How Everyone Became Depressed

The rise and fall of the nervous breakdown

Autism Speaks

...and this time about shock therapy

Blow me over. Autism Speaks, one of the major autism organizations, has recognized catatonia as an important symptom in autism, and has endorsed electroconvulsive therapy (ECT) for its treatment. This is a bit like the Mormon Church endorsing Seagram’s Crown Royal.

For so many years, the diagnosis of autism has been plagued with uninformed political correctness, its treatment encumbered with well-meaning but ineffective psychotherapies. Parts of the autism community, stealing lessons from the mental retardation activists, insisted that autism wasn’t a medical disease at all but just another “condition” on the band of normal.

Revealingly, the pediatric section of the Diagnostic and Statistical Manual of the American Psychiatric Association doesn’t mention catatonia in its section on “neurodevelopmental disorders” (of which autism is a big one) but rather “stereotypic movement disorder.” The idea is that this is a specific movement disorder that kids with autism and Intellectual Disability develop.

No! It’s catatonia!

How is it possible that official pediatric psychiatry is so out to lunch that its main representatives don’t recognize a condition that has been around since 1874, when Karl Kahlbaum in Germany coined the term and said that all this stereotypical repetitive movement, posturing, rigidity, mutism, alternation of stupor and agitation, and negativism that patients display corresponds to a single underlying disorder that he baptized catatonia.

Catatonia soon vanished as an independent syndrome and became a “subtype” of schizophrenia. That’s the reason pediatric psychiatry has shied away from catatonia, because they know their patients don’t have schizophrenia. Yet twenty years ago we stopped seeing catatonia as a form of schizophrenia and recognized its independent existence, but somehow pediatric psychiatry never got the word.

A lot of pediatric psychiatrists never got the word about convulsive therapy either. They remain stuck in the 1970s and would like to wear tie-dyed tee-shirts to work, if they could; they still clutch those dog-eared copies of Michel Foucault and RD Laing when they go to sleep at night. Under seventies-holdover, there are still major pediatric hospitals that do not offer ECT, even though it’s the treatment of choice for melancholic depression and catatonia in children.

So for pediatrician Ricki Robinson, who’s on the board of Autism Speaks, to come out now for ECT, and for benzodiazepines such as lorazepam (Ativan), in treating catatonic symptoms of autism marks a real turning of the page. This is a welcome eruption of science into a field that has been quite resistant to treatments other than behaviorism. Behaviorism, the psychological treatment advocated by BF Skinner, has its place. But catatonia is a medical disease and should be addressed at some point by medical treatments, which is to say, treatments that affect the physical substance of the brain and body, not just psychological treatments that affect “the mind.”

The parents of autistic children with the catatonic symptom Self Injurious Behavior (SIB) have been especially hard done by. SIB can be a nightmare both for parents and the affected children. The children seek ceaselessly to harm themselves, by smashing their fists against their head, or kneeing themselves in the face if their arms are restrained. They can induce cerebral hemorrhages or detach their retinas and go blind.

Here, Applied Behavioral Therapy (ABA) is useless. But some neurodevelopmental units are still dominated by behaviorists who think that ECT is the work of the devil. One behaviorist called a psychiatrist who recommended ECT for a child with serious SIB “the new Mengele.” Shock therapy, on the other hand, can abolish the self-injurious behavior, relieve other symptoms of catatonia and autism, and give the child (and the parents) a new life. A once stigmatized treatment considered abusive is now riding high in triumph back into the medical citadel, and Oxford University Press has just published a guide to something that a decade a ago would have been viewed with shock and horror.

So, yeah, kudos to Dr Robinson and Autism Speaks. Good work!

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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