Professional Documents
Culture Documents
Catatonia in autistic spectrum disorders The Elliot House team tends to see chil-
dren and adults presenting complicated
diagnostic problems. The fact that the staff
LORNA WING and AMIT TA SHAH
members have a particular interest in cata-
tonia has also become known and probably
influences the pattern of referrals.
357
W ING & S HA
AHH
of the consultation was to consider how to observation before the study began had subgroups were identified: those with no,
manage challenging behaviour, sometimes suggested that individuals with autistic impaired or deviant language (language-
including difficulties due to catatonic fea- spectrum disorders who were passive in impaired); and those with grammatical
tures. Relevant diagnostic information was their social interactions were particularly speech and an adequate or good vocabulary
collected from case notes, supplemented vulnerable to the development of severe (language not impaired).
by informants. For the 14 individuals exacerbations of catatonic features. For
(2.8%) about whose early history no infor- the individuals with catatonia, the rating
Type of residence
mant was available, as much information was based on information concerning be-
as possible was obtained from past case re- haviour before the catatonia began. For At the time when they were seen and as-
cords. In all cases, the DISCO was used as the comparison group, the rating was made sessed, individuals in the study were in four
the framework for recording details. for behaviour current at the time when they different types of residence: living indepen-
A study of interrater agreement has were seen by the Elliot House team. dently; at home with parents; in a small
recently been completed for the DISCO, residential home in the community; or in
with the participation of parents of children Psychological assessment a hospital ward.
who had not been seen at Elliot House. For Although associated cognitive deficits of
over 80% of all the developmental
developmental and any level of severity are very common, Statistical analysis
behavioural ratings made (515), kappa autistic spectrum disorders can occur in in- A one-way analysis of variance was used to
was equal to, or better than, 0.75 or, for dividuals of average or superior cognitive compare ages. Otherwise, Pearson's w2 tests
the few ratings where kappa was not appro- ability on formal intelligence tests (Rutter, were used.
priate, agreement was 90% or above 1970; Wing & Gould, 1979; Wing, 1996).
(further details available from the first Assessments of cognitive skills were carried
author upon request). out, using standardised tests appropriate RESULTS
for age and ability to cooperate. The sub-
Prevalence among referrals
Diagnosis jects were observed in structured and un-
structured situations. Because of the A total of 30 individuals with autistic
The autistic spectrum is similar to, but
difficulties of testing individuals with cata- spectrum disorders (6% of all referrals)
broader than, the category of pervasive
tonia, for this group the estimates of cogni- met the above criteria for catatonia. Their
developmental disorders in the tenth revi-
tive ability were based on performance ages when seen at Elliot House ranged from
sion of the International Classification of
before the onset of catatonia, using infor- 15 to 50 years. Table 1 shows the numbers
Diseases (ICD10) (World Health Organ-
mation obtained from case records and and percentages of these with catatonia
ization, 1993). The subgroups represented
interviews with parents or care-givers. For among all referrals, by age group when
among the individuals in the study were
the comparison group, the estimate was seen. All of those with catatonia were aged
Asperger syndrome, childhood autism
based on the findings when seen and 15 or above at referral. They represented
and atypical autism. The criteria used for
assessed by the Elliot House team. 17% of all referrals in that age range.
Asperger syndrome were those suggested
A further eight individuals (five males
by Ehlers & Gillberg (1993) because the
(one with Down's syndrome) and three
ICD10 criteria had been found to be Cognitive ability
females, aged 1036 years when seen) had
unsatisfactory (Leekam et al,
al, 2000). The On the results of assessments carried out as occasionally had problems crossing thresh-
ICD10 criteria for childhood autism and described above, individuals were classified olds and/or freezing during activity, but
atypical autism were used. When criteria into three groups: severe learning disability were not disabled enough to be included
for both autism and Asperger syndrome (IQ 049), mild learning disability (IQ 50 in the catatonic group. In two of these,
were present in one individual, the latter 69) and borderline, average or high ability the brief catatonic episodes had occurred
diagnosis was given. This is contrary to (IQ 70 and above). Because of the large dis-
ICD10 instructions but was more relevant crepancies between different areas of skill,
to the needs of the individuals concerned. Table 1 Ages when seen at Elliot House
which are characteristic of autistic disor-
ders, the estimates were approximations,
Social interaction but do give an indication of the overall level Age group Total seen With catatonia
of function. (years) n
One of the sections in the DISCO concerns n (%)
social interaction. Individuals in the study
could be assigned to one of three sub- Expressive language
1^4 90 ^ (^)
groups, based on the quality of their inter- Expressive language was assessed on stand- 5^9 159 ^ (^)
actions with others. The three categories ardised measures where possible, or on his- 10^14 82 ^ (^)
were `aloof ' (indifferent to social ap- tory and observation when testing was not
15^19 65 12 (17)
proaches, although physical contact might possible. As with other psychological
20^24 48 8 (17)
be enjoyed),
enjoyed), `passive' (accepting social ap- assessments, estimates of expressive lan-
25^29 19 3 (16)
proaches and following other's lead but guage in those with catatonia were based
not initiating any contact), and `active but on information concerning language before 30^34 20 5 (25)
odd' (making active social approaches the onset of the catatonia. For the compar- 35+ 23 2 (9)
but in an inappropriate manner) (Wing & ison group, the estimates were based on as- Total 506 30 (6)
Gould, 1979; Wing, 1996). Clinical sessments by the Elliot House team. Two
358
C ATATONI A IN
I N AU T I S T I C S P E C T RU M D I S O R D E R S
only in early or middle childhood. In one, case notes. From the onset of catatonia up According to the accounts given by re-
catatonic features were seen at school but to the time they were seen at Elliot House, latives or other carers, none had ever had
not at home. three individuals had experienced a slow the first-rank symptoms of schizophrenia.
but steady deterioration in mobility and All showed abnormalities of speech, but
practical skills. In 17, the course had been these were indistinguishable from those
Characteristics of the group
steady once the catatonia was established, found in autistic disorders. The quantity
with catatonia
while four had shown minor and six had of speech was in all cases markedly reduced
Age of onset shown major fluctuations in severity. or absent when catatonia was present.
The ages of onset of the current episode of
catatonia, obtained from the recollections Severity of the effect of catatonia
of informants, are given in Table 2. For on daily activities
Manifestations of catatonic behaviour
four individuals, the ages of onset could
The most common manifestations of cata- At the time of referral, the 30 individuals in
not be ascertained. For the rest, the major-
tonic behaviour seen in the group, each the catatonic group varied in the degree to
ity started the current episode between 10
affecting seven or more individuals, are which the catatonia interfered with their
and 19 years of age. Five individuals had
listed in Table 3. Most of the abnormalities participation in everyday activities, their
had brief episodes of slowness and freezing
of movement resulted in slowing or stop- mobility and their independence, as
during childhood, before age 10.
ping activities, but episodes of excitement follows.
and sudden impulsive actions also Twelve with the least severe symptoms
Type of onset occurred. Some could not stop actions once were mobile but were very slow in carrying
In 15 individuals, the onset was im- started. Incontinence resulted when the out all self-care activities, often freezing
mediately preceded by a period of very individual concerned did not initiate the during an activity and needing prompting
disturbed, often aggressive, behaviour. movement needed to reach the toilet. to begin moving again. They had difficulty
Eight individuals developed obsessive As shown in Table 3, 12 individuals crossing thresholds or demarcation lines,
compulsive symptoms before they became showed bizarre behaviour that could not but were able to take part in the daily
catatonic. Six of these were among those be classified under other headings. For ex- activities with much help from staff.
who had shown disturbed, aggressive ample, two individuals would never use Fourteen were more severely affected.
behaviour before the onset of catatonia. one arm and hand (the left in one case They were so slow, or so unable to cross
and the right in the other), although no thresholds, or so locked into one repetitive
physical reason could be found. One man activity, that their daily programme was
Possible precipitating factors
walked the same route to the same destina- severely impoverished.
Possible precipitating factors were sug- Four individuals were the most severely
tion each day in order to stand motionless,
gested for 13 individuals. These included affected. Their lives were completely dis-
staring for 2 hours at a spot where a build-
bereavement, pressure at school, lack of rupted by their symptoms. One stayed in
ing used to be before it was pulled down.
structure after leaving school, and lack of one room, rocking in a chair, and could
Others had occasional visual hallucinations
occupation. The individuals concerned did not leave the house unless carried out, as
or paranoid ideas that did not fit any parti-
not communicate their feelings about these stiff as a statue, completely covered by a
cular diagnosis.
events. The suggestion of a connection with blanket. One had to be half-lifted by two
the onset of the catatonia was made by the care-givers to enable him to cross any de-
Table 3 Most frequent manifestations of
parents or other care-givers. marcation lines, including cracks in pave-
catatonia
ments. One sat immobile unless physically
Course prompted, not even moving to empty her
Catatonic manifestations Feature
bladder. However, when taken out and
Information about any fluctuations in the present started on a route, she would walk for miles
catatonic state over time was obtained from n without a pause until prompted to stop.
parents or other carers and from available
The fourth was permanently confined to a
Essential criteria (slowness, difficulty 30 wheelchair, apart from one occasion when
T
Table
able 2 Ages of onset of catatonia initiating movements, needs his elderly father stumbled and nearly fell.
prompts, passive) Seeing this, the son leapt from his wheel-
Age group (years) n Odd gait 27 chair, helped his father to sit down and
Odd, stiff postures 19 then returned to immobility.
1^4 ^ None of the above variables was signif-
Freezing 17
5^9 ^ icantly related to autistic spectrum sub-
Impulsive acts 16
10^14 7 group, expressive language, level of ability
Difficulty crossing lines 16
15^19 16
Bizarre/psychotic 12
or quality of social interaction.
20^24 2
Sleep problems 10
25^29 1
Incontinence 10 Comparison with a group
Not known 4
Cannot stop actions 7
without catatonia
Total 30 Excited phases 7 The comparison group comprised 115 indi-
viduals with autistic spectrum disorders
359
W ING & S HA
AHH
360
C ATATONI A IN
I N AU T I S T I C S P E C T RU M D I S O R D E R S
3 61
W ING & S HA
AHH
autistic disorder should be considered if an Damasio, A. R. & Maurer, R. G. (1978) A neurological _ & August, G. (1991) Catatonia in autistic disorder; a
Bush, G., Fink, M., Petrides, G., et al (1996) Catatonia: Realmuto, G. M. & Main, B. (1982) Coincidence of World Health Organization (1993) The ICD ^10
I. Rating scale and standardised examination. Acta Tourette's disorder and infantile autism. Journal of Autism Classification of Mental and Behavioural Disorders:
Psychiatrica Scandinavica,
Scandinavica, 93,
93, 129^136. and Developmental Disorders,
Disorders, 12,
12, 367^372. Diagnostic Criteria for Research.Geneva:
Research. Geneva: WHO.
362