Clinical Scorecard: Effective Bilateral Electroconvulsive Therapy for Catatonia with Unusual Climbing Behavior in a Teenager with a CACNA1A Pathogenic Variant and Autism Spectrum Disorder: A Case Study

At a Glance

Key Highlights

• Bilateral electroconvulsive therapy (ECT) was safely and effectively used to treat catatonia in a teenager with a CACNA1A pathogenic variant and ASD.
• Unique catatonic symptom included novel climbing behavior conceptualized as perseverative stereotypy related to catatonia.
• Monitoring treatment response utilized clinician-rated Busch-Francis Catatonia Rating Scale, parent-reported Catatonia Impact Scale, and behavioral observations, all showing significant improvement.

Guideline-Based Recommendations

Diagnosis

• Consider catatonia diagnosis in neurodevelopmental disorders with new or worsening symptoms such as negativism, withdrawal, stereotypies, and regression including incontinence.
• Use validated rating scales such as Busch-Francis Catatonia Rating Scale and Catatonia Impact Scale for assessment.

Management

• First-line pharmacological treatment includes benzodiazepines (e.g., clonazepam).
• In cases refractory to pharmacotherapy, consider bilateral electroconvulsive therapy (ECT) with clinical consensus.
• Exercise caution with ECT in patients with CACNA1A variants due to potential risk of neurological complications, but bilateral ECT can be well tolerated and effective.

Monitoring & Follow-up

• Use multi-source monitoring including clinician ratings, parent reports, and behavioral observations to assess treatment response.
• Track symptom severity with scales such as BFCRS and CIS throughout treatment.

Risks

• Potential for prolonged neurological deficits and MRI changes post-ECT in patients with CACNA1A variants; monitor closely.
• Safety concerns related to novel behaviors (e.g., climbing) require close supervision.

Patient & Prescribing Data

Adolescent male with ASD, intellectual disability, ADHD, and CACNA1A pathogenic variant presenting with catatonia.

Initial benzodiazepine (clonazepam) and valproic acid showed limited improvement; bilateral ECT led to significant symptom reduction and was well tolerated.

Clinical Best Practices

• Obtain thorough baseline assessment including neuropsychiatric history and use of validated catatonia rating scales.
• Consider genetic factors such as CACNA1A variants when evaluating neurodevelopmental patients with catatonia.
• Use a multidisciplinary approach including psychiatry, neurology, behavior analysis, and family input for diagnosis and monitoring.
• Initiate benzodiazepines as first-line treatment and escalate to bilateral ECT if inadequate response.
• Monitor for and contextualize unusual behaviors (e.g., climbing) as possible catatonic symptoms.
• Ensure close safety monitoring during treatment due to risk of impulsivity and novel perseverative behaviors.

References

• Busch-Francis Catatonia Rating Scale (BFCRS)
• Clinical Global Impressions Scale (CGI-S)
• Autism Impact Measure by Kanner and Mazurek
• Case report of unilateral ECT in CACNA1A variant with catatonia