Decoding OCD Medications in Autism: An In-Depth Look at What We Know So Far

Obsessive-compulsive disorder is common in individuals with autism spectrum disorder (ASD), About 25% of young people with OCD also have a diagnosis of Autism according to recent studies. presenting unique challenges for patients, caregivers, and clinicians alike.  In this blog post, we will delve into the various OCD treatments used in autism, focusing on medications such as SSRIs, Clomipramine, Memantine, N-Acetylcysteine (NAC), and atypical antipsychotics, as well as the role of Exposure and Response Prevention (ERP) therapy.

SSRIs:
Selective Serotonin Reuptake Inhibitors (SSRIs) are often the first line of treatment for OCD, including in people with autism1. SSRIs work by increasing the level of serotonin in the brain, which can help reduce obsessions and compulsions1. While many SSRIs can be used for OCD in autism, the SSRIS that are FDA approved for OCD are Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), an SSRI, and Sertraline (Zoloft). In my practice, I try to avoid using paroxetine as it comes with several more side effects, like weight gain and tiredness.  The max effect of the med does take 8-12 weeks, but it doesn’t go from 0-100% at that time. You should start seeing a response within 4-6 weeks and then it plateaus in 2-3 months.

Clomipramine:
Clomipramine, a tricyclic antidepressant, has been found effective and FDA approved in treating OCD symptoms in some individuals with autism2. It is more potently affecting the brain chemical serotonin, so we often can see an increased effectiveness when this medicine is used. However, it's typically considered only after other treatments have failed due to potential side effects. Clomipramine can be a valuable tool in the therapeutic arsenal for autism and OCD, especially with co-occurring issues like migraines, nerve pain, panic disorder2. It can be used by itself, or in combination with an SSRI at lower doses. It does require regular blood work to track how much of it is in staying in the person’s bloodstream, so it is a little more medically involved than the above treatments. This drug may increase the risk of seizures and given this is an issue for at least 20-30% of autistic people, we have to use this with more caution. If one SSRI at maximum doses is well tolerated but does not work, I try a second SSRI (probably Fluoxetine) prior to clomipramine.

Memantine:
Memantine is a medication primarily used to treat Alzheimer's disease, but recent studies suggest it may also be beneficial in managing OCD symptoms in individuals with autism3. While more research is needed, initial findings are promising3.. It has no FDA approval for OCD. It works totally differently than the above medications, targeting a brain chemical called glutamate, instead of serotonin. There are also studies using this medication for aggression and anxiety in autism. In my practice, I think this medication is most helpful for OCD with a lot of rumination thoughts, and it is very easy to tolerate with minimal side effects. Because it is not very effective on its own for OCD, I will reserve this as an add on.

N-Acetylcysteine (NAC):
NAC is an over-the-counter supplement that has shown potential in treating a variety of psychiatric disorders. It is thought to work by modulating glutamate and dopamine in the brain4. It has the most scientific backing for obsessive hair pulling skin picking in adults. Nevertheless, sometimes we will add this on as a natural supplement booster.

Atypical Antipsychotics:
Atypical antipsychotics, such as risperidone and aripiprazole, are sometimes used as an add-on treatment for managing severe OCD symptoms in individuals with autism5. They can be particularly helpful when symptoms are resistant to first line treatments5. Low dose Abilify and Risperidone are my favorite meds to add on for OCD, as it helps the obsessive part quickly.

ERP Therapy:
Exposure and Response Prevention (ERP) therapy, a form of cognitive-behavioral therapy, is another effective treatment for OCD in autism6. It involves gradual exposure to obsessions to reduce the associated anxiety and prevent compulsive behaviors6. Although it requires careful adaptation for individuals with autism, ERP can significantly improve their quality of life6. Overall, young people experiencing OCD in the context of ASD benefit from ERP therapy, but to a lesser extent than typically developing children. Therapists can modify the therapy protocols for OCD in ASD to optimize treatment results. Studies show   people with co-occurring OCD + Autism can make significant improvements in functioning but are likely to remain more impaired by their OCD than typically developing youth with OCD. They often need longer-term support.

Conclusion:
Treating OCD in individuals with autism is a complex process that requires a personalized approach. The combination of medications and ERP therapy offers a promising strategy for managing this challenging comorbidity. However, it's crucial to remember that every individual is unique, and what works for one person might not work for another. Regular consultation with healthcare providers is essential to find the most effective treatment plan.