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Overview of Medications Used in Treatment of Aspergers

Debra Stokan, M.D. :: May 31, 2012 ::

An Overview of Current Medications Used in Treatment of Aspergers Disorder

It has been my pleasure to have been treating patients with Aspergers Syndrome for nearly fifteen years now.  The hallmark criteria of Aspergers Syndrome include constricted areas of interest, difficulty with age appropriate peer relationships and  difficulty reading social cues, facial expressions, and emotional reactions.  In addition, Aspergers Syndrome also contains some “common” symptoms.  One of the “commonly” seen symptoms of Aspergers that I am frequently asked to target includes anxiety.  The anxiety in Aspergers patients can be extremely intense.  I see the anxiety as adding to social problems, interfering with relationships, strengthening rigidity, and fueling agitation and anger outbursts.  Clearly, treating anxiety symptoms can be extremely important in an Aspergers patient’s quality of life.  Without treatment, the extreme rigidity created by high anxiety can make developing improved coping skills nearly impossible.  When change is presented, a combination of anxiety disorders such as Obsessive Compulsive Disorder (OCD) and Panic Disorder create huge roadblocks for both change and problem solving.  These roadblocks frequently complicate therapy or any desired behavioral changes.

In my practice, I may augment the therapy process with medications such as the SSRIs.  This class of medication has long been first line treatment of anxiety due to its efficacy and safety record.  SSRIs, which target Serotonin, include medications such as Prozac, Zoloft, Lexapro, Celexa, and Luvox.  Although these medications are generally well tolerated, I believe patients in the Autistic Spectrum Disorders are more sensitive to medications than most and must be monitored carefully for side effects.

If the SSRIs do not target the anxiety as needed, a second choice may be a trial of Buspar, which targets the GABA receptor but has no risk of dependence.  The Buspar is also generally well tolerated.  A small percentage of patients complain of dizziness, but it is more often stopped due to no clear benefit.  

When Panic Disorder is present, the SSRIs help to prevent it, but the benzodiazepines may be used to stop the intense physical reactions, such as shortness of breath and chest pain.

Another choice to target the anxiety symptoms in Aspergers Syndrome can be the Atypical Antipsychotics, such as Risperdal and Abilify.  These medications are considered “Dopamine Antagonists” but they also target Serotonin in unique ways that can help to alleviate the irrational, intense anxiety disorders seen with Aspergers.  The Atypicals also have the ability to target illogical thinking, misperceptions, and negative thinking that can hopefully decrease both anxiety and agitation.

Although there is evidence that a higher percentage of Aspergers patients than in the general population meet criteria for Bipolar Disorder, I believe the majority of the agitation seen in Aspergers patients is secondary to intense anxiety.  Treating this anxiety can allow patients to develop and utilize strategies to cope in times of stress.  Without treatment, many patients describe the building anxiety as a sensory overload that completely takes over.  During these times, irrational statements, even threats, can be made.  Unfortunately, these threats most often further exacerbate the stress of everyone involved.  This type of overreaction can cause devastating conflict in the home, school, or work environment.  With medication treatment, the intense levels of anxiety may be kept in check to the extent that the strategies can be used to prevent agitation and overreaction.  With this intense level of agitation, the class of medication known as “mood stabilizers” may also be used.

The mood stabilizers may be used both “in addition to” the anti-anxiety medications or “instead of”.  The stabilizers are often used when the Aspergers patient has side effects to the SSRIs, such as agitation or worsening of mood.  The mood stabilizers include medications such as Lamictal, Depakote and Trileptal.  As with all medications in Aspergers patients, they should be monitored closely for side effects and efficacy.  If too strong, a sedated, flattened personality with decreased interest and motivation can occur.

The other “common” symptom of Aspergers Syndrome is inattentiveness, difficulty regulating attention and distractibility (if not engaged in patient’s area of interest).  In the classroom setting, the symptoms of ADHD can be a huge problem.  Upon evaluation of difficulty focusing in the classroom, ruling out anxiety as the original culprit is always step one.  If difficulty focusing persists independent of anxiety, ADHD diagnosis and treatment may be in order.  As with all patients, helping but avoiding side effects is paramount.  In Aspergers patients, not exacerbating the anxiety may be the hardest side effect to avoid.

Fortunately, we have more options currently than in past years.  There are now two classes of non-stimulants approved for use in ADHD.  The two newest medications for ADHD treatment include long acting forms of very old, well known medications, both of which are non-stimulants.  Intuniv is the long acting form of guanfacine that is now approved for ADHD.  Kapvay is the long acting form of clonidine.  Both Intuniv and Kapvay target the “Alpha-2” receptors and work to decrease the adrenergic system.  The short acting forms of these two medications have been used for decades in ADHD, but off label.  New research gives evidence of efficacy in treating impulsivity, hyperactivity and inattentiveness by the long-acting forms. The other “non-stimulant” is the Strattera, which has been out for many years now.

The non-stimulants may be first line in Aspergers Syndrome patients with ADHD because they are least likely to exacerbate the anxiety or mood reactivity.  The non-stimulants are sometimes used in conjunction with the stimulants to help create efficacy with a power stimulant dose.  Although “mono-therapy” is preferred, two medications may work together to target symptoms while keeping side effects lower than with one alone.

Despite the rise of increasing anxiety, the stimulants are still commonly used to treat ADHD symptoms in Aspergers patients.  To ensure efficacy while minimizing the risk of agitation, treating anxiety is often step one to a successful plan involving the stimulant class of medications.