Wednesday, June 17, 2009

Q & A with Dr. Mike


(We) just took one of our adult sons with Fragile X (22 yrs old) to see an adult psychiatrist. We need help to moderate some of his obsessive traits. When he gets upset or is in anxious situations, he fixates on the name of a woman that he knows and repeatedly tells us to “call her up” or tells us that she phoned us when she didn’t, to the point where he has a blow up. Also in conversation, he’ll address people that he knows, like his grandparents, by the name of this woman. He rarely sees this woman. She’s the mother of a former classmate and one of the managers of our community Special Olympics team. This has been going on for a couple of years but seems to have gotten worse since he’s been out of high school for a year now.

So the question that I have for you concerns the drug Strattera that the psychiatrist recommends that we try on our son. Currently, my son only takes 2 mg of Tenex, 3 times daily and does not have any other health concerns (including heart or liver). When I read the information on any drug, you wonder why you would take it or give it to someone. Therefore, any opinion or additional information that you can give on this drug and it’s efficacy on a person with Fragile X Syndrome will be most helpful. Thanks in advance for anything you can tell us.

My immediate concern for our son is his obsessiveness. His talking about this other mom and reminding me often to make phone calls to people I might need to talk with is becoming more difficult to manage. I am wondering if the Strattera is a plan for attention issues not obsessions.

A: I think you're right to be concerned that Strattera is a treatment for attention deficit, not obsessional problems. In fact, Strattera may aggravate obsessional symptoms as well as anxiety, irritability, and aggression. The mainstay of treatment for these anxiety symptoms in all developmental disorders (and especially fragile X) is the SSRI class (ie Prozac, Zoloft, Paxil, Luvox, Celexa, and the various generic equivalents.) While there is some controversy about the effectiveness of SSRIs in children with "autism" (whatever that is!) as a result of 2 recent negative trials, it is quite clear that SSRIs are very effective in treating a wide range of symptoms in adults with developmental disorders, including and especially the kind of obsessional/repetitive/perseverative symptoms you describe. A number of well-done clinical trials have established efficacy in adults with MR/DD; it is my opinion that SSRIs work just as well in children, but studies are much harder to do in this population, and the results are confounded by the kinds of side effects that children often get. Most clinicians in the fragile X field have a very positive view of SSRIs, and feel that they are quite helpful with these symptoms. Strattera, on the other hand, has little information available via clinical trials in the developmental disorders population. In other words, there is no evidence that Strattera works for the kind of symptoms you describe; my clinical experience is that it doesn't, and it's certainly not the first thing I'd try (not even the fifth or sixth, actually.)