The Use and Abuse of Psychotropic Medication in People with Autistic Spectrum Disorder

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The Use and Abuse of Psychotropic Medication in
People with Autistic Spectrum Disorder

• Dr Juli Crocombe
• Consultant Psychiatrist
• Care Principles Ltd
• Clinical Lecturer Keele University

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Outline

• The nature of ASD
• Implications
• Psychotropic medication
• Other medication
• Comorbid mental illness
• Troublesome features
• Challenging Behaviour
• Prescribing issues

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The Nature of ASD

• ASD is a
• DEVELOPMENTAL DISORDER
• It is not a mental illness.

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What Does This Mean?

• YOU CANNOT TREAT ASD WITH PSYCHOTROPIC
  MEDICATION
• YOU CAN TREAT
• - COMORBID MENTAL ILLNESS
• - TROUBLESOME FEATURES OF ASD inc challenging
  behaviour

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Implications

• Correct recognition diagnosis of ASD vital.
• Correct recognition diagnosis of comorbid
  mental illness essential.
• Detailed assessment to develop full accurate
  understanding of nature cause of troublesome
  features essential.

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Psychotropic Medication

• Anxiolytics eg diazepam, lorazepam
• Antipsychotics eg haloperidol, risperidone
• Antidepressants eg fluoxetine, mirtazapine
• Mood stabilisers eg lithium, carbamazepine
• Others

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Other Drugs

• Buspirone
• Propranolol
• Opioid antagonists
• Cyproterone
• Methylphenidate

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Comorbid Mental Illness

• PwASD are at increased risk of mental illness of
  all types
• Treat mental illness in PwASD in same way as
  general population BUT be aware of increased
  likelihood of sensitivity / idiosyncratic
  responses

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Troublesome Features

• Anxiety - anxiolytics
• - antidepressant
• - buspirone
• - propranolol
• Hyperactivity methylphenidate
• Rituals or stereotypies SSRI
• Obsessive/compulsive features SSRI
• Catatonia benzodiazepines

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Challenging Behaviour is

• culturally abnormal behaviour(s) of such an
  intensity, frequency or duration, that the
  physical safety of the person or others is likely
  to be placed in serious jeopardy, or behaviour
  which is likely to seriously limit use of, or
  result in the person being denied access to,
  ordinary community facilities.
• Emerson et al, 1988.

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Challenging behaviour includes-

• Physical assault
• Damage to environment
• Self-injury
• Non-compliance
• Persistent screaming
• Pica
• Public masturbation
• Inappropriate sexual behaviour
• Recurrent vomiting

• Aggression
• Self-injurious behaviour
• Problematic sexual behaviour

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Aggression
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Consider nature of / drive for aggressive
behaviour

• Explosive/ cyclical/ episodic dyscontrol
• - carbamazepine
• Anxiety driven
• - antidepressant - SSRIs
• - mirtazapine
• - antipsychotic - typical
• - atypical
• High arousal
• - b blockers - propranolol

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Self Injurious Behaviour
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Consider nature of / drive for self-injurious
behaviours

• Aggressive act
• Endorphin model of self-injury
• - opioid antagonists - naloxone
• - naltrexone
• Mood stabilisers - lithium

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Problematic Sexual Behaviour
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Antilibidinal Drugs

• Neuroleptics benperidol
• Antiandrogens cyproterone acetate
• SSRIs - fluoxetine

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Prescribing Issues

• Capacity and consent
• Compliance
• Pharmacokinetics
• Drug interactions
• Idiosyncratic reactions
• Side effects

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Summary

• ASD is not a mental illness
• There is no psychotropic medication to treat
  ASD per se
• Psychotropic medication is used to treat
• - comorbid mental illness
• - troublesome features
• - Challenging Behaviour
• Know what you are treating and tailor medication
  accordingly
• Remember, psychotropic medication can cause side
  effects and produce problems as well as benefits

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Summary

• Choose medication only after having considered
  and addressed the following
• - environmental issues
• - communication issues
• - physical illness
• - mental illness
• Review the appropriateness of medication
  regularly, remembering it can make things worse.
• Dont forget, psychotropic medication is only one
  approach to improving the quality of life for
  PwASD

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References

• Barnard et al (2002) A systematic review of the
  use of atypical antipsychotics in autism Journal
  of Psychopharmacology 16(1) 93-101Ashcroft et al
  (2001) Are antipsychotic drugs the right
  treatment for challenging behaviour in learning
  disability? the place of a randomised trial
  Journal of Medical Ethics 27338-343
• Robertson et al (2000) Receipt of psychotropic
  medication by people with intellectual disability
  in residential settings JIDR 44(6) 666-676
• Jenkins R (2000) Use of psychotropic medication
  in people with a learning disability BJNursing
  9(13) 844-850
• Brylewski Duggan (1999) Antipsychotic
  medication for challenging behaviour in people
  with intellectual disability a systematic review
  of randomised controlled trials JIDR 43(5)
  360-371
• Santosh Baird (1999) Psychopharmacotherapy in
  children and adults with intellectual disability
  The Lancet 354 233-242
• Suresh (1998) As required neuroleptics Have
  these drugs a place in the management of
  challenging behaviour in intellectual disability?
  JIDR 42(6) 500-504
• Branford (1996) A review of antipsychotic drugs
  prescribed for people with learning disabilities
  who live in Leicestershire JIDR 40(4) 358-368
• Kiernan et al (1995) The use of anti-psychotic
  drugs with adults with learning disabilities and
  challenging behaviour JIDR 39(4) 263-274