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Asperger's and OCD

Q. My 16-year-old son has been diagnosed with Asperger's and Obsessive-Compulsive Disorder (OCD). He is not currently on any medications, because he said that the Imipramine was not doing anything. His psychiatrist just moved but I want him to be on something.

My main concern is that he has delusions of thought control and deletion that seem to be episodic. He realizes they are not rational when we discuss them. Is this type of problem allowable in the category of OCD or are we now getting into schizoid territory?

What have you had success with in this type of case? He was on Risperdol, but the motor retardation and weight gain were worse than the original symptoms. I am a doctor and familiar with the nature of these diseases and the drugs used, but would like your input.

A. Your son's symptoms may, indeed, fall into the hazy borderland between OCD, Asperger's syndrome, and perhaps one of the schizophreniform/schizotypal disorders. Although I do think it's worth trying to pin down the diagnosis, sometimes this is very tricky, even with the best diagnostic evaluation. In such cases, assuming gross neurological disease has been ruled out, I find it most helpful to develop a list of target symptoms rather than focusing too much on the DSM diagnosis.

That said--since your son's psychiatrist has left, this may be the time to get a fresh diagnostic and treatment perspective from a psychiatrist with special expertise in OCD and pervasive developmental disorders, if one is available in your area. (A medical school department of psychiatry is a good place to get referrals).

Now, to answer your question about delusions--in the strict understanding of OCD, actual delusions are not considered a part of the disorder. However, if the individual is able to "reality test" his/her belief--that is, appreciate the irrational or unrealistic nature of the idea--then, technically, the idea is not a bona fide delusion, but an overvalued idea or an obsession. But patients can vary in the degree to which they have insight, and sometimes their reality testing is very shaky. In such cases, a psychotic process may be present.

Similarly, obsessive-compulsive symptoms may be seen in Asperger's and related disorders, but not amount to classical OCD. While neuropsychological testing may sometimes be helpful in clarifying these issues, an empirical approach is often the more feasible avenue, in my experience. Fortunately, the selective serotonin reuptake inhibitors (SSRIs) are both the treatment of choice in OCD, and a somewhat useful approach to autism spectrum disorders, such as Asperger's (though SSRIs are not FDA-approved for Asperger's Syndrome--nor, for that matter, is any medication).

For refractory OCD--or OCD that has psychotic-like features--the addition of an atypical antipsychotic to an SSRI seems to be the most promising approach; however, one could also argue in favor of sequential SSRI trials (at least two or three), since all the SSRIs (fluoxetine, sertraline, citalopram, paroxetine, fluvoxamine) are slightly different.

As your son has experienced, the atypical antipsychotics may have significant side effects. None is FDA-approved for the treatment of OCD, though risperidone has been the most widely used. There are also occasional reports of worsening OCD symptoms in response to atypical antipsychotics--but this is usually seen in patients with schizophrenia. Thus, if sequential SSRI trials were not helpful in your son's case, consideration could be given to adjunctive use of one of the newer atypical antipsychotics, such as ziprasidone or aripiprazole, neither of which is likely to promote weight gain.

Each, of course, has risks and benefits including but not limited to pharmacokinetic interactions--that you would need to discuss carefully with the psychiatrist. Depending on the specific target symptoms, other medications could be considered as augmenters, such as clonazepam or buspirone. (The combination of an SSRI with clomipramine may also be considered in refractory OCD, though the side effects may be troublesome).

Finally, if your son is not involved in some form of cognitive-behavioral therapy, I would strongly recommend discussing this with his new psychiatrist, as CBT can be quite helpful in both OCD and autistic spectrum disorders. Good luck with getting your son feeling better.

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January 2004

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