Catatonia and autism spectrum disorder: A common comorbid syndrome or a core feature?

Table 1 Summary of Diagnostic and Statistical Manual of Mental Disorders-III-R diagnostic criteria for autism disorder

Qualitative impairments in reciprocal social interaction	Impairment in communication	Restricted interest/resistance to change and repetitive movements
Lack of awareness	No communication	Stereotypies
Seeking comfort	Abnormal nonverbal	Parts of objects
Imitation	Imaginative activity	Environmental change
Social play	Production-speech	Insistence-routine
Peer friendship	Form/content-speech	Restricted interests
	Conversation

Table 2 Summary of the Diagnostic and Statistical Manual of Mental Disorders-IV and Diagnostic and Statistical Manual of Mental Disorders-IV-TR diagnostic criteria for autism spectrum disorder

Qualitative impairment in social interaction, as manifested by two of the following	Qualitative impairment in communication as manifested by at least one of the following	Restricted repetitive and stereotyped patterns of behavior, interest, and activities, as manifested by at least one of the following
Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures that regulate social interaction	Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime)	Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that are abnormal either in intensity or focus
Failure to develop peer relationships appropriate to the developmental level (e.g., by a lack of showing, bringing, or pointing out the object of interest)	In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others	Inflexible adherence to specific, nonfunctional routines or rituals
Lack of social or emotional reciprocity	Stereotyped and repetitive use of language or idiosyncratic language	Stereotyped and repetitive motor manners (e.g., hand or finger flapping or twisting or complex whole-body movement)
	Lack of varied, spontaneous make-believe play or social imitative play appropriate to the developmental level	Persistent preoccupation with parts of objects

Table 3 Summary of the Diagnostic and Statistical Manual of Mental Disorders-5 and Diagnostic and Statistical Manual of Mental Disorders-5-TR diagnostic criteria for autism spectrum disorder

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the current or by history	Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following
(1) Deficits in nonverbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication to abnormalities in eye-to-eye contact and body language, or deficits in understanding and use of gesture, to total lack of facial expression and nonverbal communication	(1) Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys, or flipping objects, echolalia, idiosyncratic phrases)
(2) Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties in behavior to suit various social contexts, difficulties in sharing imaginative play or making friends, to the absence of interest in peers	(2) Insistence on sameness, inflexible adherence to routine, ritualized patterns, or verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route, or eating daily)
(3) Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or making friends, to an absence of interest in peers	(3) Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to preoccupation with unusual objects, excessively circumscribed or perseverative interests)
	(4) Hyper-reactivity or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement)

Table 4 Symptoms of catatonia based on the Diagnostic and Statistical Manual of Mental Disorders-5-TR

Catatonia symptoms	Definitions
Mutism	No or very little verbal response (excluding known aphasia)
Posturing	Spontaneous and active maintenance of a posture against gravity
Stupor	No psychomotor activity; not actively relating to the environment. An extreme manifestation of the previous phenomena
Agitation	Emotionally restless, not as a result of external stimuli
Waxy flexibility	Slight, even resistance to positioning by the examiner
Catalepsy	Passive induction of a posture held against gravity
Echolalia	Mimicking another’s speech
Echopraxia	Mimicking another’s movements
Negativism	Opposition or no response to instruction or external stimuli. Negativism can be a complex behavior
Stereotypies	Repetitive, abnormally frequent, non-goal-directed movements
Mannerisms	Odd, circumstantial caricature of normal actions
Grimacing	Displaying contorted facial expressions

Table 5 List of catatonia symptoms reported by the Diagnostic and Statistical Manual of Mental Disorder-5-TR and catatonia clinical scales (Bush Francis Catatonia Rating Scale, Modified Rogers Scale, Rogers Catatonia Scale, Northoff Catatonia Rating Scale, Kanner Scale, Brauning Catatonia Rating Scale, and Pediatric Catatonia Rating Scale), with the overlap between these catatonia presentations and Diagnostic and Statistical Manual of Mental Disorders-5-TR diagnostic criteria for autism spectrum disorder

Overlapping features of catatonia on the DSM-5-TR and the (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS) scales	Corresponding similar or related symptoms in ASD based on the DSM-5-TR criteria and other features reported in ASD
Echolalia/echopraxia (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS)	Reported
Stereotypy (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS)	Reported
Mannerism (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS)	Reported
Excitement (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS)	Reported
Grimacing (BFCRS, NCRS, Kanner, BCRS, and PCRS)	Reported (facial mannerisms/stereotypies)
Verbigeration (BFCRS, MRS-C, RCS, NCRS, Kanner, BCRS, and PCRS)	Reported
Impulsivity (BFCRS, NCRS, Kanner, BCRS, and PCRS)	Reported
Combativeness (BFCRS, Kanner)	Reported
Perseveration (BFCRS, NCRS, Kanner)	Reported
Abnormal speech (MRC-S, RCS, NCRS)	Reported
Rituals (MRC-S, NCRS)	Reported
Compulsive behaviors (NCRS, PCRS)	Reported
Compulsive-like speech (NCRS)	Reported

BFCRS: Bush Francis Catatonia Rating Scale; MRS-C: Modified Rogers Scale-Catatonia Subscale; NCRS: Northoff Catatonia Rating Scale; BCRS: Brauning Catatonia Rating Scale; PCRS: Pediatric Catatonia Rating Scale; RCS: Rogers Catatonia Scale; DSM: Diagnostic and Statistical Manual of Mental Disorders; ASD: Autism spectrum disorder.

Table 6 Applying Robins and Guze validity criteria to autism spectrum disorder in relation to catatonia[90]

Robins and Guze factors[90]	Criteria satisfaction
Clinical description	Several identical features between catatonia and ASD
Exclusion of other disorders	It is challenging to exclude and differentiate both syndromes from each other based on criteria
Follow up studies	Good response to similar modalities of treatment, such as lorazepam and ECT; ASD-related catatonia may be more chronic than catatonia associated with mood, psychotic, and systemic medical disorders
Laboratory studies	This area is in its infancy. However, a significant report shows an overlap in neurobiology
Family studies	No data available

ASD: Autism spectrum disorder; ECT: Electroconvulsive therapy.