Case illustration

For example, a clinical vignette shared by colleagues during academic collaboration in Tashkent described a 38-year-old woman who lived alone and worked as a translator. She presented with a 2 year history of gradually worsening behaviour. She adopted a restrictive vegetarian diet and became preoccupied with the composition of food products, resulting in a weight loss of 10–12 kg. Over the year preceding her clinical presentation, she developed rituals related to eating and sleeping, accompanied by episodes of motor freezing. Her speech output gradually diminished to an occasional whisper. She became increasingly socially withdrawn and homebound, with a reduction in food and fluid intake.

At presentation, she was diagnosed with acute psychosis with schizoid personality traits. However, the presence of mutism, posturing, psychomotor slowing and refusal of food and fluids led to a revised diagnosis of catatonia, which had not initially been recognised. After medical causes had been excluded, she received a course of ECT, which resulted in rapid and marked clinical improvement.

According to relatives, she had longstanding social withdrawal, shyness and difficulty with interpersonal relationships, raising the possibility of previously unrecognised ASD. This vignette illustrates how catatonia may be overlooked in psychosis-oriented services and highlights the potential for effective treatment when it is recognised.

Clinical implications

Although this paper is based on clinical observations in Central Asia and a narrative synthesis of the literature rather than empirical research, similar structural challenges are likely to exist across other LMIC and post-Soviet settings undergoing psychiatric reform. Comparable diagnostic challenges have been reported in LMIC contexts in which adult ASD remains under-recognised and catatonia is not routinely incorporated into psychiatric training and clinical assessment. When adult ASD is not routinely considered within general psychiatry services, schizophrenia may become the default diagnosis for social withdrawal, atypical communication styles or behavioural rigidity. ^{Reference Nyrenius, Eberhard, Ghaziuddin, Gillberg and Billstedt2} Catatonia may in turn be interpreted as negative symptoms, medication effects, psychosis or non-specific treatment resistance. ^{Reference Fink and Taylor4,Reference Walther and Strik5} However, the co-occurrence of catatonia with ASD and schizophrenia should not be interpreted as evidence that one condition causes another; it may instead reflect chance or shared underlying pathways. In clinical practice, these overlapping features may contribute to a diagnostic pathway and a pattern of misclassification, particularly in settings in which diagnostic frameworks remain strongly oriented towards schizophrenia.

Catatonia is a cross-diagnostic neuropsychiatric syndrome characterised by motor, behavioural and autonomic abnormalities. ^{Reference Fink and Taylor4,Reference Walther and Strik5} It occurs in association with mood disorders, psychotic disorders, medical conditions and ASD. ^{Reference Ghaziuddin, Andersen and Ghaziuddin8} It may also be diagnosed as catatonia associated with another mental disorder or as unspecified catatonia. Assessment should include consideration of affective, medical and medication-related causes, including neuroleptic malignant syndrome. Importantly, catatonia is frequently responsive to benzodiazepines ^{Reference Ungvari, Leung, Wong and Lau6} and (in refractory cases) to ECT. ^{Reference Sienaert, Dhossche, Vancampfort, De Hert and Gazdag7} Untreated catatonia may lead to dehydration, malnutrition, thromboembolism and, in severe cases, death. ^{Reference Ghaziuddin, Andersen and Ghaziuddin8} Despite this, it remains under-recognised in many settings and receives little attention in global mental health policy.

Catatonia has received comparatively little emphasis in LMIC mental health frameworks, which have appropriately prioritised depression, psychosis and suicide prevention. Published research on catatonia from Central Asia is limited, and epidemiological data are scarce. ^{Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton9,Reference Gazizova, Mazgutov, Kharabara and Tsoyi10} A targeted, illustrative PubMed search using the terms ‘catatonia’ and ‘Central Asia’, followed by additional searches combining ‘catatonia’ with the names of individual Central Asian countries, yielded only two publications. Conditions that are not systematically studied are unlikely to be systematically recognised or treated. The relative absence of catatonia from training curricula and service guidelines may therefore contribute to ongoing under-detection.

The knowledge gap extends beyond catatonia itself. Surveys of psychiatrists in LMIC contexts have demonstrated variability in knowledge regarding ASD and its adult presentation. Where contemporary neurodevelopmental frameworks are insufficiently integrated into training, the interface between ASD and catatonia may remain poorly understood. Adolescents and young adults with undiagnosed ASD may experience increasing academic, occupational and social demands. ^{Reference Nyrenius, Eberhard, Ghaziuddin, Gillberg and Billstedt2} In the presence of stress or mood disturbance, catatonic features may emerge. ^{Reference Ghaziuddin, Andersen and Ghaziuddin8} Without awareness of this possibility, clinicians may delay diagnosis and treatment of catatonia.

Transition age represents a critical window for diagnostic precision. Early adulthood shapes educational attainment, employment trajectories and social integration, and misclassification during this period can influence long-term outcomes and contribute to stigma and institutionalisation. If patients are incorrectly diagnosed with schizophrenia, they may be exposed to prolonged treatment with antipsychotic medications. In individuals with unrecognised catatonia, such treatment may worsen catatonic symptoms or precipitate malignant catatonia or neuroleptic malignant syndrome, thereby delaying appropriate recognition and treatment of the underlying condition. ^{Reference Ghaziuddin, Andersen and Ghaziuddin8} In regions undergoing rapid social and economic transformation, improving mental healthcare for young adults is integral to broader development goals. ^{Reference Patel, Saxena, Lund, Thornicroft, Baingana and Bolton9}

System-level considerations and recommendations

Addressing these challenges does not require high-cost technological solutions. Catatonia is a treatable condition. Clinicians should maintain a low threshold to screen for catatonia in patients with psychosis or ASD, particularly when motor, behavioural or speech changes are present. Brief structured tools such as the Bush–Francis Catatonia Rating Scale, ^{Reference Bush, Fink, Petrides, Dowling and Francis11} combined with lorazepam challenge and medical evaluation, provide practical approaches suitable for most clinical settings. ^{Reference Fink and Taylor4,Reference Walther and Strik5} Initial assessment should include a basic medical review, including vital signs, hydration and nutritional status, medication history, and screening for metabolic, neurological and infectious causes. Benzodiazepine challenge protocols are inexpensive and feasible in most clinical settings. ^{Reference Ungvari, Leung, Wong and Lau6} ECT infrastructure exists in many LMIC contexts, although utilisation and stigma vary. In parts of Central Asia, ECT – an evidence-based treatment for severe catatonia – remains concentrated in a limited number of tertiary psychiatric facilities, reflecting broader constraints in specialised mental health services in the region. ^{Reference Gazizova, Mazgutov, Kharabara and Tsoyi10} Increasing recognition of adult ASD similarly depends primarily on training and awareness rather than specialised equipment. ^{Reference Nyrenius, Eberhard, Ghaziuddin, Gillberg and Billstedt2,Reference Brugha, McManus, Bankart, Scott, Purdon and Smith3}

International collaboration may support progress, particularly through partnerships that emphasise capacity building, curriculum development and locally grounded research. At the same time, reform must remain context sensitive. The aim is not to replace one diagnostic emphasis with another but to enhance clinical precision and flexibility within existing systems.

Central Asia offers a useful illustrative case of psychiatric services in transition. Similar patterns may be present in other LMIC and post-Soviet regions where training systems have been historically centred on psychotic disorders and adult ASD services remain underdeveloped. Increasing the attention paid to catatonia and adult ASD does not diminish the importance of schizophrenia; rather, it refines diagnostic practice and reduces the risk of oversimplification.

Limited recognition of catatonia in transition-age populations represents a remediable gap in LMIC psychiatry. Strengthening training in catatonia assessment, improving recognition of adult ASD and encouraging research on diagnostic trajectories in young adults are feasible steps towards improving outcomes. As mental health systems continue to evolve in LMIC settings, ensuring that treatable syndromes such as catatonia are recognised early and appropriately managed should remain an important priority for clinical training, research and service development.

Limitations

This paper is based primarily on clinical observations and a narrative synthesis of the literature rather than systematically collected data. The limited availability of region-specific data restricts generalisability. In addition, only English-language publications were included. Further research from Central Asia and other LMIC settings is needed to better characterise these diagnostic patterns.