Dec 4, 2014
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Wondering what, if any, other med option ideas folks might entertain for the following situation - someone with moderate ID, OCD, ASD, getting excellent comprehensive behavioral supports but driven/OCD-like behaviors have been extremely increased past couple of months. Already on SSRI and abilify; clomipramine or anything else requiring EKG probably not an option. This is not a client of mine; I just recently sat in on a meeting where it was being discussed and have been pondering the situation since and curious if there even are any other med options that might be considered in such a situation -- SSRIs and occasionally clomipramine are the only Rx that I have seen in my IDD folks with OCD thus far, but OCD isn't something I see super frequently, and certainly not driven to this extreme, so curious to learn more.
 

thoffen

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Is this someone with well-established OCD with clearly traceable childhood anxiety origins? Or possibly treatment-emergent OCD. Abilify not so much tied to this and even some data suggesting benefit (not my personal experience), but worth noting.

Otherwise, switch SSRI to fluvoxamine. Unsure if this could be a person who could do exposure/response prevention therapy. If it's legit moderate intellectual disability, probably not.
 
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singasongofjoy
Dec 4, 2014
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Is this someone with well-established OCD with clearly traceable childhood anxiety origins? Or possibly treatment-emergent OCD. Abilify not so much tied to this and even some data suggesting benefit (not my personal experience), but worth noting.

Otherwise, switch SSRI to fluvoxamine. Unsure if this could be a person who could do exposure/response prevention therapy. If it's legit moderate intellectual disability, probably not.
Thanks for your thoughts!

Abilify not Rx for OCD - just thought it might be relevant. Increase in long-present anxiety due to several major life changes in past few months... everyone's hope seems to be if everyone can get through the next several months, things will return to baseline. There's also an increase in driven behavior related to ASD/special interests that have been similarly problematic.
 
Mar 24, 2014
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Thanks for your thoughts!

Abilify not Rx for OCD - just thought it might be relevant. Increase in long-present anxiety due to several major life changes in past few months... everyone's hope seems to be if everyone can get through the next several months, things will return to baseline. There's also an increase in driven behavior related to ASD/special interests that have been similarly problematic.
Just saw that you posted this while I was writing my response. Seems to align :) Also, with the major life changes, one of them could be one of the prior coping tools or mitigating factors. Change in relationships can be huge for these individuals.
 
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thoffen

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There is some data on n-acetylcysteine for OCD. Might be worth a try given low likelihood of side effects.
Interesting given data on autism and aggression.
 
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singasongofjoy
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He wasn't saying that. He was saying that antipsychotics in general have been linked to worsening OCD symptoms.
Ah, i see. Thank you for the clarification. That is certainly a useful bit of knowledge for me in this field. If I learned that in my bio psych class, it didn't stick in there well enough. Thanks!

Anyone have recs for books or websites that might be good psychopharm reading / reference for a psychologist to keep on hand, either in general or particularly for one working in IDD?
 
H

HarryMTieboutMD

Wondering what, if any, other med option ideas folks might entertain for the following situation - someone with moderate ID, OCD, ASD, getting excellent comprehensive behavioral supports but driven/OCD-like behaviors have been extremely increased past couple of months. Already on SSRI and abilify; clomipramine or anything else requiring EKG probably not an option. This is not a client of mine; I just recently sat in on a meeting where it was being discussed and have been pondering the situation since and curious if there even are any other med options that might be considered in such a situation -- SSRIs and occasionally clomipramine are the only Rx that I have seen in my IDD folks with OCD thus far, but OCD isn't something I see super frequently, and certainly not driven to this extreme, so curious to learn more.
The first thing is to be clear on phenomenology. Is it really OCD or is it autistic rigidity/restricted-repetitive behaviors? If his lifelong "anxiety" (highly comorbid with autism) is worsening it could really be either. In talking to some of the ASD experts in our department the key phenomenological difference is ego dystonicity in OCD. DSM IV made diagnosing both pretty restrictive, but there is more laxity in DSM 5. Was there a pediatric YBOCS done?

In terms of treatment it depends on phenomenology again. If it is OCD agree with switch to Luvox. Also it is not true that antipsychotics in general worsen OCD symptoms; this depends on D2 vs 5HT2 blockade. The stronger D2 blockers (Haldol, risperdal) tend to alleviate obsessions, whereas the stronger 5HT2 antagonists (clozapine) tend to worsen or even cause them (have several patients with clozapine emergent obsessionality). So, you could also change Abilify to risperdal because it could help with both autistic aggression and obsessionality.
 
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singasongofjoy
Dec 4, 2014
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503
Status
Psychologist
The first thing is to be clear on phenomenology. Is it really OCD or is it autistic rigidity/restricted-repetitive behaviors? If his lifelong "anxiety" (highly comorbid with autism) is worsening it could really be either. In talking to some of the ASD experts in our department the key phenomenological difference is ego dystonicity in OCD. DSM IV made diagnosing both pretty restrictive, but there is more laxity in DSM 5. Was there a pediatric YBOCS done?

In terms of treatment it depends on phenomenology again. If it is OCD agree with switch to Luvox. Also it is not true that antipsychotics in general worsen OCD symptoms; this depends on D2 vs 5HT2 blockade. The stronger D2 blockers (Haldol, risperdal) tend to alleviate obsessions, whereas the stronger 5HT2 antagonists (clozapine) tend to worsen or even cause them (have several patients with clozapine emergent obsessionality). So, you could also change Abilify to risperdal because it could help with both autistic aggression and obsessionality.
I see the guy occasionally, but he's not one of my guys so I can't speak to the phenomenology specifically, but my impression is that in this case it may very well be both. CYBOCS parent report - he is probably too old for that to have been done, but to hear staff and clinicians talk about his history, seems to be clear history of obsessions w distress/compulsions that relieve distressing thoughts in addition to the RRBIs.

He fairly recently cross-tapered from risperidone to abilify - I'm not sure what the reason for the change was - & I've been looking up some research on that thanks to comments folks have made above. Increased aggression has been a sig. problem recently. So thanks for the food for thought everyone. Hope I'll be able to hear some updates on this case in a few weeks.