22.3 SELF-INJURIOUS BEHAVIOR IN CATATONIA IN AUTISM SPECTRUM DISORDER: POINTERS, PEARLS, AND CHALLENGES

Abstract

The objectives of this presentation are to provide an overview of the current understanding regarding repetitive self-injurious behavior as a symptom of catatonia in autism spectrum disorder (ASD), the paradigms and lessons learned, as well as longstanding and novel challenges. The literature review and direct clinical experience will be discussed. Catatonia is reported to occur in 12% to 20% of youth with ASD, with significant advances in understanding over the past 2 decades. Some youth with ASD experience more “expected” psychomotor-retarded catatonic symptoms, such as slowness, rigidity, getting “stuck,” and posturing, speech abnormalities, or frank mutism, which are often coupled with prominent skill regression. This presentation can lead to massive clinical devastation, as is also the case when psychomotor agitation dominates the catatonic picture, often in the form of intractable self-injury devoid of any operant function, unresponsive to any behavioral intervention, and often requiring the most desperate measures of bodily restraint to prevent catastrophic tissue damage. Three current cases will be reviewed describing catatonia in ASD, where life-threatening self-injurious behavior (SIB) dominated the catatonic clinical picture. One youth had experienced prior catatonic episodes resulting in severe malnutrition and bilateral retinal detachment from head-directed SIB before relative stability was achieved with ECT; maintenance ECT remained de rigueur for months as this patient’s illness course waxed and waned. Another youth spent 9 months restrained in a pediatric unit in a state of chronic agitated catatonia until ECT introduction; despite massive improvement with ECT, this patient exemplified the complexity of such cases in terms of additional behavioral complexities requiring intensive management. A third youth with intractable head-directed SIB experienced prompt relief with ECT introduction; his treatment, however, was inadvertently disrupted by the COVID-19 pandemic, with many lessons learned from his brief relapse and subsequent renewed recovery. Recognition of repetitive SIBs devoid of environmental function as part of the catatonic spectrum in ASD is no longer novel. Much continues to be learned, however, about both the acute and long-term management of such patients, with pearls, new challenges, and vistas for improvement.