Mr. A, an 18 year-old high school junior with high-functioning autism, was an athlete in Special Olympics, worked as a grocery store stocker, and had aspirations of studying sharks in a university program for students with autism. After 1 week of insomnia, he presented to the Emergency Department (ED) with delusions and aggression including head-banging. His mother reported a stressful incident 2 weeks prior, when Mr. A awoke to a SWAT team evacuating his building for an active shooter situation. His entire family was rushed out of their apartment to await the "all clear" outside for several hours.
Mr. A was prescribed oral mixed amphetamine salts (Adderall) 30 mg daily and risperidone 7 mg daily for the past 7 years by a developmental pediatrician, for ADHD and aggression related to autism. On inpatient psychiatric admission, he exhibited behaviors including intermittent agitation, muttering, and urinating on the floor. He displayed periods of psychomotor agitation as well as stupor (Figure 1). His speech was slow with sporadic muteness, but he had times of clear sensorium, more normal speech, and behavioral control. During an initial brief hospitalization, medication changes included adding sodium valproate (Depakote) 250 mg PO TID for affective stability and impulsivity, lowering risperidone to 3 mg PO BID, and discontinuing mixed amphetamine salts due to potential to worsen insomnia and psychosis.
Mr. A had four subsequent psychiatric admissions of increasing length, and his case perplexed staff and the psychiatric team. He slept 1-2 h per night and was rarely at rest. He displayed purposeless and bizarre stereotypical movements, including repetitive knocking on walls and flapping his arms. He perseverated on activities such as opening and closing his door. At times he muttered or was mute. Staff attributed these behaviors to autism though he had never exhibited such behaviors previously. Disinhibited behavior included episodes of maniacal laughter and compulsive masturbation for up to 5 h. He jumped impulsively into the nurse's station and wandered into other patients' rooms, taking belongings. He flooded bathrooms, gleefully running through the water or urine, yelling "Poseidon!". He impulsively stabbed a social worker with a plastic fork. Over 3 months and five hospitalizations, he was exposed to more than 10 psychotropic medication including: 3 atypical antipsychotics, 2 first-generation antipsychotics, divalproex, and 4 antihistamines or sedating antidepressants for sleep (Table 1). Diagnoses postulated included: obsessive compulsive disorder (OCD), acute psychotic disorder, schizophreniform disorder, acute stress disorder, delusional disorder, amphetamine-induced psychotic disorder, and cannabis-induced mood disorder.
Collateral history from his mother indicated clear behavioral change from his baseline unrelated to his autism. A covering psychiatrist, noting an obsession with water, repetitive purposeless behaviors, and unresponsiveness to the external world, made a presumptive diagnosis of catatonia and performed an initial lorazepam challenge of 2 mg intramuscularly (IM) which was markedly positive. Scores following the lorazepam challenge on the Bush Francis Catatonia Rating Scale (BFCRS) decreased from 27 to 12. Mr. A received lorazepam 9 mg IM total that day; repetitive behaviors decreased and speech improved. He began following instructions and was oriented to place, time, and situation. On day 5, he received lorazepam 16 mg IM with substantial improvement. The second rotating psychiatrist verified capacity and consent for ECT, tapering lorazepam off in preparation, but Mr. A refused ECT, believing it was a lobotomy. The second psychiatrist believed the patient had progressively worsening symptoms of autism and psychosis, not catatonia. Antipsychotic medication was restarted, and agitation, repetitive behaviors, and aggression toward staff returned. Despite increasing antipsychotic doses over the next 11 days, aggression worsened. On day 18, the relieving psychiatrist stopped all antipsychotics and restarted lorazepam 2 mg IM Q 2 h, with extra doses prn stuporous or repetitive behaviors. Mr. A received 22 mg of lorazepam over 24 h with dramatic improvement in mentation and behavior, and tolerated another 60 mg of lorazepam over the next 80-h period. He was then again oriented, and could clearly articulate his diagnosis. He consented to treatment with his mother present, requested to have ECT immediately to resolve the catatonia and to remove the shooting incident memory, stating, "It's all I have been thinking about."
Mr. A's first ECT treatment on hospital day 22 resulted in further dramatic response. Lorazepam was held for 10 h until slight stereotypic head turning and muttering returned. The next day he remained at baseline; lorazepam 2 mg po TID was continued. He was discharged home after three additional ECT treatments. He continued outpatient ECT treatments three times per week for a total of 8 treatments, without maintenance ECT, as catatonic symptoms had resolved. He was readmitted within 1 month due to relapse into excited catatonia. Following successful treatment with a short course of ECT, a plan was made for maintenance-ECT (M-ECT) initially every 14 days. Relapses requiring repeat admissions continued for 7 months whenever ECT frequency averaged more than 7 days.
Throughout his admissions, the treatment team debated the diagnosis of catatonia. Mr. A explained his aggressive outbursts and agitation as frustration or anger toward his family. Some staff had not witnessed catatonic behavior due to rapid improvement with ECT. Many attributed less recognizable motor signs of catatonia to his autism, including stereotypies, tics, hand-flapping, finger-snapping, and head-turning.
After 14 months, Mr. A returned to his premorbid functioning, attending school and living with his family, while receiving weekly M-ECT treatments. Attempts to space ECT treatments further apart resulted in recurrent motor symptoms. At the time of this writing, maintenance medication included mixed amphetamine salts XR 30 mg PO daily, olanzapine 20 mg PO daily, sodium valproate 1,000 mg PO BID, and trazodone 50 mg PO QHS. The patient also took cannabidiol for anxiety and sleep.