Non-NMDA autoimmune encephalopathy and catatonia treated with electroconvulsive therapy: A pediatric case series and treatment guidelines

Introduction Autoimmune encephalitis (AE) is an inflammatory condition which may present with encephalopathy, including psychiatric symptoms of psychosis and catatonia. When catatonia becomes life-threatening or refractory to medication, electroconvulsive therapy (ECT) should be considered. This case series represents a compilation of patient care experiences in which ECT served as a highly effective augmentation strategy for catatonia associated with autoimmune encephalitis other than NMDA AE. Methods We performed a retrospective case-study analysis of four patients with autoimmune encephalitis and catatonia who had disease onset prior to the age of 18. Cases were selected from the patients evaluated by the child psychiatry consultation and liaison inpatient service (n=460) in which care overlapped with both the autoimmune brain disease program (n=35) and the ECT program (n=4). Retrospective chart review focused on Bush Francis Catatonia Rating Scores, medication treatments targeting catatonia, ECT protocols, and special ethical considerations in patient care. Results Significant improvement in features of catatonia as evaluated by the Bush Francis Catatonia Rating Score (BFCRS) were seen in each patient treated with ECT. Across these four cases we encountered special considerations related to ECT that were specific to pediatric auto-immune catatonia. Conclusions We recommend ECT as a part of the treatment plan for patients who present with refractory features of catatonia (i.e. non-medication responsive). We advocate for following established practice parameters for the use of ECT in adolescents, with proposed modifications for patients with catatonia from this cause who often present with an increased level of medical complexity.