Chapter 4 Challenging Behaviour and Autism

4. PEOPLE WITH CHALLENGING BEHAVIOUR

AND / OR AUTISM

Most people are aware that medication is not the answer. We need psychological insights into the causes of the ‘behaviours’. However medication can be very helpful at reducing anxiety and depression which sometimes cause aggressive behaviours. So we need to work on ‘Reactive Strategies’ before resorting to medication. It takes skilled and dedicated care to manage very autistic people, to find out why they behave the way they do. It is easier now they are in smaller units.

Anxiolytics:

Benzodiazepines are the most commonly used medicines for anxiety. They also help reduce a build up of agitated aggressive behaviours. These days we use either lorazepam which is safe, sedative, and short acting or diazepam which is similar but its effects last longer. Continued use can lead to dependence so they will lose their effectiveness if used frequently or regularly over a few weeks. The normal BNF max dose for lorazepam is 4mg in 24 hours. We sometimes use them to sedate before a trip to the dentist or podiatrist. The dose will need to be carefully decided on. There is a PAL for Benzodiazepines

Sometimes SMALL regular doses of antipsychotics can help to relieve the build up of anxiety in autistic people. In the past Thioridazine was used, now it is more likely to be Risperidone. Zuclopenthixol, Chlorpromazine, and Olanzapine are also used. Thioridazine is still licensed in this country but only as a second line drug for schizophrenia--not for anxiety, so we need to be sure that it is the right medication for that person. Its licence was restricted because it may cause heart irregularities so patients on it should have regular blood tests and monitoring of their hearts.

Forensic patients:

These are PLD whose challenging behaviour has led them to be in conflict with the law. This may be due to difficult to manage aggressive and/or inappropriate sexual behaviour. They may have been in secure institutions and are now looked after by us with very strict precautions. Besides antipsychotics and moodstabilizers they may also be on antilibidinal drugs such as cyproterone, to reduce their sex drive. They will cause ‘feminisation’ e.g. increased breast tissue and a typical weight gain and can also cause liver damage. The advantage is that they can leave the secure institutions instead of being there for life.

Moodstabilizers:

These drugs are used to help people who have serious problems with mood swings and irrational aggression. We are not sure how they work but through experience it has been found they can be helpful especially with patients who have aggressive challenging behaviour. It may be caused by an imbalance of chemicals or hormones. Drugs that have been found useful are:

Anticonvulsants e.g. Valproate, Carbamazepine and Lamotrigine

SSRI antidepressants

Beta Blockers e.g. Propranolol as it reduces adrenaline levels

Lithium Carbonate (there is a PAL)

Lithium is a chemical closely related to sodium, which is very common in the body, and maybe it helps to stabilise various chemical reactions. It is most important that people on lithium have regular intake of salt and fluids, not too much and not too little so that a balanced concentration of lithium is maintained in the blood. If anything happens to upset this balance, there is a danger that toxic levels may build up e.g.:

diarrhoea, vomiting (if severe stop and inform doctor)

increased sweating in hot weather (give more drinks)

fever ( “ )

This balance can also be upset by NSAIDs (Non Steriodal Anti Inflammatory Drugs taken for pain), e.g. Ibuprofen (AVOID use Paracetamol instead)

Blood tests are needed every 3 to 6 months to check that the right dose is being used as lithium has a narrow therapeutic window and patients can easily slip into toxic levels. Serum levels should be between 0.4 and 1.0mmol/litre taken 12 hours post dose. The PAL lists signs of Lithium toxicity. We also need to make sure that kidney and thyroid function are healthy.

Antidepressants

Tricyclics (TCAs) There is a PAL

These are the first generation antidepressants e.g. Amitriptyline and Imipramine so called because of their 3 ring cycle structure. They work by blocking re-uptake of Noradrenaline and Serotonin, and blocking Cholinergic and Histaminergic receptors thus increasing the amount of neurotransmitter in the synapse. This causes various side effects e.g. anticholinergic (dry mouth, constipation) histaminergic (drowsiness weight gain), and they are cardiotoxic in overdose.

Selective Serotonin Re-uptake Inhibitors (SSRIs) there is a PAL

These are the new ‘wonder’ drugs like Fluoxetine (‘Prozac®’) you hear of in the papers. They are supposed to only inhibit the re-uptake of 5HT(Serotonin) so we eliminate some of the unpleasant side effects of TCAs. They are safer in over dose, not cardiotoxic, no anticholinergic effects and no weight gain. The main problems are nausea and headaches, which often go after a few days. Fluoxetine is alerting and Paroxetine (‘Seroxat®’) is helpful with anxious depressives. They are also licensed for Obsessive Compulsive Disorder (OCD). When withdrawing these drugs especially Paroxetine it should be done slowly to prevent unpleasant side effects. Citalopram(‘Cipramil®’) is less likely to interfere with the effects of other drugs. The bad press they have had is partly due to how helpful they are and so they have been over used, and we are finding they do not suit everyone.

Serotonin Noradrenaline Reuptake Inhibitor (SNRI) There is a PAL

Venlafaxine (Efexor) is the first one. It inhibits the reuptake of Noradrenaline and Serotonin but unlike the TCAs does not block the Cholinergic or Histaminergic receptors. It is used as a second line antidepressant.

Mono Amine Oxydase Inhibitors (MAOIs) there is a PAL

These are not used much as patients have to be careful with their diet. They inhibit the enzyme Monoamine Oxydase from breaking down neurotransmitters and so increase their availability at the synapse but they interfere with the metabolism of foods containing Tyramine e.g. mature cheese, pickled herrings, marmite and fermented foods and can cause a nasty hypertensive incident which can kill. They are useful if patients do not respond to TCAs. Patients should carry a MAOI card with a list of the foods to avoid. Best to stick to fresh food

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ÓSouth Birmingham Primary Care Trust

Learning Disabilities Service Pharmacy Department

Greenfields Monyhull Birmingham B30 3QQ