The following excerpt is taken from Chapter Five of
Pervasive Developmental Disorders: Finding a Diagnosis
and Getting Help by Mitzi Waltz, copyright 1999 by
O'Reilly & Associates, Inc. For book orders/information,
call 1-800-998-9938. Permission is granted to print and
distribute this excerpt for noncommercial use as long as
the above source is included. The information in this
article is meant to educate and should not be used as an
alternative for professional medical care.
Although the U.S. Food and Drug Administration has never
approved a drug for the treatment of autism or PDDs, most
of the medical treatments currently available for PDDs
are drugs. Drugs are prescribed to address specific PDD
symptoms, such as difficulty in focusing, hyperactivity,
self-abusive behavior, depression, anxiety, and
uncontrollable aggression. This section discusses the
major types of drugs currently used, and explains why
they work for at least some people with PDDs.
Sometimes medications that have not been formally approved
by government regulators are available under "compassionate
use" laws, including medications that normally would be
available overseas. These rarely apply to PDDs. Some
unapproved drugs may be made available to participants in
human research trials. It is sometimes possible--if not
absolutely legal--for a physician in one country to prescribe
a medication available only overseas, and for patients to
then have the prescription filled at an overseas pharmacy.
Most of the drugs used for PDDs have an effect on the
neurotransmitters, particularly serotonin and dopamine.
They include antidepressants, antispasmodics, neuroleptics
and atypical neuroleptics, and stimulants, among others.
Unless otherwise noted below, most of these medications
have not been specifically tested on people with autistic
Note for non-U.S. readers:
Most of the brand names provided in this article are those
used in the U.S. Brand names and formulations may vary in
other countries, and some drugs may not be available
elsewhere. Conversely, there may be new medications
approved for use in Asia or Europe that have not made
it to North America yet. If you're curious about an
unfamiliar medication, look it up by its generic name
to find the names of non-U.S. equivalents, or ask your
doctor whether something similar is available where you
You might wonder why medications have not been created
specifically for autistic symptoms. Truthfully, with the
past decade's explosion of drugs that work on the
neurotransmitter system, researchers have barely completed
preliminary research on medicines already discovered that
might help people with PDDs. "Investigation is still
warranted into the drugs that we do have available to
see in which clinical population drugs are going to be
effective," says Dr. Potenza. "There have been significant
advances in regards to our abilities to target specific
symptoms," he added, but more research is needed. It's
likely that the next decade will bring psychiatric
medications that target specific neurotransmitters
more precisely, improving the quality of medical treatment
nd reducing side effects.
Some people with PDDs are clinically depressed, but that's
not the only reason these drugs are increasingly used in
autistic spectrum disorders. Low levels of serotonin, or
problems in regulating the amount of or use of serotonin,
are believed to be one of the root causes of autistic
symptoms. Various antidepressants may also affect the
production or use of other neurotransmitters. And these
drugs do not affect the brain alone: the same
neurotransmitters are also involved, if not always so
directly, in carrying regulatory messages to the immune
system and the gastrointestinal tract. They can even
change the way a person perceives pain. Properly used,
antidepressants can create global changes.
Today's antidepressants are much more advanced than those
used just a decade ago, but they're still a blunt instrument
for attacking brain dysfunction. There are several different
types, and within each group related medications may function
quite differently. That's why you shouldn't write off a whole
family of drugs just because one was a disaster. A slightly
different medication may turn out to be infinitely
All of the antidepressants should be used with care. Check
package inserts and pharmacy information sheets to avoid
interactions with other medications. Be sure to tell your
doctor about any over-the-counter drugs you use, even
aspirin, herbal medicines, or supplements.
Selective Serotonin Reuptake Inhibitors (SSRIs)
The brain is chock-full of serotonin receptors, tiny sites
that bind with serotonin molecules to move chemical impulses
through the brain. The SSRIs block certain receptors from
absorbing serotonin. Researchers believe this results in
the brain. Overtime, SSRIs may cause changes in brain
chemistry...hopefully in the direction of improved
changes in brain structure with prolonged use. There are
also receptor sites elsewhere in the central and peripheral
nervous systems, so SSRIs can have an impact on saliva
production, appetite, digestion, skin sensitivity, and
many other functions.
Five drugs are currently considered to be part of the
These medications are not identical in either their
chemical composition or their effects on the brain.
Prozac and Zoloft tend to have an energizing and focusing
effect as well as reducing depression, for example, while
Paxil may calm anxious or agitated patients who are also
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- sertraline (Zoloft)
- citalopram (Celexa)
Each SSRI has major or minor side effects of its own--for
adults, sexual dysfunction is often the greatest concern.
There are two serious side effects you should be aware
of when starting to use SSRIs, or increasing SSRI dosage.
First, SSRIs can trigger manic episodes in some
people with bipolar disorder ("manic depression"). Manic
episodes may be characterized by non-stop talking
("pressured speech"); grandiose thoughts, speech, and
actions; paranoia; lack of need for sleep; flight of ideas;
uncharacteristically risky behavior; and hyperactive
movements. This effect is most often seen when SSRIs are
used to treat depression in a person who actually has
bipolar disorder rather than simple, unipolar depression.
An acute manic episode can be dangerous to the patient's
health, not because of any physical effect but due to the
impulsive, extreme behavior that may occur during the
Second, people who use SSRIs in overly high doses--or mix
them with other medications that potentiate (increase)
their effects, including herbal remedies like St. John's
Wort--run the risk of serotonin syndrome. When the
brain has too much serotonin, patients may experience
shivers, headaches, diarrhea, profuse sweating, confusion,
and a "jumpy" feeling that's intensely uncomfortable. If
this happens, stop taking the SSRI immediately and see your
doctor without delay. In extreme cases, serotonin syndrome
can be fatal, although no fatalities have yet been reported
from the combination of an SSRI and St. John's Wort.
Before Prozac became famous, the tricyclic antidepressants
were the wonder drugs for depression and Obsessive-
Compulsive Disorder (OCD). They are still the best choice
for some patients, although today doctors will usually try
an SSRI or two first. There are several tricyclic
antidepressants, many of which combine more than one
Of these, only clomipramine and nortriptyline are used
with any regularity by people with autistic-spectrum
disorders. Clomipramine is particularly helpful for
treating obsessive-compulsive behaviors. Along with
treating depression and OCD, these tricyclics may help
with nighttime bed-wetting, appetite, sleep, alertness,
anxiety, and hyperactivity.
- amitriptyline (Elavil)
- amitriptyline/perphenazine (Etrafon, Triavil)
- amitriptyline/chlordiazepoxide (Limbitrol)
- amoxapine (Asendin)
- clomipramine (Anafranil)
- desipramine (Norpramin)
- doxepin (Sinequan)
- imipramine (Tofranil)
- nortriptyline (Avenytl, Pamelor)
- protriptyline (Vivactil)
- trimipramine (Surmontil)
The tricyclic antidepressants work by inhibiting the
uptake of various neurotransmitters at adrenergic nerve
terminals, resulting in an increase of monoamine
These drugs require regular monitoring for heart problems
and other potentially serious side effects. They can lower
the seizure threshold. As with the SSRIs, there is a
danger of sending people with bipolar disorder into a
manic phase. Some patients also complain of excessive
Two serious side effects are associated with some
tricyclics. The first is neuroleptic malignant
syndrome (NMS). This potentially fatal condition
is characterized by rigid muscle movements, fever,
irregular pulse and heartbeat, rapid heartbeat,
irregular blood pressure, heavy sweating, and strange
states of mind. Discontinue the medication immediately
and call your doctor if these symptoms occur. In
extreme cases, the patient may need emergency care at
a hospital. Physicians should report episodes of NMS
to the Neuroleptic
Malignant Syndrome Information Service, which has set
up a registry to help researchers reduce the incidence
of this problem.
Tricyclics may also carry a risk of Tardive
Dyskinesia, an irreversible muscle movement disorder
more usually associated with long-term use of the older
neuroleptic drugs, such as Haldol. Between 20 percent
and 30 percent of long-term neuroleptic users eventually
develop this disorder, which is characterized by twisting
motions of the hands and feet, and smacking or chewing
movements of the mouth. It is hoped that some new
medications may help patients prevent or treat this
permanent side-effect. Some physicians recommend that
people who take drugs that carry a risk for TD also take
Vitamin E supplements, which appear to stave off the
disorder in some people.
Three Monoamineoxidase Inhibitors (MAOIs) are currently
available in the U.S. These medications address
depression by inhibiting the metabolization of the
neurotransmitters serotonin, norepinephrine, and dopamine:
MAOIs are rarely prescribed for people with PDDs, and
are not used to treat depression as often as they once
were. MAOIs can have unpleasant and even life-threatening
interactions with many other drugs, including common
over-the-counter medications. People taking MAOIs must
also follow a special diet, because these medications
interact with many foods. The list of proscribed foods
includes chocolate, aged cheeses, beer, and many more.
- moclobemide (Aurorex)
- phenelzine (Nardil)
- tranylcypromine sulfate (Parnate)
If you or someone you care for is taking a MAOI, check
for warning labels on everything, and familiarize
yourself thoroughly with the dietary restrictions.
MAOIs can also produce hallucinations, and have been
abused by some drug users to get this effect.
The drug buproprion (Wellbutrin, Zyban) is a unique
aminoketone antidepressant. It appears to have mild
effects on serotonin, dopamine, and norepinephrine, and
it also seems to be a mild general CNS stimulant. It
may help with symptoms of depression and ADHD.
Lithium carbonate and lithium citrate (Eskalith, Lithane,
Lithobid, Lithonate, Lithotabs) are different from all
other antidepressants, because they can control bipolar
disorder. Made from a naturally occurring salt, lithium
is probably the oldest psychiatric remedy on earth.
Natural lithium springs were frequented by Native Americans
and ancient Europeans alike.
Lithium users need to have blood tests at regular intervals
to monitor heart and kidney function, and to make sure the
dose is at a therapeutic level. When this drug is taken
with a neuroleptic, doses and side effects must be
watched very carefully. There is a danger of encephalopathic
syndrome with this combination. Encephalopathic syndrome's
symptoms mimic those of neuroleptic malignant syndrome,
of which it may be a variant. Lithium can be toxic in doses
that are not much higher than the therapeutic dose. Despite
these cautions, for most patients who experience extreme
mood swings, lithium is well-tolerated and provides relief.
Described by its manufacturer as a Noradrenergic and
Specific Serotonergic Antidepressant (NaSSA), mirtazapine
(Remeron) affects the neurotransmitter noradrenaline as
well as some serotonin receptors. It has both energizing
and anti-anxiety effects. It may have ill effects on white
blood cell counts in some people, depressing the immune
system. If you experience fever, aches, sore throat, or
infections, call your doctor.
Nefazodone (Serzone), another unique antidepressant,
blocks the uptake of serotonin and norepinephrine in
the brain. It also increases the levels of two natural
antihistamines in the bloodstream.
Reboxetine, marketed under the brand name Edronax in the
U.K., is a brand-new antidepressant classified as a
non-tricyclic selective Norepinephrine Reuptake Inhibitor
The antidepressant venlafaxine (Effexor, Effexor XR) is
also in its own category. It limits absorption of at least
three neurotransmitters: serotonin, norepinephrine, and
dopamine. Some people who have not tolerated SSRIs well
have had better results with Effexor.
The National Alliance for the Mentally Ill is one of the
best resources for information on new drugs for
neurological disorders. Its Web site, http://www.nami.org/, often has "reviews" of
new drugs, and previews of medications that are undergoing
St. John's Wort, an herbal supplement billed as a
"natural" anti-depressant, has been in the news lately.
It's important to know that some natural substances may
act on the neurotransmitter system like prescription
antidepressants. St. John's Wort is one with a very real
track record in European clinical trials, and as mentioned
above, lithium salts also occur in nature. Inositol,
a component of lecithin, also has a growing track record.
Based on reported effects and clinical trials, St. John's
Wort appears to combine aspects of the SSRIs and the MAOIs.
For that reason, it should be taken with the same care and
caution as these types of prescription drugs. There have
been anecdotal reports of patients with manic episodes
attributed to St. John's Wort, or (more rarely) with
unpleasant food or medicine interactions like those that
can occur when taking MAOIs. There have been documented
instances of serotonin syndrome associated with St. John's
Wort, generally when a patient taking a prescription
antidepressant "supplemented" it with this herbal remedy.
Recent reports implicate this herb in temporary nerve
damage, which can occur if the patient stays in the sun
too long. Melatonin, a supplement used to regulate sleep,
may also affect serotonin. Be sure to tell your doctor
about any supplements, herbal medications, or folk
remedies you add to your medication regimen.
Perhaps one of the most important natural anti-depressants
is sleep. Researchers speculate that at least some of the
positive effects attributed to anti-depressants are
actually due to their sleep-inducing powers. Lack of
adequate sleep is a powerful depressant, and sleep
disturbances are often the first sign of impending
depression. People with PDDs frequently have unusual
sleep schedules, sleep disturbances, or full-fledged
sleep disorders. Medications, exercise, relaxation
techniques, and scheduling adjustments can help you get
control over these problems. Proper sleep can make a
huge difference, and it's best if you can achieve it
Daily activities can be powerful mood-enhancers as well,
from eating a healthful diet to cultivating interests that
occupy the troubled mind. Scheduling, even right down to
fifteen-minute blocks, can provide daily motivation and
the reward of purposeful activity. This is precisely the
approach to depression used by the best institutions for
the mentally ill, in concert with medication and "talk
therapy." You can take these preemptive steps to keep
your general physical and mental health in balance, and
they may enhance your immune system functions as well.
I think that you should try to find things that are fun
for you, like work and school, a class that you really
look forward to. That will help you, because you'll have
a reason to go to sleep at bedtime. And eat breakfast,
it really helps! --KayCee, age 16 (diagnosed OCD and bipolar
Most of the drugs prescribed for anxiety are in the
benzodiazepine family of tranquilizers. Some of these
medications may also help to prevent seizures and ease
depression. They include:
Doctors try to avoid prescribing tranquilizers for
long-term use. These drugs slow down CNS activity,
they often don't mix well with some other medications,
and they can be addictive. However, for patients with
severe anxiety, benzodiazepine tranquilizers can be very
effective. Some people can take these on an "as-needed"
basis, avoiding medication dependency.
- alprazolam (Xanax)
- chlordiazepoxide (Librium)
- clonazepam (Klonopin)
- clorazepate (Tranxene)
- diazepam (Valium)
- lorazepam (Ativan)
- oxazepam (Serax)
- prazepam (Centrax)
Buspirone (BuSpar) is a non-benzodiazepine anti-anxiety
drug and tranquilizer. Because it doesn't carry the
addiction risk of a benzodiazepine, it may be preferable
for some people. Four small studies have shown that BuSpar
may be useful for reducing aggressive behavior,
hyperactivity, and stereotypic movements in people with
autistic symptoms. However, anecdotal reports indicate
that some patients find this medication difficult to
Buspirone is available as a transdermal patch as well as
a pill. The patch has been tested for use in children,
and was found to address hyperactivity in some with less
of a "rebound effect" than amphetamines like Ritalin.
Sometimes BuSpar is added to an SSRI to prolong its
Although seizures are not part of the DSM IV definition
of Pervasive Developmental Disorders, many people with
PDDs have seizures, and seizures can have a deleterious
effect on neurological function. In some cases, seizures
may be the root cause of a PDD, as in the case of
Kyle was on Depakote for seizure control [from] ages
five to seven. This controlled seizures. One seizure, in
which he was non-responsive for twenty or thirty seconds,
caused our son to lose all expressive language for a week.
Other symptoms of minor seizures included rapid eye
movements back and forth for two to four seconds, followed
by laughter or crying. These were controlled by Depakote,
which may have helped preserve gains made by taking
Prednisone. --Joe, father of seven-year-old Kyle
(diagnosed PDD-NOS with autistic features)
For that reason--and also because seizures can be
intensely uncomfortable, embarrassing, and dangerous for
patients--seizure control is often the first line of business
when they occur with PDDs. Commonly used antispasmodic
(seizure-control) medications include:
Tegretol and Depakote are probably the anticonvulsants
used most commonly in people with PDDs, mostly because
there is quite a bit of information available about how
these drugs work in concert with other psychiatric
- carmazepine (Tegretol)
- clonazepam (Klonopin)
- ethosuximide (Zarontin)
- ethotoin (Peganone)
- fosphenytoin (Cerebyx)
- gabapentin (Neurontin)
- lamotrigine (Lamictal)
- mephenytoin (Mesantoin)
- phenobarbital (Luminol, Solfoton)
- phenytoin (Dilantin)
- primidone (Mysoline)
- toiramate (Topamax)
- valproic acid (Depakene) and
- divalproex sodium (Depakote, Depakote Sprinkles)
Phenobarbital can be addictive, and at too-high doses
can produce an effect that looks like alcohol intoxication.
For these reasons, it is rarely used anymore, except in
low doses or as part of a combination that includes a newer antispasmodic.
Antispasmodics are often prescribed in combinations, as
two can be more effective together than one. However,
mixing drugs can increase the risk of side effects.
Monotherapy (treatment with a single drug) is
believed to be the best choice whenever possible.
Some forms of epilepsy may also be treated with a
combination of steroids, such as Prednisone, and
antispasmodics. Steroids tend to cause weight gain and
mood swings, and they suppress the immune system. Unless
nothing else works, steroids should be avoided.
This relatively new anticonvulsant has been getting rave
reviews from patients. It appears to have fewer side
effects than the rest, and can be used as an adjunct to
these and other drugs. Not only does it provide seizure
control, but it also helps level the mood swings
experienced by some patients with bipolar disorder or
severe episodic aggression.
Other ways to address seizures
Adolescent and adult patients with seizures can often make
lifestyle changes that reduce the number or severity of
episodes. One of the most important of these is becoming
aware of environmental triggers. Avoiding discos with
strobe lights, certain types of carnival rides, and
uncontrolled stress, for example, can be helpful. Learning
relaxation techniques, such as meditation or biofeedback,
is another good step.
Some people with seizure disorders have reported
beneficial effects from special diets and supplements,
particularly from vitamin B6, and the supplements lecithin
and DMG. These claims have been partially substantiated in
small studies. One intervention that can definitely help in
extreme cases is the ketogenic diet. This high-fat,
low-protein, low-carbohydrate regimen has proved very useful
for some young children with epilepsy, although it's a less
than pleasant experience for the patient and should
never be undertaken without medical supervision.
In a very few cases, seizure disorders cannot be
controlled with medication, diet, or other efforts.
Surgery may be considered. A new procedure involves
implanting a small device called a vagus nerve stimulator
in the chest.
People with uncontrolled epilepsy must take steps to
prevent harm during a seizure. They may need to wear a
helmet, change their surroundings, or avoid driving a car.
Antispasmodic drugs for aggression or SIB
Physicians may also prescribe antispasmodic medications,
particularly Depakote (and now Neurontin), to treat
uncontrolled aggressive or self-injurious behavior (SIB)
rather than seizures per se. Sometimes this approach works,
perhaps because the aggressive episodes are set off by
seizures deep in the brain. These subclinical seizures
may be affecting areas of the brain that control behavioral
inhibition, emotion, or the "fight or flight" response.
It's also possible that some antispasmodics have other,
as yet unknown, effects on brain chemistry.
The stimulant drugs have a generally energizing effect on
the "normal" brain and body, but in many hyperactive
individuals they appear to even out brain activity,
calming the person down and allowing them to focus their
attention more appropriately. It's believed that these
drugs increase how much dopamine and norepinephrine are
released from the sympathetic nervous system, and inhibit
uptake of these neurotransmitters by the caudate nucleus.
They also increase the flow of blood to all parts of the
Stimulants are the drugs most frequently prescribed to
children with PDDs, despite the fact that no studies of
stimulant use have been done in this population. In fact,
the Autism Research Institute's database indicates that
many autistic-spectrum patients have bad reactions to
stimulants, including increased hyperactivity, aggression,
and stereotypic behaviors or tics. Out of 2,788 families
who replied to a survey question about Ritalin, 45 percent
reported that it made their autistic children's behavior
Some researchers believe that stimulant use can cause
brain damage. Certainly this is sometimes the case with
illegal amphetamines. Ritalin has been in use for ADHD for
quite some time now, but there still isn't much information
available on the effects of long-term use.
Stimulants may be appropriate for some people with PDDs,
however. If you choose to try them, start with a small dose
and titrate very slowly for the best effect.
Miles has been on Ritalin since the age of five. It has
enabled him to learn in a classroom environment, and to
reduce the incidence of unsafe behaviors. We tried
Dexedrine for about three months, it depressed Miles' mood
significantly. --Amy, mother of seven-year-old Miles
(diagnosed PDD-NOS and ADHD)
Some people (including quite a few doctors) swear that
the brand-name Ritalin is superior to its generic
counterpart. It may be worth trying the brand-name version
if the generic didn't work well.
Stimulants that may be prescribed for symptoms of PDDs
These drugs work pretty much the same way, but for
different lengths of time and with varying danger of
the dreaded "rebound effect." This phenomenon's symptoms
range from manic-like euphoria to depression or
- dextroamphetimine sulfate (Das, Dexampex, Dexedrine,
Dexedrine Spansules, Dextrostat, Ferndex, Oxydess)
- dextroamphetimine/amphetamine (Adderall)
- methamphetamine (MTH)
- methylphenidate hydrochloride (Ritalin)
- pemoline (Cyclert)
The rebound effect can be rather nasty, but it's easily
solved with careful dosing. Ritalin is the shortest-acting
stimulant, and therefore the one with which the greatest
amount of rebound trouble occurs. Doctors often ask that
it be given at two-and-a-half to three-hour intervals,
with half of a regular dose at bedtime to permit better
sleep. A sustained-release version of Ritalin (Ritalin SR)
is available, but gets low marks from patients when used
alone. Dexedrine has a longer life (four to six hours),
and the Dexedrine Spansule formulation can maintain its
beneficial effects for up to eight hours.
Adderall is not as well-known as Ritalin, but it may be
a better choice for many patients. It time-releases
different amphetamine compounds smoothly over several
hours, resulting in less chance of rebound.
Cyclert has a long action period, but is rarely used
unless all of the others have failed to have positive
effects. Regular liver monitoring is a must with this
Stimulants and tic disorders
There is a persistent myth that stimulants can cause
tic disorders, including Tourette's syndrome. Studies
indicate that this is not so: many children diagnosed
with ADHD before the school years will go on to evidence
signs of a tic disorder later on, often around the age of
seven, regardless of whether stimulants are used or not.
The two conditions appear to be related, and often occur
in the same families or the same individuals. Stimulants
are often prescribed around the age of five, hence the
appearance of a "cause and effect" relationship between
stimulants and tics.
It is possible that stimulants cause tics to appear
sooner than they would have otherwise, or that they make
tics worse. Many people with Tourette's syndrome avoid
stimulants because they have found this to be the case
Note to non-U.S. readers: Stimulants are not used
as widely in Europe as they are in the U.S. for conditions
other than narcolepsy. Patients in the U.K. and France may
experience particular difficulty in obtaining any
prescription medication for hyperactivity, regardless
of how severe the problem is. Persistence--and seeking out
a doctor who specializes in treating ADD/ADHD or who has
experience in using stimulants with PDD patients--seems to
be the key.
Stimulants and addiction
Ritalin and similar stimulants are now among the
medications most frequently prescribed to children in
the U.S. Many parents fear that this widespread use of
amphetamines could lead to addiction to street drugs
Dr. Maria A. Pugliese, a Board-Certified Psychiatrist
with added qualifications in Addiction Psychiatry at
Pennsylvania Hospital and the Malvern Institute, says
their fears are largely unfounded. "The biggest risk of
addiction in children with ADD/ADHD comes from their
genetic inheritance, not from their exposure to stimulant
medication," says Dr. Pugliese. "There is a large crossover
between families with ADD/ADHD and families with addictive
The greatest danger of prescription stimulant abuse occurs
in junior high, when friends, siblings, or even parents may
poach the patient's pills to get an illicit high.
"There are many safeguards built into the system to protect
the public from stimulant abuse," Dr. Pugliese notes. "All
stimulants except Cyclert are Schedule II drugs, meaning
they must be written prescriptions, not phone-ins; they must
be filled within seventy-two hours of being written, and
there are no refills allowed without a new prescription.
There are no indications that the stimulants that are
prescribed for children with ADD/ADHD are addictive by
themselves in therapeutic doses."
Parents need to make sure that proper safeguards are in
place when medications are stored at home and at school.
There have been many cases of theft or accidental use,
sometimes with tragic results.
As for the fear that kids given stimulants or other
psychiatric medications will come to think pills are the
answer to all ills, says Dr. Pugliese, education is the
answer--and it works. "Children come to learn quite early
the difference between medications and 'drugs', because
of schools' drug education and awareness programs," she
says. "By the end of elementary school they are able to
say the medication is 'good' and 'helps you get better',
and that 'drugs' are 'bad for you' and 'make your life
sad'." In addition, she notes, "if they have a serious
psychiatric illness, they are much less likely to develop
an addiction problem as an adult if their psychiatric
illness is well-treated in childhood."
Some patients and parents have experimented with
over-the-counter stimulants, particularly
phenylpropanolamine (PPA). PPA is present in "diet pills",
usually in combination with caffeine. PPA is also found in
a number of common medicines, especially cold remedies.
While benefits have been reported anecdotally, these
medications can be dangerous if misused or mixed with
other drugs. They are certainly not advised for anyone
with a heart condition, or whose heart function has never
Side effects reported include high blood pressure,
nausea, restlessness, anxiety, insomnia, irritability,
and hallucinations. There have been cases of death,
generally due to heart attack, from OTC stimulants based
on PPA, ephedrine (or the herb Ephedra, also called Ma
Huang, from which it is made), or even caffeine. If you
insist on using these stimulants, tell your doctor, and
monitor side-effects carefully.
The neuroleptics are also known by slightly scarier
name anti-psychotics. These medications are used
to treat a wide variety of serious mental illnesses, but
they are certainly not limited to the treatment of outright
psychosis. Most of these medications affect dopamine
production or absorption; some also work on serotonin or
The very first neuroleptics were discovered in the 1950s
and 1960s, and represented the first major breakthrough in
medical treatment for mental illness. However, the excitement
was short-lived when the results of long-term use and
verdose were discovered. Many of these older medications are
still prescribed for people with PDDs today, however. They
Although for some patients they may be the only viable
choice, knowledgeable physicians no longer use these
older neuroleptics first. The atypical neuroleptics are
infinitely preferable, if anything this strong is needed
- chlorpromazine (Thorazine)
- diphenylbutylpiperdine (Pimozide or Orap)
- fluphenazine (Prolixin, Prolixin Decanoate)
- haloperidol (Haldol, Haldol Decanoate)
- loxapine (Loxitane)
- mesoridazine (Serentil)
- molindone (Moban)
- perphenazine (Trilafon)
- prochlorperazine (Compazine)
- thioridazine (Mellaril)
- thiothixene (Navane)
- trifluoperazine (Stelazine)
- triflupromazine (Vesprin)
People involved in the care of institutionalized patients
have noted that the older neuroleptics are used more often
in these settings than one might think, possibly as a way
to control patients in understaffed or poorly run
facilities. Psychiatric nurses derisively refer to this
approach as "using a chemical straightjacket." If you care
for an institutionalized person, the potential for misuse
or overuse of neuroleptics is something you should be on
the lookout for.
The so-called atypical neuroleptics are recent
discoveries. They blend functionality against
schizophrenia, psychosis, self-injurious behavior, painful
ticcing, and other major mental-health symptoms with far
fewer side effects and dangers than their ancestors.
Patients currently taking older neuroleptics should
definitely ask their physician about making a switch.
The atypical neuroleptic family includes:
Of these, risperidone and olanzapine have gotten the
most attention for their beneficial effects on some
people with PDDs. The two are similar in that they both
target serotonin and dopamine receptors, but there are
subtle differences. Perhaps they each block different
receptors. Several recent studies have pronounced these
two medications to be reasonably effective for problems
ranging from Tourette Syndrome with rage attacks to severe
- clozapine (Clozaril)
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- quetiapine (Seroquel)
- ziprasidone (Zeldox)
Side effects to watch out for with all neuroleptic
drugs include agranulocytosis (a dramatic drop in
white blood cell count), Neuroleptic Malignant Syndrome
and Tardive Dyskinesia, and withdrawal dyskinesias
(temporary episodes with symptoms similar to Tardive
Dyskinesia, which occur when the medication is stopped).
Neuroleptics may also cause extrapyramidal side
effects (EPS). Physical symptoms include tremor,
slurred speech, akathesia (an intensely uncomfortable
itchy, jumpy sensation that may make the patient move
around incessantly), and dystonia (uncontrollable
muscle contractions). Emotional symptoms include anxiety,
distress, paranoia, and bradyphrenia (slow thought
processes).These are serious problems, the kind that
understandably make patients want to stop taking their
medicine. Careful medication choice and dosage adjustment
should reduce these problems, and complimentary adjustments
to diet, vitamins, supplements, and relaxation techniques
may also help.
Excessive weight gain is also a common problem with
both older and atypical neuroleptics.
A few medications that don't fit into one of the categories
above have proved useful for some people with PDD-NOS or
Atypical PDD, or are currently being investigated.
Foremost among these are two drugs more commonly used to
treat high blood pressure:
These drugs act on the nervous system to dilate blood
vessels, presumably increasing the flow of blood in the
brain as well as in the rest of the body.
- catapres (Clonadine)
- guanfacine (Tenex)
Clonadine or Tenex are often used to curb hyperactivity
when stimulants don't work, or can't be combined with
other medications. Both may also help curb aggression.
Clonadine is available in pill or patch form, although
only the pill is available as a less-expensive generic.
Patients generally prefer the patch. It's easier to use,
and pill users tend to experience sleepy "crashes" as the
medication is first absorbed in the bloodstream. The crash
effect can interfere with school or work.
The Clonadine pill was definitely a wash. Our son was out
like a light by ten a.m., and napped for well over an hour.
We saw great improvements in his ability to pay attention,
stay on task in class, and clamp down on his own
inappropriate, impulsive behavior, but we had to go to
the patch instead so he wouldn't sleep through first grade.
The patch tends to fall off before it should, but it's a
much smoother medication.
When using the Clonadine patch, place it on a part of the
body where it's likely to stay and be properly absorbed.
Adults usually prefer the upper arm. For children,
hard-to-reach areas on the back work well. The foam-like
overlays packaged with this medication don't work very
well, so you may have to buy your own overlay bandages to
get the patch to stick. Clonadine users report that the
best overlay is the transparent film dressing Tegaderm,
although it's expensive. They haven't worked for everyone,
but the extra-large semi-transparent "Tattoos" bandages
made by Nexcare often do a good job at a lower cost.
Both Clonadine and Tenex can affect heart function and
blood pressure, so regular monitoring is a must. Neither
medication can be stopped suddenly, due to the risk of a
dangerous drop in blood pressure.
These medications are most often used as part of a
comprehensive detoxification program for addiction to
drugs and alcohol, but some doctors feel they may have a
role in addressing some symptoms of PDDs. The opioid
antagonist naltrexone (ReVia, Trexan, or NTX) has been
used by autistic children in several studies, with mixed
results. A subgroup of people with autism are definitely
helped by this drug, and it appears to be especially
effective in cases of SIB.
Recent studies have shown that nicotine can
potentiate (increase the efficiency of)
neuroleptics, and may have other beneficial effects.
This does not mean that people with PDDs should take up
smoking! Quite the contrary: smoking has serious health
risks, and doesn't deliver a controlled dose of this
potent drug. The nicotine patch is preferred.
People with PDDs who do smoke or chew tobacco need
to be aware that nicotine use can affect the potency of
psychiatric medications, and take precautions accordingly.