DRUG THERAPIES FOR
SLEEP TROUBLES, HYPERACTIVITY
AND AGGRESSION IN YOUNG ADULT AUTISTICS
Renato COCCHI, a neurologist and a
medical psychologist
Summary
Parents of eight 16-25 years autistic
adults with histories and diagnoses of Pervasive Developmental Disorder
(DSM-III, R: 299.00: early onset Autistic Disorder) asked to have their sons or
daughters relieved for sleep troubles, psychomotor agitation, and aggressiveness.
Six of them have drug therapies, mostly using neuroleptics.
At six months checkups, revision of
previous drugs therapies with an individualized prescription led to noticeable
improvements in the 6 cases whose parents had good compliance.
Drug therapy in autistic adults
should not replay drug therapies of normal psychotics. Adult autistics seem to
have a different psychopathological frame, needing more specific drug
treatments.
Key words: autism; adults; sleep
troubles; psychomotor agitation; aggression; drug therapy.
* Autism
* Mental retardatioń
* Drug therapy of stress reactions
* Symptoms
In previous research I referred about
some epidemiological and clinical features of eight young adult autistics
(Cocchi, 1994).
As a second study on the same casuistry,
I started this one for to the analysis of more detailed clinical features and
therapeutical results.
This time too I would put forward what I
am thinking about. Adulthood of autistic children seems a no-man land where
skilled professionals of autistic childhood left room to adult psychiatrists
often without any experience with autistic people.
Of course, this opinion refers to the
Italian setting and does not necessarily suit to other countries.
[I reproduce now (2001) this report
since I maintain that autism, as an illness, has also stress reactions that
need heving treatment.]
Results
From the records of the 8 young adult
autistics previously referred as for epidemiology and some clinical features I
reported in Tables 1-6 more clinical features and therapeutical results.
Table 1: Summary of epidemiological
data.
|
Datum |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Sex |
M |
M |
M |
M |
F |
F |
M |
M |
|
Age (yrs) at first consultation |
25 |
21 |
19 |
17 |
20 |
16 |
21 |
18 |
|
Retrospective diagnosis |
|
|
|
|
|
|
|
|
|
DSM-III,R: 299.00 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
Onset before 36 mnts of age |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
Schooling |
No |
No |
No |
++ |
No |
No |
No |
No |
|
EEG troubles |
No |
No |
No |
Yes |
No |
No |
No |
No(*) |
(*) he has epileptic fits,
but clear EEG (only few controls)
In retrospect, according to DSM-III, R
all these eight cases had confirmed a diagnosis of early onset Pervasive
Developmental Disorder. Schooling suggests a severe mental retardation in seven
people, and a lesser degree of it in the case no. four.
Table 2: More significant symptoms'
summary.
|
Symptom checked |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Sleep troubles |
+++ |
++ |
+ |
+ |
++ |
+++ |
+++ |
++ |
|
Sudden mood changes |
? |
++ |
+++ |
++ |
+++ |
+++ |
++ |
+++ |
|
Psychomotor agitation |
+(#) |
++ |
+++ |
++ |
+++ |
++ |
++ |
+++ |
|
Aggression |
+++ |
++ |
+++ |
++ |
|
|
|
+++ |
|
Self-aggression |
++ |
|
+++ |
+ |
|
|
|
|
|
Excessive eating |
+++ |
|
|
|
+++ |
|
|
|
Keys: (+) mild; (++)
moderate; (+++) severe; (#) very sedated at 1st consultation.
Sleep troubles, sudden mood changes -
possible also in case one, who has aggression as derived symptom -, psychomotor
agitation although sedated in case one, are common symptoms. Two females and
one male do not show aggressiveness. Seven cases out of eight showed evident
mood troubles, not due to a reactive depression, as stated in DSM III, R.. In
my opinion also the case one had them as confirmed by therapy results. Despite
it, none of these subjects was taking antidepressants when they first came to
consultation.
Table 3: drug therapy already prescribed
(daily doses in mg).
|
Drug |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Haloperidol |
|
|
|
|
|
4.5 |
|
|
|
Clothiapine |
60 |
|
120 |
|
|
|
(*) |
|
|
Clopentixol |
25 |
|
|
|
25 |
25 |
|
|
|
Flunitrazepam |
|
|
|
|
2 |
|
|
|
|
Carbamazepine |
600 |
|
|
|
|
|
|
|
|
Levomepromazine |
100 |
|
|
|
100 |
|
|
|
|
Fenobarbital |
|
|
|
|
|
|
|
100 |
|
Delorazepam |
|
|
|
|
|
1.5 |
|
|
(*) unreported doses, because
it varied according the outcome of side-effects.
Previous prescribed therapies mostly use
neuroleptics, save case eight where a barbiturate has to face a form of
epilepsy, probably a temporal form.
Table 4: Parents' requests.
|
Control of the symptom : |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Sleep |
Yes |
Yes |
Yes |
|
Yes |
Yes |
Yes |
Yes |
|
Aggression |
Yes |
Yes |
Yes |
|
|
|
|
Yes |
|
Agitation |
|
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
Excessive eating |
Yes |
|
|
Yes |
|
|
|
|
Parents asked for the help of an adult
psychiatrist for these habitual and disturbing symptoms.
Table 5: Proposed drug therapies (daily
doses in mg, if not otherwise noted).
|
Drugs (newly prescribed) |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Clothiapine |
80 |
10 |
30 |
|
|
|
|
|
|
Carbamazepine |
600 |
100 |
400 |
300 |
|
200 |
100 |
400 |
|
Delorazepam |
|
|
2 |
0.5 |
|
1 |
|
2 |
|
Nortriptyline |
|
|
25 |
|
|
|
|
|
|
Pyridoxine |
|
|
|
15' |
150 |
150 |
75 |
150 |
|
Glutamine + pemoline |
|
|
|
90 + 10 |
|
|
90 + 10 |
|
|
5-hydroxy-triptophan |
|
|
|
50 |
|
|
|
100 |
|
Viloxazine |
|
|
|
50 |
100 |
|
|
100 |
|
Clopentixol |
|
|
|
|
25 |
|
|
|
|
Flunitrazepam |
|
|
|
|
1 |
|
|
|
|
Clonidine (gammas) |
75 |
|
|
|
|
75 |
|
75 |
|
Bromazepam |
|
|
|
|
|
|
0.75 |
|
|
Diazepam |
|
2 |
|
|
|
|
|
|
|
Naltrexon |
|
5 |
|
|
|
|
|
|
|
Clobazam |
20 |
|
|
|
|
|
|
|
|
Amitriptyline |
10 |
|
|
|
|
|
|
|
Compared with the therapies these autistic
adults were taking, I prescribed more modulated therapies, by using 16 drugs
when they had only eight. Of these drugs only two are neuroleptics (12.5%),
instead of four out of eight drugs previously in use (50%).
I prescribed antidepressants (25%) never
tried before and a larger choice of benzodiazepines. As mood stabilizer I used
carbamazepine.
Table 6: Results on leading symptoms at
6 months checkups.
|
Symptom checked |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Case 6 |
Case 7 |
Case 8 |
|
Sleep (before new therapy) |
+++ |
++ |
+ |
+ |
++ |
+++ |
+++ |
++ |
|
(after new therapy) |
+ |
++(#) |
= |
(&) |
+ |
= |
+ |
+ |
|
Mood (before) |
(?) |
++ |
+++ |
++ |
+++ |
+++ |
++ |
+++ |
|
(after) |
= |
++ |
+ |
|
= |
+ |
+ |
+ |
|
Agitation (before) |
+ |
++ |
+++ |
++ |
+++ |
+++ |
++ |
+++ |
|
(after) |
= |
++ |
+ |
|
++ |
= |
= |
+ |
|
Aggression (before) |
+++ |
++ |
+++ |
++ |
|
|
|
+++ |
|
(after) |
+ |
++ |
= |
|
|
|
|
= |
|
Self-aggression (before) |
++ |
|
+++ |
+ |
|
|
|
+++ |
|
(after) |
+ |
|
+ |
+ |
|
|
|
++ |
|
Excessive eating (before) |
+++ |
|
|
|
+++ |
|
|
|
|
(after) |
++ |
|
|
|
++ |
|
|
|
(#) He only took
naltrexon, without noticeable results (Cocchi, 1991); (&) Therapy never
started. (=) normalized behaviour
At six months check-ups I found good
results on all disturbing behaviours, with some variations as for each person,
except a mild improvement of excess eating.
Discussion
We could think that psychiatrists who
prescribed previous drugs faced these troubles like they used to afford
psychotic states of non mentally retarded adults. In fact, they gave them
mostly neuroleptics, aiming to have strong sedative and partly antipsychotic
results.
If such conduct could work in mentally
retarded adults gives a matter of a debate. Even more we can ask ourselves, if
to have simply moved on to autistic adults did the right choice.
As I suggested in my previous study, we
can find three reasons for it have happened
As adult, the 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 and now ask for a minimum.
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, the psychiatrists
follow the guidelines of adults' psychiatry. So they afford the disturbing
behaviours of autistic adults aiming to sedation, and hope this acts at least
on sleep, psychomotor agitation, aggression and self-aggression. Unlucky, 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.
References
American Psychiatric Association:
Diagnostic and statistic manual of mental disorders. Third edition, revised.
A.P.A., Washington D.C., 1987 (Seconda edizione italiana: Masson, Milano 1993).
Cocchi R.: The pharmacological approach
to treating childhood psychoses. Theoretical basis. Ital. J. Intellect. Impair.
1990, 3: 185-193.
Cocchi R.: Esperienze sull'uso del
naltrexone in soggetti autistici. Uno studio clinico. Riv. Ital. Disturbo
Intellet. 1991, 4: 261-266.
Cocchi R.: Autisti diventati adulti: 8
casi. Riv. Ital. Disturbo Intellet. 1994, 7: 241-248.
First printed on It. J. Intellect. Impair.
1995, 8: 169-173
Author's address : dr. Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy)
renatococchi@libero.it
Autism
Mental retardatioń
Drug therapy of stress reactions
Symptoms