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Mirtazapine for Inappropriate Sexual Behaviors in Autism.

To the Editor: A 15-year-old Kuwaiti youngster, a known case of autism spectrum disorder (ASD), intellectual disability, and epilepsy, attending special schooling, maintained on valproate for seizure control, was escorted by his parents for escalating behavioral dyscontrol, notably irritability, fitful sleep, and socially flouting oversexualized behaviors. Medical and environmental causation of this behavioral decompensation was meticulously ruled out. He could not tolerate a trial on risperidone where he developed recurrent extrapyramidal side effects. He failed a 6-week trial on 15 mg/d aripiprazole. Clonidine was also tried but prematurely aborted for severe hypotension and symptomatic bradycardia. We suggested a trial with mirtazapine, as data from the literature support its use for sexually inappropriate behaviors in ASD, and also to help with sleep and irritability. We went to 45 mg/d over 4 weeks. Sleep improved markedly, irritability diminished significantly, and most importantly, sexual behaviors were greatly tamed. Both frequency and severity of aggression became obviously less. This was well sustained at follow-ups week 4, 8, and 12. ASD, especially the low-functioning, is typically coupled with a multitude of challenging behaviors that might interfere with acquisition of more functional and adaptive behaviors, add to caregiver distress, and, are primarily cause of referral to child psychiatrists. One of these problem behaviors that emerge with transition into adolescence is the inappropriate sexual behaviors (ISBs) in up to 30% of cases, in tandem with hormonal surge, which is often difficult to accommodate and surprisingly less well studied in literature.1 These behaviors include, inter alia, masturbation (onanism) in public, disrobing, inappropriate touching, copropraxia (obscene gestures), pornographomania. This is further compounded in this population by deficits in social communication and theory of mind, which lie at the core of ASD with executive dysfunction and poor social judgement rendering psycho-education of “sexuality” difficult to contemplate. Moreover, in conservative and religious communities, like ours, talking openly about these issues remains a “taboo.” In ASD population, ISBs might subserve self-soothing or self-stimming (sensory) functions that tend to maintain these maladaptive behaviors. It might then turn part of routine. Although these behaviors can be seen normative in neurotypicals, in ASD population, it might prove seriously risky. Lack of education, using inappropriate “fetish,” too excessive masturbation, self-injury during the act, indecent exposure, associated aggression, and forensic repercussions. all can accentuate ramifications of ISBs in ASD and call for action. Working differential for oversexualized behaviors in ASD should entail sexual abuse (heightened vulnerability), drug-induced impulse dyscontrol (eg, aripiprazole with partial D2 agonism),2 communication vehicle (albeit ineffective), superimposed bipolarity, imitating behaviors (exposure to nudity in the vicinity). When parents opt to go for medications, when it goes out of control, which is usually the case, only few pharmacological choices are available and unfortunately with only flimsy evidence base that might be ascribed to the complex nature of these behaviors and factors at play. Apart from the ethical dilemma surrounding the topic, these options include the atypical antipsychotic, risperidone by virtue of potent D2 blockade in the tuberoinfundibular pathway can result in hyperprolactinemia and ergo decreasing sexual drive. Herguner et al3 have reported the effectiveness of risperidone–paroxetine combination for ISBs in an adolescent with ASD/intellectual disability. Selective serotonin reuptake inhibitors might be used similarly, especially if these ISBs have a compulsive flavor or part of restricted and repetitive behaviours.4 Agonistic actions at 5HT2A might be contributory. In the same vein, Ayaydin and Ulgar5 have reported on an interesting case of an autistic 30-month-old girl with global developmental delay that favorably responded to escitalopram 1.5 mg/d for early childhood masturbation. The NaSSA antidepressant, mirtazapine, has been proven effective for ISBs in case series of 9 subjects with ASD by Coskun et al.6 Other case reports again by Coskun and Mukaddes,7 by Albertini et al,8 and also by Nguyen and Murphy9 have attested to the efficacy of mirtazapine for ISBs in ASD due to antilibidinal properties. The b-blocker, propranolol, at a low dose (10 mg bid) has been reported by Deepmala and Agrawal10 to help with ISBs in an adolescent with ASD. Mechanisms include reduction in central sympathetic outflow, impaired vasodilatation of corpora cavernosa, Letters to the Editor e751