PFA Tips: Medication Management and ASD (Part 2)
By Rick Silver, MD, Thrive Emerge
Download a printable version of “Medication Management and ASD (Part 2)”
In this segment, I cover medication treatments for several psychiatric conditions that are often comorbid diagnoses with ASD: depression; social anxiety; sleep; and psychological presentations that masquerade as psychosis and bipolar disorder.
Depression and suicidality
Depression symptoms can include: lower mood; loss of interest, even in things that used to provide joy; low motivation, negative self-talk, hopelessness; and suicidal ideation and actions. Antidepressants have a good track record for helping manage these symptoms and returning the person to improved functioning. Side effects need to be managed carefully. Medications that alter serotonin signaling in the brain, such as Prozac or Viibryd, can create weight gain, fatigue, and sexual dysfunction.
Depression can stem from a number of sources: trauma associated with the developmental challenges of neurodivergence including bullying, academic failures and social struggles; conflicts in the family around neurodivergence; and from genetically-driven brain structures and processes.
If the antidepressants are not fully effective in resolving depression symptoms, the doctor might also prescribe an atypical antipsychotic such as Seroquel or Abilify, which can also play an important role in reducing symptoms of severe anxiety. Used at lower doses than for treating psychotic symptoms, these medications are powerful treatment agents but must be monitored carefully for a variety of side effects.
Suicidality often arises for autistics, stemming from poor self-esteem, hopelessness about the future, and at times, an impulsive response to unmanageable feelings of overwhelm. Antidepressants generally help with the management of these symptoms, but for some people, they could experience an increase of dark thoughts and suicidal ideation.
Frequent communications, access to the treating provider, and support from family are all needed to monitor the success and risks of the treatment.
Suicidal thought can have an acute or chronic nature. Although acute suicidal plans present the most urgent risk to the patient, chronic suicidal ideation is significant as it marks a long-standing, underlying despair about life – a giving up, as it were. That sense of inner emptiness that pervades the person’s experience and diminishes their desire to make life changes, or to believe that changing will make any difference, offers a relatively grim outlook.
It is quite understandable that for autistics who have experienced years or decades of failures and trauma, a chronic, deep sense of hopelessness and vague suicidal ideation is part of their psychological makeup. Medication can play a role here, but these complex perceptions require multiple interventions that establish a sense of belonging and connection, provide successes, and lead toward the development of meaning and purpose in life.
Sleep issues
Sleep problems can be common for autistics and can range from pondering and racing thoughts, sensory sensitivities, sleep apnea and the impact of depression. If chronic sleep problems persist, it is critical that this problem be tackled early in treatment, as the sleep deprived brain will struggle to normalize cognitive and emotional functions and will exacerbate symptoms of ADHD, anxiety and depression.
A wide range of sleep medications exist that can improve sleep onset and duration. Although controversy exists about the value of medicating insomnia over a long period, my practice is to utilize sleep medications as long as is necessary to produce consistent quality sleep foundational to brain and psychological health.
Treating Social Anxiety
Many autistics experience some level of social anxiety, often severe. The primary driver is often the experience of the struggle to “get” neurotypical social interactions and the fear of making social mistakes, not fitting in, and being judged. Avoidance of social engagement is a frequently utilized coping mechanism, despite the impact that poorly-practiced “in real life” social interactions can have on the person’s life functioning.
Although there is no medication that can alter the challenges in social awareness and cueing that are often part of the autistic’s experience, the antidepressants can positively impact social anxiety and markedly alter social functioning. Techniques to improve feeling overwhelmed by social situations include Dialectical Behavioral Therapy and training in specific social skills. A recent patient of mine had severe social anxiety that prevented him from leaving the house over an extended period. The use of an antidepressant allowed him to return to a normal level of social engagement.
Treating Psychological Masquerades
When diagnosing autistics, I often observe symptoms that seem to masquerade as other disorders. But often they are instead phenomena that arise from the unique ways the autistic brain processes sensory and emotional information, or focuses concretely in detail and in less flexible thought patterns. Here are a few examples.
Psychosis
John
“I hear voices”. This patient responded positively and very concretely, without elaboration, to a question of hearing voices. He did not by himself, without prompting, elaborate on when or what he had experienced, to the nuances that help us distinguish between one diagnosis and another. He. Heard. Voices.
On face value, this would be diagnosed as a psychotic experience. But a more subtle understanding was that he was having hypnopompic hallucinations — the sensations that can occur while falling asleep. But without understanding the autistic’s tendency to think in concrete terms, and to have poor interoception — i.e., challenges in sensing and naming internal experiences — a doctor might have moved quickly to an incorrect diagnosis of psychosis and missed the complexity of how the autistic brain processes information.
Ella
Ella’s sensory sensitivities keep her from functioning in socially complex situations. At the airport, she becomes so overwhelmed by sound and movement that she states, “I dissociate. Everyone turns into two dimensional paper people who stop moving, then move a little bit.”
By some criteria, if you report seeing “paper people” at the airport, you are psychotic. But for Ella, this experience was rooted in a highly sensitive and dysregulated sensory system. Her perceptions were actually adaptive in that they briefly allowed her brain to “freeze” when it had an overload of sensory data to process, then returning to what we might recognize as a more neurotypical sensory experience.
A neurosensitive clinician would be familiar with sensory sensitivities — sometimes so severe that they are highly disruptive to an individual’s ability to organize sensory data or to function in a typical manner. Failure to appreciate the fascinating ways that autistic brains experience the world can lead to treatments that are inappropriate, ineffective and potentially even harmful.
Bipolar Disorder
Kathy
The ability to regulate one’s emotional reactions forms the foundation of all other adaptive skills. For Kathy, emotions are hard to manage, with excessive emotional responses that are difficult to bring back to center. Her emotions can swing widely and frequently, disrupting her ability to function.
From some diagnostic perspectives, these “mood swings” bear a resemblance to bipolar disorder and are diagnosed as a “rapid cycling” variant. My observations are that this phenomenon lacks most of the symptoms characterizing bipolar disorder and is better grouped with the many executive dysfunctions so typical of ADHD and ASD.
For some individuals, using stimulant medications — a standard treatment for ADHD — helps the brain organize itself and reduces some of the troublesome emotional variability. A diagnosis of bipolar disorder, on the other hand, would lead us away from this treatment option, since stimulants may increase the risk of a manic episode.
Additional Resources
PFA Tips: Explaining the Autistic Brain
PFA Tips: Medication Management and ASD (Part 1)
Pathfinders for Autism Online Provider Database
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