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Case report

Catatonia as a presentation of autism in a child: a case report

  • Catatonia commonly refers to a cluster of movement abnormalities, behaviour, volition and speech that has long been associated with psychiatric disorders in adults. Recent evidence suggests increasing prevalence in adolescents and older children with autistic spectrum disorder (ASD), but its occurrence in younger children is rare. Here we describe a 6-year-old boy presenting with catatonic autism, highlighting the diagnostic challenge and demonstrating the importance of timely assessment and management.

    Citation: Robin Quilliam, Samantha Quilliam, Morag Turnbull, Shelagh Parkinson, Godwin Oligbu. Catatonia as a presentation of autism in a child: a case report[J]. AIMS Neuroscience, 2020, 7(3): 327-332. doi: 10.3934/Neuroscience.2020019

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  • Catatonia commonly refers to a cluster of movement abnormalities, behaviour, volition and speech that has long been associated with psychiatric disorders in adults. Recent evidence suggests increasing prevalence in adolescents and older children with autistic spectrum disorder (ASD), but its occurrence in younger children is rare. Here we describe a 6-year-old boy presenting with catatonic autism, highlighting the diagnostic challenge and demonstrating the importance of timely assessment and management.


    This paper concerns the existence of τ-periodic brake orbits (τ>0) of the autonomous first-order Hamiltonian system

    {J˙z(t)=H(z(t)),z(t)=Nz(t),tR,z(t+τ)=z(t), (1.1)

    where HC2(R2n,R) with H(Nz)=H(z), zR2n, J=(0InIn0) and N=(In00In) with In the n×n identity matrix.

    As shown in [1,2], for x=(x1,,xn) and y=(y1,,yn), we set

    V(x,y)=diag{x1,,xn,y1,,yn}R2n×2n.

    For z=(p1,,pn,q1,,qn), we have

    V(x,y)(z)=(x1p1,,xnpn,y1q1,,ynqn).

    Below are the conditions cited from [3] with minor modifications.

    (H1) HC2(R2n,R), H(Nz)=H(z), zR2n.

    (H2) There exist γi>0 (i=1, , n) such that

    lim|z|+H(z)ω(z)=0,

    where ω(z)=ni=1(|pi|1+γi+|qi|1+1γi).

    (H3) There exist β>1 and c1, c2, αi, βi>0 with αi+βi=1 (1in) such that

    min{H(z),H(z)H(z)V(z)}c1|z|βc2,    zR2n,

    where V(z)=V(α,β)(z) with α=(α1,,αn), β=(β1,,βn).

    (H4) There exists λ[1,β2β+1) such that

    |Hzz(z)|c2(|z|λ1+1),    zR2n,

    where Hzz means the Hessian matrix of H.

    (H5) H(0)=0 and H(z)>0, |H(z)|>0 for z0.

    Note that (H2) is a variant subquadratic growth condition which has superquadratic growth behaviors in some components and has subquadratic growth behaviors in other components, while [4] provided one other kind of variant subquadratic growth condition, we also call such conditions anisotropic growth conditions.

    In the last decades, brake orbit problems have been investigated deeply, see [5,6,7,8,9,10,11,12,13] and references therein. In [14], the existence of brake orbits and symmetric brake orbits were proved under the classical superquadratic growth conditions. Meanwhile, the minimal period estimates were given by comparing the L0-index iterations. Later, in [15], the authors obtained the same minimal period estimates under a weak growth condition which has super-quadratic growth only on some J-invariant plane. In [4,16], the authors considered first-order anisotropic convex Hamiltonian systems and reduced the existence problem of brake orbits to the dual variation problem, moreover, in [4], the minmality of period for brake orbits was obtained. In [1], the authors removed the convex assumption in [16] and obtained brake orbits with minimal period estimates under more general anisotropic growth conditions which are variant superquadratic growth conditions.

    The following is the main result of this paper.

    Theorem 1.1. If H is a Hamiltonian function satisfying (H1)–(H5), then there exists ˜τ>0 such that when τ˜τ, the system (1.1) has a nontrivial brake orbit z with the L0-index estimate

    iL0(z,τ2)0. (1.2)

    Futhermore, if the above brake orbit z also satisfies

    (H6) Hzz(z(t))0, tR and τ20Hqq(z(t))dt>0, where Hqq(z) means the Hessian matrix w.r.t. q for z=(p,q), p, qRn.

    Then the brake orbit z has minimal period τ or τ2.

    We remind the readers that the minimal period τ2 may not be eliminated generally. See Remark 4.2 in [14], for example, the minimal period is τ2 under the condition (H6). In [2], we also consider the symmetric brake orbit case under the above conditions with small changes using different index iteration inequalities.

    If ˜z is a brake orbit for the system (1.1), then z(t)=˜z(τ2t) satisfies

    {J˙z(t)=τ2H(z(t)),z(t)=Nz(t),z(t+2)=z(t). (1.3)

    The converse is also true. So finding brake orbits for the system (1.1) is equivalent to finding 2-periodic brake orbits for the system (1.3).

    In Section 2, we recall the L0-index theory and the related Sobolev space. In Section 3, we prove the existence of a nontrivial brake orbit with minimal period 2 or 1.

    The Maslov-type index theory is higly-developed and widly-used to study the existence, minimality of period, multiplicity and stability of periodic solutions of Hamiltonian systems, see [17]. And to estimate the minimal period for brake orbits, Liu and his cooperators introduced the L0-index theory —a topologically variant Maslov-type index theory, see the monograph [18] and the recent survey paper [19].

    We denote by L(R2n) the set of all 2n×2n real matrices, and denote by Ls(R2n) its subset of symmetric ones. The symplectic group Sp(2n) for nN and the symplectic path Pτ(2n) in Sp(2n) starting from the identity I2n on [0,τ] are denoted respectively by

    Sp(2n)={ML(R2n) | MTJM=J},Pτ(2n)={γC([0,τ],Sp(2n)) | γ(0)=I2n}.

    As showed in [18], for the Lagrangian subspaces L0={0}×Rn and L1=Rn×{0}, there are two pairs of integers (iLk(γ,τ),νLk(γ,τ))Z×{0, 1, , n} (k=0,1) associated with γPτ(2n) on the interval [0,τ], called the Maslov-type index associated with Lk for k=0,1 or the Lk-index of γ in short. When τ=1, we simply write (iLk(γ),νLk(γ)).

    The L0-iteration paths γj:[0,j]Sp(2n) of γP1(2n) (see [18]) are defined by

    γ1(t)=γ(t),    t[0,1],
    γ2(t)={γ(t),         t[0,1],Nγ(2t)γ(1)1Nγ(1),  t[1,2]

    and more generally, for jN,

    γ2j(t)={γ2j1(t),      t[0,2j1],Nγ(2jt)N[γ2(2)]j,    t[2j1,2j],
    γ2j+1(t)={γ2j(t),      t[0,2j],γ(t2j)[γ2(2)]j,    t[2j,2j+1].

    Then we denote by (iL0(γj),νL0(γj)) the L0-index of γj on the interval [0,j].

    Assume B(t)C([0,τ],Ls(R2n)) satisfies B(t+τ)=B(t) and B(τ2+t)N=NB(τ2t), consider the fundamental solution γB of the following linear Hamiltonian system

    {J˙z(t)=B(t)z(t),    t[0,τ],z(0)=I2n.

    Then γBPτ(2n). Note that γkB satisfies

    {J˙z(t)=B(t)z(t),    t[0,kτ],z(0)=I2n.

    The L0-index of γB is denoted by (iL0(B),νL0(B)), called the L0-index pair with respect to B.

    Moreover, if z is a brake orbit of the system (1.1), set B(t)=H(z(t)), denote by (iL0(z),νL0(z)) the L0-index of γB, called the L0-index pair with respect to z.

    See [17] for the Maslov-type index (i1(γ),ν1(γ)) of γP(2n). And we refer to [18] for the indices (iL01(γ),νL01(γ)) and (iL01(B),νL01(B)) for τ=1.

    Below are some basic results needed in this paper.

    Lemma 2.1. ([11]) For γP(2n), there hold

    i1(γ2)=iL0(γ)+iL1(γ)+n    and    ν1(γ2)=νL0(γ)+νL1(γ).

    Lemma 2.2. ([14]) Suppose B(t)C([0,2],Ls(R2n)) with B(t+2)=B(t) and B(1+t)N=NB(1t). If B(t)0 for all t[0,2], then

    iL0(B)+νL0(B)0    and    iL01(B)0.

    Lemma 2.3. ([14]) Suppose B(t)C([0,2],Ls(R2n)) with B(t+2)=B(t) and B(1+t)N=NB(1t). If B(t)=(S11(t)S12(t)S21(t)S22(t))0 and 10S22(t)dt>0, then iL0(B)0.

    Lemma 2.4. ([18]) The Maslov-type index iteration inequalities are presented below.

    1 For γP(2n) and k2N1, there holds

    iL0(γk)iL0(γ1)+k12(i1(γ2)+ν1(γ2)n).

    2 For γP(2n) and k2N, there holds

    iL0(γk)iL0(γ1)+iL01(γ1)+(k21)(i1(γ2)+ν1(γ2)n).

    Now we introduce the Sobolev space E=WL0 and its subspaces as in [10,14].

    E=WL0={zW12,2(R/2Z,R2n) | z(t)=Nz(t) fora.e. tR}={zW12,2(R/2Z,R2n) | z(t)=kZexp(kπtJ)hk, hkL0}.

    For mN, define

    E±={zWL0 | z(t)=±kZexp(kπtJ)hk, hkL0},E0=L0,Em={zWL0 | z(t)=mk=mexp(kπtJ)hk, hkL0},

    and set E+m:=EmE+, Em:=EmE. Then E=E0EE+ and Em=E0EmE+m. Moreover {Em,Pm} forms a Galerkin approximation scheme of the unbounded self-adjoint operator Jddt defined on L2([0,2];L0), where Pm:EEm denotes the orthogonal projection. Furthermore, define the following bounded self-adjoint operator A on E

    Az,ζ=20J˙zζdt,    z, ζW1,2([0,2];L0)E,

    and, obviously, Az,z=2(z+2z2), Az=Az+Az, zE.

    Remark 2.1. ([1]) For zE, there holds V(x,y)zE. And for zEm, we have V(x,y)zEm. As for the Fourier expression for V(x,y)z, see [1] for details. Note that for V defined in (H2) and zE, we have V(z)E. Moreover, a simple computation shows that

    Az,V(z)=12Az,z,    zE.

    In our case, assume B(t)C([0,2],Ls(R2n)) satisfies B(t+2)=B(t) and B(1+t)N=NB(1t), define the following bounded self-adjoint compact operator B

    Bz,ζ=20B(t)zζdt,    z, ζE. (2.1)

    For any d>0, denote by Md(), M0d(), M+d() the eigenspaces corresponding to the eigenvalues λ belonging to (,d], (d,d), [d,+) respectively. Set (AB)=(AB|Im(AB))1. The following result is crucial to esmiate the L0-index.

    Lemma 2.5. ([20,21]) For B(t)C([0,2],Ls(R2n)) satisfying B(t+2)=B(t), B(1+t)N=NB(1t) and 0<d14(AB)1, there exists m0>0 such that for mm0, we have

    dimM+d(Pm(AB)Pm)=mniL0(B)νL0(B).dimMd(Pm(AB)Pm)=mn+n+iL0(B).dimM0d(Pm(AB)Pm)=νL0(B).

    As shown in [10,14], searching for brake orbits for the system (1.3) can be transformed into finding critical points of the following functional

    g(z)=τ220H(z)dt12Az,z,    zE.

    By (H4), we have gC2(E,R), then, let us now set gm=g|Em, mN. To find the critical points of gm, we shall prove that gm satisfies the hypotheses of the homological link Theorem 4.1.7 in [22]. The following several lemmas are essential.

    Lemma 3.1. If H(z) satifies (H1), (H3) and (H4), then the above functional g satisfies (PS) condition with respect to {Em}mN, i.e., any sequence {zm}E satisfying zmEm, gm(zm) is bounded and gm(zm)0 as m+ possesses a convergent subsequence in E.

    Proof. We follow the ideas in [3].

    Let {zm} be a sequence such that |g(zm)|c3 and gm(zm)0 as m, where c3>0. To prove the lemma, it is enough to show that {zm} is bounded.

    For m large enough, by Remark 2.1 and (H3), we have

    c3+zmg(zm)gm(zm),V(zm)=τ220(H(zm)H(zm)V(zm))dtτ220(c1|zm|βc2)dt,

    then there exists c4>0 such that

    zmLβc4(1+zm1β). (3.1)

    For large m, we have

    z±mgm(zm),z±m=τ220H(zm)z±mdtAzm,z±m. (3.2)

    By (3.2), (H4), H¨older's inequality and the embedding theorem, we obtain

    z±m2=±12Azm,z±mτ4|20H(zm)z±mdt|+12z±mc520(|zm|λ+1)|z±m|dt+12z±mc5(20(|zm|λ)βλdt)λβ(20|z±m|ββλdt)βλβ+c5z±mL1+12z±m=c5(20|zm|βdt)λβ(20|z±m|ββλdt)βλβ+c5z±mL1+12z±mc6(1+zmλLβ)z±m, (3.3)

    where β>λ1 for (H3), (H4) and c5, c6>0 are suitable constants.

    Combining (3.1) and (3.3), for m large enough, there exists c7>0 such that

    z±mc7(1+zmλβ). (3.4)

    Set ˆzm=zmz0m=z+m+zm. By (H4), (3.4) and the embedding theorem, we obtain

    |20[H(zm)H(z0m)]dt|=|2010Hz(z0m+sˆzm)ˆzmdsdt|202λc8(|z0m|λ+|ˆzm|λ+1)|ˆzm|dtc9(1+zmλ+λβ), (3.5)

    where c8, c9>0 are suitable constants. From (3.4) and (3.5), we see

    τ220H(z0m)dt=g(zm)+12Azm,zmτ220[H(zm)H(z0m)]dtc10(1+zmλ+λβ), (3.6)

    where c10>0. From (H3), it follows that

    20H(z0m)dt20(c1|z0m|βc2)dt. (3.7)

    From (3.6) and (3.7), we see that

    |z0m|c11(1+zmλ+λββ2), (3.8)

    where c11>0. From (3.4), (3.8) and λ+λββ2<1, we see {zm} is bounded.

    For u0E+1 with u0=1, define S=(EE0)+u0.

    Lemma 3.2. If H(z) satifies (H1), (H4) and (H5), then there exists ˜τ>0 such that for τ˜τ, there holds infSg>0.

    Proof. The ideas come from [23].

    For zS, we have

    g(z)=τ220H(z)dt+z21. (3.9)

    There exist two cases to be considered.

    Case (i) If z>1, then by (H5), we have

    g(z)=τ220H(z)dt+z21>0.

    Case (ii) If z1, set Ω={zSz1}, then Ω is weakly compact and convex.

    Since the functional z20H(z)dt is weakly continuous, then the functional achieves its minimum on Ω, assume the minimum is σ achieved at u+u0S. Since u00, we have u+u00, then σ>0 by (H5).

    Set ˜τ=2σ, for τ>˜τ, by (3.9), we have

    g(z)τσ21>0.

    Therefore, the lemma holds.

    Choose μ>0 large enough such that σi=μ1+γi>1 and τi=μ1+1γi>1. For ρ>0, we set

    Lρ(z)=(ρσ11p1,,ρσn1pn,ρτ11q1,ρτn1qn),

    where z=(p1,,pn,q1,,qn)E. Note that Lρ is well-defined on E by Remark 2.1. The operator Lρ is linear bounded and invertible and Lρ1, if ρ1.

    For any z=z0+z+z+E, we have

    ALρz,Lρz=ρμ2Az,z=2ρμ2(z+2z2). (3.10)

    Lemma 3.3. If H satisfies (H2), then there exists ρ>1 large enough such that supLρ(Q)g<0, where Q={zE+zρ}.

    Proof. For any ϵ>0, by (H2), there exists Mϵ such that

    H(z)ϵni=1(|pi|1+γi+|qi|1+1γi)+Mϵ,    zR2n. (3.11)

    For zQ, from (3.10) and (3.11), we have

    g(Lρz)=τ220H(Lρz)dt12ALρz,Lρzτε2ni=120(ρ(σi1)(1+γi)|pi|1+γi+ρ(τi1)(1+1γi)|qi|1+1γi)dt+Mϵτρμ(nτϵc121)ρμ+Mϵτ, (3.12)

    where c12>0 is the embedding constant.

    Choose ϵ>0 such that nτϵc12<1, then for ρ>1 large enough, we have supLρ(Q)g<0.

    Lemma 3.4. Set Sm=SEm and Qm=QEm. For ρ>1 defined as above, we have Lρ(Qm) and Sm homologically link.

    Proof. Since ρ>1, ρ>L1ρ=L1ρ. By direct computation, we can check that PLρ:E+E+ is liner, bounded and invertible (see [24]). Let ˜Pm:EmE+m be the orthogonal projection. Note that Lρ(Em)Em by Remark 2.1, then (˜PmLρ)|Em:E+mE+m is also linear, bounded and invertible.

    Then the assertion follows from Lemma 2.8 in [3].

    Theorem 3.1. Assume H satisfies (H1)–(H5), then there exists ˜τ>0 such that for τ˜τ, the system (1.3) possesses a nontrivial 2-periodic brake orbit z satisfying

    iL0(z,1)0. (3.13)

    Proof. The proof is standard, we proceed as that in [10,14].

    For any mN, Lemmas 3.1–3.4 show that gm=g|Em satisfies the hypotheses of the homological link Theorem 4.1.7 in [22], so gm possesses a critical point zm satisfying

    0<infSgg(zm)supLρ(Q)g. (3.14)

    By Lemma 3.1, when ττ0, we may suppose zmzE as m, then g(z)>0 and g(z)=0. By (H5), we see the critical point z of g is a classical nontrivial 2-periodic brake orbit of the system (1.3).

    Now we show (3.13) holds. Let B be the operator for B(t)=τ2Hzz(z(t)) defined by (2.1), then

    g(x)(BA)0    as    xz0,  xE. (3.15)

    By (3.15), there exists r0>0 such that

    g(x)(BA)<d,    xBr0={xE | xzr0},

    where d=14(BA)1.

    Hence, for m large enough, there holds

    gm(x)Pm(BA)Pm<d2,    xBr0Em. (3.16)

    For xBr0Em and wM+d(Pm(BA)Pm){0}, (3.16) implies that

    gm(x)w,wPm(BA)Pmw,wgm(x)Pm(BA)Pmw2d2w2>0.

    Then

    dimM+(gm(x))dimM+d(Pm(BA)Pm),    xBr0Em. (3.17)

    Note that

    dimMd(Pm(BA)Pm)=dimM+d(Pm(AB)Pm),dimM0d(Pm(BA)Pm)=dimM0d(Pm(AB)Pm). (3.18)

    By (3.17), (3.18) and the link theorem 4.1.7 in [22], for large m, we have

    mn=dimQmm(zm)+m0(zm)dimMd(Pm(BA)Pm)+dimM0d(Pm(BA)Pm)=mniL0(z,1).

    Hence, we obtain iL0(z,1)0.

    Theorem 3.2. Assume H satisfies (H1)–(H6), then there exists ˜τ such that for τ˜τ, the system (1.3) possesses a nontrivial brake orbit z with minimal period 2 or 1.

    Proof. The idea stems from [14], we proceed roughly.

    For the nontrivial symmetric 2-periodic brake orbit z obtained in Theorem 3.1, assume its minimal period 2k for some nonnegative integer k. Denote by γz,1k and γz the corresponding symplectic path on the interval [0,1k] and [0,1] respectively, then γz=γkz,1k.

    As shown in [14], we have the L1-index estimate

    iL1(γz,1k)+νL1(γz,1k)1. (3.19)

    By (H6), we see B(t)=H(z(t)) is semipositive, Lemmas 2.1 and 2.2 and Eq (3.19) imply that

    i1(γ2z,1k)+ν1(γ2z,1k)n=iL0(γz,1k)+νL0(γz,1k)+iL1(γz,1k)+νL1(γz,1k)1. (3.20)

    By Lemmas 2.2 and 2.3, we see

    iL0(γz,1k)0    and    iL01(γz,1k)0. (3.21)

    If k is odd, by Lemma 2.4, we see

    iL0(γz)iL0(γz,1k)+k12[i1(γ2z,1k)+ν1(γ2z,1k)n] (3.22)

    From (3.13), (3.20)–(3.22), we see k=1.

    If k is even, If k is even, by Lemma 2.4, we see

    iL0(γz)iL0(γz,1k)+iL01(γz,1k)+(k21)[i1(γ2z,1k)+ν1(γ2z,1k)n]. (3.23)

    From (3.13), (3.20), (3.21) and (3.23), we have k=2.

    The first author is supported by the Scientific and Technological Innovation Programs of Higher Education Institutions in Shanxi (Grant No. 2021L377) and the Doctoral Scientific Research Foundation of Shanxi Datong University (Grant No. 2018-B-15). The authors sincerely thank the referees for their careful reading and valuable comments and suggestions.

    The authors declare there is no conflicts of interest.



    Consent



    Informed consent was obtained from the family for publication of this case report and any accompanying images.

    Contributors' statement



    GO conceptualized and designed the study. RQ reviewed the literature, analysed the result, wrote the first draft, and co-ordinated the production of the manuscript. RQ and GO had full access to all the results in the study and take responsibility for the integrity of the results and the accuracy of the data. All authors were involved in the interpretation of the result and writing the report; all authors approved the final version.

    Conflict of interest



    No potential conflict of interest relevant to this article was reported.

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