The Treatment of Refreactory Agression and Self Abusive Behaviors with Proporanolol

Background:   Although not the core signs of the ASDs, aggression and self abusive behaviors are often the most disturbing and dangerous symptoms for affected individuals and their families. These symptoms can sabotage school, work and other treatment programs, and is often is the cause of hospitalization or residential placement. Currently two antipsychotics are approved for this use in the ASDs and despite their  documented efficacy,  in many cases they provide inadequate benifit and in other cases, side effects limit their use. High dose proranolol has been used for the treatment of aggression in various disorders and  has been best studied in aggression associated with brain injury. A Cochrane Database review found propranolol the most effective medication for this indication. The literature on the use of propranolol in ASD is very limited and includes only a few anecdotal cases.

Objectives: This submission presents the results of 30 cases of individuals with ASD treated with high doses of propranolol. All subjects had inadequate responses to at least one antipsychotic and also after trials on many psychotropic medications.

Methods: This is a retrospective chart review of one clinician’s cases over approximately 10 years. Each subject was reviewed for diagnosis, age, gender, symptoms being targeted, and general observations of the cases being presented. Their CGI –S (Clinical Global Impression Severity) score is presented before and after the treatment with propranolol and their CGI- I (Improvement) rating is also presented. . In all cases the propranolol was used as an “add on” medication to other medications which showed at least partial benefit and clinically needed to be continued.  

Results: Approximately 30% of the subjects were rated as extremely ill and 50 % were rated as severely ill on the CGI –S scale prior to the administration of the propranolol. Approximately 80% of the cases reported were either very much improved or much improved on the CGI-I after treatment. Nearly all of the subjects were followed on propranolol for greater than one year thus suggesting that the results were long lasting. Only one of the subjects discontinued propranolol due to side effects (bronchiospasm) The other side effects observed were lethargy and lowering of blood pressure and these side effects were rare and clinically minor. Other symptoms such as hyperactivity and repetitive behaviors showed a great deal less improvement on the propranolol. Of the 20% who showed less improvement or no improvement on the CGI-I, approximately three quarters had ongoing poorly controlled seizures and had an ongoing adjustments of antiseizure medications while being studied  

Conclusions: In a group of subjects who had very severe symptoms of aggression and self abusive behaviors, the use of propranolol was extremely efficacious with  minimal adverse affects. This suggests a novel and safe treatment for this very difficult to treat group.  Although this review is methodologically limited, (being a retrospective report of one clinician' cases), the large number of cases presented and the outstanding efficacy reported makes this important preliminary data justifying more rigorous study of this medication's potential for ASD.