosed in the context of major mood disorders, psychotic disorders, general medical conditions, or in isolation. Notably, up to 17% of adolescents and adults with ASD also experience catatonia. In individuals with ASD, catatonia can present as slowed movement and verbal responses, increased reliance on prompting for daily activities, lack of motivation, tremor, eye-rolling, dystonia, agitation, and repetitive behavior. As these symptoms often overlap with baseline ASD behaviors, diagnosing catatonia can be challenging. Diagnosis of catatonia in a hospital setting often relies on tools like the Bush-Francis Catatonia Rating Scale (BFCRS), which provides a structured way to identify key symptoms. In resource-limited settings or where psychiatry is not readily available, hospitalists can perform a thorough assessment and initiate a lorazepam challenge, where symptom improvement after lorazepam strongly supports the diagnosis. Red flags such as worsening rigidity, autonomic instability, or dehydration necessitate immediate recognition and treatment.
Conclusions: Diagnosing catatonia in individuals with ASD requires recognizing its symptoms and differentiating them from ASD. Attributing symptoms to existing psychiatric or developmental disorders, recent stressors, or typical adolescent behavior can delay diagnosis. An assessment of motor and behavioral symptoms, use of standardized rating scales, and the lorazepam challenge test are essential in identifying catatonia. Timely recognition and treatment, primarily with lorazepam and electroconvulsive therapy, are crucial for symptom improvement, as delays can lead to severe morbidity or mortality. With the increasing strain on psychiatric resources, hospitalists should recognize the signs of catatonia, particularly as the prevalence of ASD diagnosis increases.