DRUG THERAPY FOR SLEEP
DISORDERS, SYCHOMOTOR AGITATION AND AGGRESSIVENESS IN A YOUNG ADULT WITH AUTISM
(Updated September 2006).
Renato COCCHI, a neurologist and a medical
psychologist.
Summary
The parents of an autistic young man of
19 years with previous diagnosis of Pervasive Developmental Disorder (DSM-IV:
Autistic trouble with precocious onset ) asked a drug therapy for the sleep
troubles, the psychomotor agitation and the aggression or selfaggression of
their son. In past, the treatment with neuroleptic drugs had worsened the
situation and it was to be hanging.
After 35 months, an individualized
regimen without neuroleptics drew to improvement in all target symptoms and
other ones, among which in the language.
A drug therapy in autistic adults, as
already observed in the 8 cases previously described (Cocchi, 1994; Cocchi,
1995) doesn't have to be a reproposition of what we do in the psychotic adults.
The adult autistics seem have a differented psychopathologic picture, and
require a specifically formulation of their drug therapy.
Key words: Autism, adult, sleep,
aggressiveness, psychomotor agitation, drug therapy.
Drug modulation of stress reactions
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In two preceding investigations I examined
the epidemiological and clinical data of eight autistic persons in adult age,
brought to consultation by their parents for behavioural disorders ( Cocchi,
1994; Cocchi, 1995).
In the first survey, of each I reported a
short clinical history. I even collected the more evident symptoms and the
request of the parents for better drugs management of the sons' disturbs. In
the survey I did a deepening of those case histories, with attention to the
prescribed therapy and to its results, when it was token.
Here I shall report a new case, under drug
therapy since 15 months.
The case history
The beginning of October 2003, the first
consultation. A male, 19 years old, an autistic adult who was an autistic
child.
He is aggressive, against the things,
against himself, and against others, mainly against his already elderly
parents.
Since long time he has troubles of the
sleep-waking rhythm, with difficulty in falling asleep, frequent interruptions
of the sleep ( he goes to the bathroom 3-4 times every night), and
early-morning awakening.
He is hyperactive. In past he did some
neuroleptics therapies, which drew him even more aggressive. Currently he
doesn't take any drug, but the parents cannot control him anymore, and they
hope in a some relief. They are feeling worn out and discouraged, and they
would at least reduce his aggressiveness against them and the sleep disorders.
His faeces incline to be hydrated, but not
diarrhea. He eats much and searches for sweet things, but he prefers the
chocolate. He doesn't like the meat or cube broth. In the morning, he has not
always breakfast. He suffers from the heat, and often he is sweating, with an
ugly odour. In the morning he is more irritable.
He has fat hair. As a child he was tearing
his hair and he was putting his flat hand into his mouth. His hunger is
"dreadful", but he is not particularly obese. In moments his looking
becomes "bad". Always erection to the morning occurs. There is some
masturbation, but perhaps less than usual for his age. Weather changes irritate
him. He has a good control of the urine and faeces. When out, he holds back the
urine. Often there is drooling. During the day he has frequent episodes of
rocking. Gaze aversion occurs. He counts loudly, backwards, from a figure,
which is not always the same. The language is present, stereotyped and poorly
communicative, but well pronounced. He uses it a few. Often he sings softly.
Test therapy (daily doses, by the oral via):
Carbamazepine 300mg; Delorazepam 0.5mg; Amitriptyline 10mg; Clonidine 0.075mg.
November 2003, the first checkup after 35
days of therapy. The drugs did not induce any side effects. He does a little
more labours to fall asleep and to maintain the sleep. He is less aggressive.
Unchanged bowel function. He eats always much. Perhaps he looks for fewer sweet
things. Now, in the morning he has breakfast. Stereotypies of the voice and of
the hands came back. In the morning he has less irritation. He doesn't exhale
more the previous bad odour. His bad looking reduced. Masturbation runs as
first. Perhaps he applies less to the rocking. He sings softly more. The habit
of not urinating out of his house did not change. Now he quarrels less with his
brother. He is paying more attention, and he observes more, or at least he does
see it more.
Therapeutic variation (daily doses, by the
oral via): Carbamazepine 400mg; Delorazepam 0.75mg.
February 2004, the second checkup, after 123
therapy days. In the morning he is less aggressive. He has a strange cry and he
goes in hyperpnea. It occurs in the first hours of sleeping. Now, he does fewer
labours in falling asleep and in maintaining his sleep. He eats always much,
perhaps more, but has not fattened up. In the morning he has breakfast with
cookies. Stereotypies appear reduced. He is more interest in things around, and
gaze aversion decreased. Now, he became more cunning. The bad odour missed. His
bad looking is rare. The masturbation diminished, as the rocking too. When he
is at the table, his behaviour is better. Singing softly has some less. Now he
is reading the newspaper. When he is out of his house, he doesn't urinate. Some
quarrels with his brother occurs, but less. Now he is more affectionate. At the
educational centre where he goes five days for every week, the care-givers
found him more orderly. Perhaps he has less sameness. In the morning he has
become slow. Oversweating still happens much.
Therapeutic variation (daily doses, by the
oral via): Amantadine 50mg; Delorazepam 1mg.
June 2004, the third checkup. As for the
parents, no variations occurred. Currently he can easily be managed. For the
father, he reduced the genital stimulation for a little. He is little more
calm. At the morning he is less aggressive, when compared to the checkup of
February. The parents think that the amantadine is giving problems [??]. The
nighttime hyperpnea diminished. He eats always much, but less chocolate. He
doesn't have any difficulty to take the drugs. Now, he wants not more to drink
water, but only soft drinks. The frequency of rocking did not change, as for
other stereotypies too. Now, he used breaking anything. His bad looking missed.
He bears more the other people's watching at him. He is reading much, to loud
voice. No soft sing nearly occurred anymore. Even fewer quarrels with his
brother, but he searches him more, and he is more affectionate. At the
educational centre the care-givers found him more orderly and at times he is
that lays the table. In the morning he is a little slow.
Therapeutic variation (daily doses, by the
oral via): Amantadine 25mg.
Beginning of February 2005, the fourth
checkup. As for the parents even this time no variations happened. He is much
less aggressive and more sociable, understands more, but not always he obeys.
He is speaking more, but did not improve the language, except some new words.
In some moments he can use more complex sentences [when he becomes irritable?].
The rocking did not vary, that goes at times, perhaps when the weather is
changing. When he is happy, he is rocking more. Perhaps he is reading a little
less. With extraneous people he goes to sympathy. Even at the centre that
attends, the care-givers found him better, more open, more available, more
collaborating. He marks with his saliva the things that are of interest for
him. His health did well. The hyperpnea still diminished, but when he eats too
much in the evening, then he breathes badly.
As usual, he is eating too much, but a
little less than first. He seems that he is taller, because his pants became
short. He ribs more the buttons of the shirts and of the pillowcases of his
bed, but he does it with less anger. As in past, he sings softly. He
collaborates more with his brother. Generally, he is more affectionate. The
genital stimulation is as first, or a little diminished. In the morning he is
less slow. Meanwhile, he did not decrease his greediness for the chocolate. He
like to drink tea, mineral salts solution for the sportsmen, soft drinks. At
night there are no awakenings for going to the bathroom. He does not count more
in the contrary. He has less the need to disrobe.
Prescribed therapy (daily doses, by the oral
via): S-adenosil-l-methionine 200mg; Clonidine 0.075mg; Amantadine 25mg;
Delorazepam 0.5m; Amitriptyline 10mg; Carbamazepine 400mg.
Beginning September 2005, The fifth checkup. The
parents say that he is doing a little better. The language is improved, with
some new sentences. He takes part in a right way in the domestic speaking. The
language quantity did not increase, but he uses new words.
In this life time span, he had tonsillitis,
treated with antibiotics, and a current cold. His appetite is good, and his
diet is more varied. He is more regulated in food's amount, because he is less
avid, but always has greediness for the meat and the chocolate. Even his bowel
function runs better. In the past he usually went to the bathroom even 10 times
in a day, while now he reduced to 3-4 times. He drinks much as in past, but now
he does not search gasified drinks. Usually he sleeps all the night long.
In summer he was more irritable and
aggressive, because his Centre closed, for the summer holidays. Furthermore,
the father had surgery, so he cannot bring him out of home, for walking. In
fact, he needs doing always some movement. He uses screams and skips "for
relieving." The masturbation increased. According to the assistants of the
Centre he attends, he is progressing even by little footsteps. The rocking
diminished.
He does nor bear again of the weather's
changes. Now is more vivacious and he succeeds to joke. He marks still with the
saliva the things that are of interest for him. He tears always the
pillowcases, but less the shirts. With his brother now is more collaborating
and generally he is more affectionate. Only a time has counted digits backwards.
No therapeutic variation.
The last eight days of February 2006, the
sixth checkup after 28 months of drug therapy.
His parents say that he is doing better and
they find him more prone to personal relationships. He speaks more and in better
way. At the diurnal Centre he attends, the staff found him clearly improved.
Now, he is a little thinner because he is
not more continuously bulimic, and he used to eat only at meals. His sleeping
is regular, even if, in the morning, he would like to stay some more in his
bed. The anger fits reduced, but he reacts, when provoked.
Hyperactivity did not change, but he is not
more busy for no reason. Now, he uses less the bathroom, but he masturbates
always often. The rocking increased. He is a little euphoric, not does not need
to count backwards anymore. In this time he did not show any self-aggression.
Therapeutic variation (daily doses, by the
oral via): Amantadine 100mg.
First ten days of September 2006, the
seventh checkup after 35 months of drug therapy.
He is still improved, in particular in the
expressive language. He speaks better and in a substantially way. Now, he
answers to the point (His father says: "in the matter" ). He
socializes more with whom are willing to understand him. He shows more interest
in what is surrounding him. His face changed, being now more relaxed and
serene.
The staff of the diurnal Centre found him
still improved. He is easily distracted. Some time he irritates still when
someone reproaches him. He bears always badly to have reproaches, but less than
in past. Even overweighted, he is still grown thin. The feeding is more
controlled, but he has times where he gorges himself on food. Usually he eats
in a less avid way and less hasty.
Without any doubt, he is always hyperkinetic,
and he doesn't always succeed to end a meal without get up from the chair.
Often he stays closed in the bathroom to masturbating, and sometimes he does it
even still overtly.
Rocking even occurs, but less. He doesn't
count anymore. There is an interest in readings of heraldic type. Now he
watches television. The self-aggression missed, and now he doesn't attack the
mother, when this scolds him. The parents hung for the delorazepam since a long
time, without warning me, because at night their son went to apnoea [???].
Therapeutic variation (daily doses, by the
oral via): By keeping the hang up of the delorazepam, I prescribed oxazepam
30mg.
Discussion
I faced this case too with a drug therapy
the reasons of which I reported in a preceding article (Cocchi 1990 ).
The attempt to use neuroleptics, as made by
other physicians, led to worsening. If the problem is not the dopamine or o
there was even its deficit, to act by reducing its action could have driven to
other unbalance.
One would say that anyone had prescribed
those drugs, faced this psychopathologic frame in the same way who they face
the psychotic troubles of the adult, with or without mental retardation.
In effects they wanted to act on
aggressiveness and on psychomotor agitation with a primarily sedative action.
If this therapeutic choice was for the adult
mentally retarded - and some people strongly debates it, and I too - we have to
aske ourselves if it can transferred as such to an autistic person who became
an adult. In fact, it seems to have occurred exactly so.
As I wrote in my previous research (Cocchi,
1994) this way to go further seem to have at least three justifications.
First, as adult, autistic subjects left the
child psychiatrist competence for that of an adult psychiatrist who often does
not have any practice in treating them.
Parents, exhausted after many even clearly
absurd failed therapies they made during their daughter's or son's childhood,
had themselves resigned. Now they ask only for a minimum, for a situation
worsen with the age growing of her son
They usually expect only a more viable
condition for their son or daughter and for themselves. They are getting on in
years and have been left as the only ones to bear the weight of their
children's illness.
As a third reason, psychiatrists follow the
guidelines of adults' psychiatry. So they afford the disturbing behaviour of
autistic adults aiming to sedation, and hope this acts at least on sleep,
psychomotor agitation, aggression and self-aggression. Unlucky, as we saw here,
they cannot achieve such results.
But who had something to do with mentally
retarded people has no problems in noticing that autistic adults are different,
though they belong to mentally retarded people too.
Autistic adults show very typical and
visible features. An experienced professional can usually do a diagnosis of
autism soon after few minutes of observation, just before he starts to collect
the case history.
However, in the therapy of this case I did
not use any neuroleptic.
There is a new problem, which however I have
already met with other patients.
If at the beginning, the parents ask the
minimum, when reached the results that allow them to be less deeply involved,
perhaps they hope of recovery. Therefore they seem unable in remembering too
little improvements between one checkup and the other. Having not what they
hoped, they give negative information.
In past, as I wrote in the third and in the
quarter checkups, to my initial generic question, (How he does? Better, worse, such
and that?) the parents answered that they did not observe any variation. Then,
when I did specific questions, they admitted some positive variations. Now,
they admit at once the improvement.
I never promised "recovery" of any
kind, and I said that the therapy would have been long and difficult. It should
be necessary to "convince" the brain that it can work to a more
evolved level, and The therapy did not possess rapid times.
ON other hand, in my report both the first
examination and of the following checkups, I transcribe always what the parents
answered, and my possible doubts are integrated between square brackets.
The evolution of this subject was similar of
those observed in the eight preceding cases (Cocchi 1995).
References
Cocchi R.: The pharmacological approach
to treating childhood psychoses: Theoretical bases. It. J. Intellect. Impair.
1990, 3: 185-193. <www.stress-cocchi.net/Autism7.htm>
Cocchi
R.: Formerly autistich children who had become adults: Otto casi. In Italian on
Riv. It. Disturbo Intellet.1994, 7: 241-248. In English on Internet on July
2001 >www.stress-cocchi.net/Autism5.htm>
Cocchi R.
Drug therapies for sleep troubles, iperactivity and aggression in young adult
autistics It. J.
Inttelct. Impair 1995, 8: <www.stress-cocchi.net/ Autism4.htm>
First posted on internet on 11 February
2005. Copyright by Renato Cocchi, 2005
Author's address: dr. Renato COCCHI, via Rabbeno 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
Drug modulation of stress reactions
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