Behaviour - Which medications and when?
By Dr. Paramala Santosh, Consultant in Psychiatry, Great Ormond Street Hospital, 2005.
This article, in note form, written primarily for medical professionals, discusses the relationship between behaviour and medications.
Dr. Santosh deals with Organic Brain Disorders such as TS, Hunter’s, San Fillipo Disease, Acquired Brain Injury (RTA), Post-encephalitic (from malaria etc.), uncontrolled Epilepsy and brain dysmaturation related difficulties.
The Concept of Comorbidity
You have two types of physician. One type, the “Lumpers†put all the sufferers from a condition or disorder into one big pigeon hole. The other type, like Dr. Santosh, the “Splitters†who split the conditions into symptoms. It is not possible to manage a disorder, but it is possible to manage symptoms.
In discussing Genotype versus Phenotype you can use both behavioural intervention and drugs interchangeably.
In a disorder-specific approach you would attempt to treat a whole disorder such as ADHD or depression with a general approach.
In a symptom-based approach you would treat hyperactivity, insomnia, obsessions, tics, psychosis, impulsivity, labile moods etc. as separate problems requiring separate (drug) solutions. Some symptoms may require behaviour modification as well, such as aggression, rituals, self-injury or depression. Other symptoms may require specific remedies such as academic difficulties or problems with sporting ability.
Drugs vs. Symptoms
| noradrenaline | dopamine | serotonin | |
| Obsessions | ++++ | ||
| Depression | ++ | +++ | |
| Inattention | ++ | + | + |
| Impulsivity | + | ++ | |
| Stereotypes | - | + |
ADHD (Hunden et al 1999, Anun et al 2002)
(Hunden et al 1999, Anun et al 2002)Risperidone was used to treat hyperactivity, severe social withdrawal, crying, irritability, aggression and impulsivity.
(Hunden et al 1999, Anun et al 2002)Risperidone was used to treat hyperactivity, severe social withdrawal, crying, irritability, aggression and impulsivity.ADHD and Epilepsy together can mimic memory problems. It can occur in MR ?cumny?. Adequate AED cover must be ensured. ADHD must be treated with stimulants. AED induced hyperactivity must be ruled out. There is not much research in this area, but MPH is probably safe. Use dexamphetamine if nothing else.
(Hunden et al 1999, Anun et al 2002)Risperidone was used to treat hyperactivity, severe social withdrawal, crying, irritability, aggression and impulsivity.ADHD and Epilepsy together can mimic memory problems. It can occur in MR ?cumny?. Adequate AED cover must be ensured. ADHD must be treated with stimulants. AED induced hyperactivity must be ruled out. There is not much research in this area, but MPH is probably safe. Use dexamphetamine if nothing else.Autistic Spectrum Disorder (ASD) Triad
(Hunden et al 1999, Anun et al 2002)Risperidone was used to treat hyperactivity, severe social withdrawal, crying, irritability, aggression and impulsivity.ADHD and Epilepsy together can mimic memory problems. It can occur in MR ?cumny?. Adequate AED cover must be ensured. ADHD must be treated with stimulants. AED induced hyperactivity must be ruled out. There is not much research in this area, but MPH is probably safe. Use dexamphetamine if nothing else.social relationships, social language and communication skills, imagination – with Autism in the middle of the 3 circles.
Reproductive/Stereotypes/Circumscribed/Interests
ASD+ADHD
In Organic Brain Damage children commonly have both ASD and ADHD. Stimulants are effective 50% of the time.
(Arnold et al 2003) Risperidone can help with irritability, self-injury and tantrums. The side-effects are increased appetite, weight gain and metabolic syndrome.
Repetitive behaviour can be fixed with different drugs. Ways can be made less rigid using the drugs so patients can do more things.
Clomdine is useful in ASD + ADHD / Tourette’s Syndrome. There is an improvement in hyperactivity, impulsivity, oppositional behaviour and socialisation. The side-effects are sedation, hypertension, tolerance and fatigue.
Mood Stabilisers such as Sodium Valproate, Lamotrigine and Atypical antipsychotics can be used where the following indicators are present:- labile affects, bipolar disorder, explosive rage, epilepsy, EEG abnormalities.
Sleep Disorders
Sleep hygiene, melatonin, Clomdine, Trazodone and Zolpidem can all be used. A normal sleep pattern is important.
Preparation
Subjects with TS find MRI scans or blood tests difficult, and may necessitate a general anaesthetic. This often leads to late intervention. For mildly affected use oral Midocolum. For moderate to severely affected use oral Ketomins. Routine flights, antiemesis prophylaxis.
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Constipation
Coordinate behaviour and medication together. Effects can be in cardiac, liver, kidney, neuropsychological. The ease of administration (affecting likely compliance). Specific issues.
Future Directions
Oxytocin and social reciprocity (Hollander et al 2003). Earlier pharma intervention and pharma-cogenetics (from the human genome project) could all be used.
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