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Catatonia in Autism or the Blind Men and the Elephant

(PSYCHIATRIC TIMES) - The sixth [blind man] no sooner had begun About the beast to grope, Then, seizing on the swinging tail That fell within his scope, 'I see,' quoth he, 'the Elephant Is very like a rope!' " -- From The Blind Men and the Elephantby John Godfrey Saxe (1816-1887)

Autistic spectrum disorders (ASD), as defined here, include autistic disorder, Asperger disorder, childhood disintegrative disorder (CDD), and pervasive developmental disorder not otherwise specified. They are a group of early-onset neuropsychiatric disorders of unknown origin for which we lack truly effective therapies. (The terms "ASD" and "autism" are used interchangeably throughout this article.)

Current treatments for children with ASD include behavioral treatment programs and speech therapies,1 as well as a wide range of psychotropic medications. All are useful in some cases, but so far, have little enduring impact on core social and communicative deficits.2 It is understandable that many parents try nonconventional treatments that often border on, or are, quackery.

As in the fable of the elephant and the blind men who are unable to grasp the nature of the beast, researchers have argued at various points that ASD are environmentally induced, toxin induced, related to infections or autoimmunity, or of genetic origin. In fact, all these different claims may apply to as yet unidentified subgroups, since ASD are undoubtedly both etiologically and pathophysiologically heterogeneous.

In this article, we aim to highlight the intriguing features of ASD, the fact that there is considerable overlap between autistic and catatonic symptoms, and the observation that full catatonia seems to develop in a significant proportion of people with ASD. Maybe this observation is not unlike the sixth man's claim that the elephant is like a rope, but we believe that further study of catatonia in autism may provide a new window into the origins, pathophysiology, and, most importantly, treatment of autism.

Here we provide a brief review of the pertinent current literature showing that in the past 15 years, catatonia has been increasingly recognized in adolescents and young adults with ASD. We present and discuss a case vignette of an adolescent with ASD and catatonia and provide recommendations for the assessment and treatment of catatonia in ASD. A case vignette of lorazepam treatment for catatonia in ASD and a case vignette of electroconvulsive therapy (ECT) for catatonia in a child who also met the criteria for CDD, or late-onset autism, are presented, and practical and research implications are discussed.

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