Catatonia is often associated with severe mood disorders or schizophrenia, but research shows that individuals with autism spectrum disorder (ASD) are also at increased risk—particularly adolescents and young adults.
Known as autistic catatonia, this underrecognized condition is both serious and treatable, but often misdiagnosed or mistaken for progression of autism itself.
Catatonia is a neuropsychiatric syndrome marked by abnormalities in movement, speech, and behavior, which may include stupor, mutism, posturing, repetitive movements, and refusal to eat or drink. Once thought to be a subtype of schizophrenia, we now know catatonia can occur across a wide range of psychiatric and medical conditions (Taylor & Fink, 2003). The DSM-5 criteria for catatonia require at least three of 12 characteristic symptoms, including motor
immobility, echolalia, negativism, waxy flexibility, agitation, or grimacing (American Psychiatric Association, 2013).
Autistic catatonia refers to the presence of catatonic symptoms in individuals with autism, often superimposed on their baseline developmental and communicative differences. Symptoms can include sudden loss of speech or reduced verbal output, decreased engagement or initiation, slowed movements or freezing mid-task, increased rigidity or repetitive behaviors, periods of unresponsiveness or stupor, and difficulty initiating actions or thoughts (Levy et al., 2021).
These changes often emerge in adolescence or early adulthood, sometimes following a stressor, trauma, or loss of support systems. The overlap with autism symptoms (like mutism, rigidity, and repetitive behavior) can make diagnosis challenging, but timely recognition is critical. Studies estimate that 12–20% of individuals with autism may experience catatonia, especially during teenage years and young adulthood (Wing & Shah, 2006; Ghaziuddin et al., 2012). Risk factors include high levels of anxiety, sudden life transitions, comorbid intellectual disability, loss of structure or routine, and previous trauma or sensory overload (DeJong et al., 2014)
Unfortunately, many cases are misdiagnosed as regression, behavioral decline, or worsening autism, delaying intervention. Though not fully understood, catatonia is believed to involve dysfunction in GABAergic and glutamatergic systems, particularly in the basal ganglia and frontal cortex. Neuroimaging studies have shown abnormal activity in cortico-striato-thalamo-cortical circuits, which also play a role in motor control and repetitive behaviors seen in autism (Dhossche et al., 2009).
Stress and sensory dysregulation may serve as triggers for catatonia in autistic individuals, who often already experience chronic hyperarousal or allostatic overload (Levy et al., 2021). Key signs of emerging autistic catatonia include: marked decrease in motor activity or responsiveness; withdrawal from usual activities or social engagement; sudden loss of functional skills or speech; new onset of psychomotor slowing, rigidity, or posturing; and refusal to eat, drink, or move. These symptoms may fluctuate, making them harder to detect without baseline comparison. Clinicians can use structured tools like the Bush-Francis Catatonia Rating Scale or Kanner Catatonia Rating Scale, adapted for developmental populations (Dhossche et al., 2006).
- Autistic catatonia requires urgent intervention. Without treatment, it can progress to malignant
catatonia, a life-threatening state with autonomic instability. Treatment often includes:
1. Benzodiazepines: Lorazepam is the first-line treatment. In some cases, even a single dose
leads to dramatic improvement, a phenomenon known as the lorazepam challenge (Dhossche et al., 2010).
2. Electroconvulsive Therapy (ECT): When benzodiazepines fail, ECT is highly effective and often lifesaving. Studies show ECT can reverse catatonic symptoms even in nonverbal autistic patients (Wachtel, 2014). ECT is safe and well-tolerated in pediatric populations under careful supervision.
3. Environmental and Behavioral Support: Reintroducing structure, minimizing sensory overload, and validating the individual’s distress can help reduce exacerbations. Multidisciplinary care is essential.
4. Addressing Underlying Triggers: Catatonia can be precipitated by trauma, loss of routines, or unrecognized medical illness. A thorough workup should rule out metabolic, infectious, or neurological causes.
Importantly, antipsychotics are not first-line treatments for catatonia and may worsen symptoms unless comorbid psychosis is present (Taylor & Fink, 2003). With early recognition and treatment, many individuals recover from catatonia and regain previous functioning. However, relapse is possible, especially in high-stress contexts or during transitions like moving schools or aging out of pediatric services (DeJong et al., 2014). Ongoing psychiatric and developmental monitoring is critical.
Autistic catatonia is a serious but treatable condition that demands greater clinical awareness. When autistic individuals suddenly lose speech, become withdrawn, or exhibit extreme motor slowing, catatonia. not just “behavioral regression”, should be considered. Early intervention can be life-changing, or even life-saving
Written By Ivy Stevens- Bowdoin College
Reviewed By Nicolas Sikaczowski, DO Board Certified Adult & Child Psychiatrist
Disclaimer:
The information provided in this blog is intended for general informational and educational purposes only and should not be considered medical or psychiatric advice. It is not a substitute for consultation with a licensed healthcare professional. If you have questions about your mental health or medical condition, please speak with your doctor or a qualified provider.
If you’re seeking personalized psychiatric care, we’re here to help. You can request an appointment with one of our clinicians at Peace Behavioral Health by visiting: https://peacebh.intakeq.com/booking
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
DeJong, H., Bunton, P., & Hare, D. J. (2014). A systematic review of catatonia treatment in people with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44(9), 2127–2136. https://doi.org/10.1007/s10803-014-2083-y
Dhossche, D., Carroll, B. T., & Carroll, T. D. (2006). Catatonia and autism: A historical review, clinical presentations, and treatment. Journal of Autism and Developmental Disorders, 36(3), 317–326. https://doi.org/10.1007/s10803-006-0076-y
Dhossche, D. M., Wachtel, L. E., & Goetz, M. (2010). Catatonia in psychiatric illnesses, developmental disorders, and medical conditions. In D. M. Dhossche (Ed.), Catatonia in autism spectrum disorders (pp. 1–17). Nova Science Publishers.
Ghaziuddin, M., Dhossche, D., & Marcotte, K. (2012). Retrospective chart review of catatonia in autistic youth. Acta Psychiatrica Scandinavica, 125(1), 33–38. https://doi.org/10.1111/j.1600-0447.2011.01772.x
Herman, J. (1992). Trauma and recovery. Basic Books.
Levy, T., Wachtel, L. E., & Dhossche, D. M. (2021). Catatonia spectrum disorders in autism: A review. Current Psychiatry Reports, 23(7), 39. https://doi.org/10.1007/s11920-021-01258-0
Taylor, M. A., & Fink, M. (2003). Catatonia: A clinician’s guide to diagnosis and treatment. Cambridge University Press.
van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.
Wachtel, L. E. (2014). Electroconvulsive therapy for catatonia in an autistic child. American Journal of Psychiatry, 171(11), 1175. https://doi.org/10.1176/appi.ajp.2014.14040578
Wing, L., & Shah, A. (2006). Catatonia in autistic spectrum disorders. British Journal of Psychiatry, 176(4), 357–362. https://doi.org/10.1192/bjp.176.4.357
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