SOCIALIZATION FACTOR (UNIT 9)

WHAT TO DO WITH THE PROSOCIALIZATION CONCEPT

9-A THE USE OF THE SOCIALIZATION FACTOR IN APPROACHING AUTISM
Autism is the singularly most difficult psychiatric disorder . There is still very little agreement on its cause, its exact diagnosis , and its treatment.

9-A There are four opinions generally presented by the academic community about autism which seem to counter to the madisondoctrine’s experience.

9-A1 General opinion 1) Autism is a genetic condition.

Response: Many point to certain families that have a high proportion of autism and autistic spectrum disorders and state that we can expect in the future to identify the genetics of Autism. There are many other situations that do not point there being a standard genetic cause.

9-A1.a) Too wide a spectrum for simple genetics. Roughly 5% of individuals with Down’s have autism, 10% with Fragile X, and over 15% with Tuberous Sclerosis. It is not reasonable to suspect that the genetic flaws of these three conditions, which have diverse gene abnormalities, would cause autism in the same way. – especially since Down’s is not an error of faulty genes but is caused by having a surplus chromosome. It is more reasonable to state that the three conditions, like many others, have a disorganizing affect on the brain, and that disorganizing effect can lead the brain to function autistically.

9-A1.b) The lesson from Rett’s disease: The syndrome termed Rett’s syndrome is separate from autism since its cause is understood. It occurs only in girls and is an inherited disorder. Those who are afflicted appear neurologically normal at birth, but they have an inborn error of brain chemistry function. They are unable to sustain the function of the MECP2 gene, which contains instructions for the synthesis of a protein called methyl cytosine binding protein 2 (MeCP2). This ordinarily acts as a biochemical switch that tells other genes when to turn off and stop producing their own unique proteins. As the young girls become 3 or 4, this inability causes increasing damage to the nerves; and brain function deteriorates. As it does the individual increasingly demonstrates symptoms of autism. This change seems to be a reversing of the process of brain maturation -- and again points to the concept that autism is an innate primitive organization of the brain on which are developed more sophisticated brain functions under normal circumstances. If these functions are not there, then the more primitive autistic function is demonstrated. The existence of Rett’s syndrome also points out that there are some individuals with autism caused by neurological injury which are not reversible.

9-A2 General opinion 2) Medication helps the behavior of autistic individuals but does not change the basic disorder of Autism.

Response: There are many medications that improve the foundational negative socialization traits of the Autistic, but the effect does not eliminate the autistic drives. Many of these meds show the benefits at very low doses. The higher doses of atypical antipsychotic commonly used for behavior control sometimes seem to mask the prosocialization effect seen at lower doses.

9-A3 General opinion 3) Young children with Autism should be placed in behavioral programs early, but medicines should be withheld as a last resort.

Response: This would be valid only if medications did not modify the socialization inhibition of the autistic – which they do. Young children should have both treatments available.

9-A3.a It is dangerous to give powerful psychotropics to children younger than five, or three, or one—or to newborns, since we do not know the long range damage they can do to the nervous system.

Response. There is abundant evidence of the tremendous damage that the prolongation of autistic activities does to the life of the child. It is also a standard clinical practice to give hundreds of other drugs to treat physical disorders to young children, and there is a considerable experience of exposure to many drugs during pregnancy. The concept of weighing the risk and the benefits of any treatment is accepted in respect to other treatments, and this concept must be used relative to psychotropics.

9-A4 General Opinion – not universal 4) Since there are no medicines which have proven benefit, medication trials should be done one medicine at a time.

Response: Multiple medicines have the ability to modify the body reactions in several system at once, and Autism often involves malfunction of multiple systems.

9- B1) Problems applying the concept of the socialization factor to autism. Since most people who have kept reading through this mass of material will be looking for answers to autism --for themselves or a loved one -- this section will present some ideas which might be used to make a difference. This paper has seemed to promise some answers and some hope. But it still does not contain a coherent action plan for defeating autism. Autism is such a complex phenomenon that it will take the cooperation of many people to solve its many unknown areas, and the following situations make any universal coordinated attack on autism still seem far off.

9- B1.a) Lack of any universally acceptable understanding about the autism phenomenon -- means that the workers in the field will have continued difficulty communicating with each other their understanding about the phenomenon. It is especially true that the medical/psychiatric branch does not communicate with the behavioral branch.

9- B1.b) Treatments complicated. Even if the concepts in paper were all true, the treatments suggested to counter the influence of disturbance of the socialization factor are very complicated and may even cause significant behavioral disturbances.

9- B1.c) Prescriptions required. Most of the medication treatments recommended are prescription medications, meaning that treatment would be dependent on physicians who would be able to accept a concept based on many questionable assumptions.

9- B1.d) Atypical dosing. The medicines themselves are rarely obtainable in a dosage size small enough for effective treatment.

9- B1.e) The need for early intervention. If there is a great potential for reversing the autistic function in some severely impaired individuals, it would seem to require early intervention as soon as it is detected. But early intervention with medication goes against the long-standing feeling shared by many that giving psychotropic medicine to infants and young children is wrong and likely do harm.

9- B1.f) Behavior side effects --can occur when seeking to treat a dissociatively suppressed socialization factor. These may be severe psychotic or manic symptoms that are difficult to control without the use of potent psychiatric medications. -- and possibly the use of a psychiatric unit or emergency room.

9- B1.g) Stabilization There is a need for stabilization of immaturity reactions such as rages giddiness, hyperactivity, obsessive compulsion, and anxiety. If these are not stabilized the prosocialization meds may not be effective. Few doctors are knowledgeable or comfortable about the use of the medications regimes that are useful to control these behavioral difficulties.
9- B2) For medical practitioners there are additional problems.
9- B2.a) FDA, Practicing physicians are generally would have to use medications for uses not officially approved by the Food and Drug Administration.

9- B2.b) There is no tradition for initiating most of these specific prosocialization meds. The only ones with such a tradition are the atypical antipsychotics. And their use is still questioned if used outside of specific indications of schizophrenia and bipolar disorder despite their wide spectrum of effectiveness.

9- B2.c) Many practitioners are not accustomed to prescribing the number of different medications that may be necessary to stabilize manic mood swings, prevent psychotic breaks, and calm the various immature reactivities which can prevent an individual gaining socialization. -- especially since medicines as beta-blockers, alpha-blockers, narcotic blockers typically are not routinely used in behavioral medicine.

9- B2.d) There is difficulty dealing with informed consent when the treatment is not well formulated and the physician is not familiar with the nature of the medicines.

9- B2.e) Insurance companies may not recognize symptoms as a true disorder, refuse to pay for treatment, and for the medications prescribed.

9-B3) Thus there are a number of good reasons for people to say that it is best to wait till the understanding is more scientifically proven.--- when it becomes a standard treatment. There are several issues with this position.

9-B2.a) Such a time may come slowly -- indeed may never come. The peculiar differences in this treatment regime and other difficulties of socialization factor concept may prevent standard research techniques from ever proving or disproving it. In fact, most of the expert opinions about medication and autism deny that medicine has any affects on the basic difficulty of autism..

9-B2.b) People have already been seeking some medicinal or programming help and many believe they have found an answer. Earlier was listed some 8 different suggestions for treatments that can be tried to overcome the problems of autism. (People are going to try something, The MNDA acting medications seem to be the closest place to look to find a real solution.)

9-B2.c) The apparent relationship of dissociation, socialization and the AMPT receptor mechanism would seem to be a coherent explanation for the many confusing features of autism. Yet research about dissociation is rare and has not provided many answers. It would seem that there needs to be many more anecdotal reports of the various and confusing results seen with these treatments before we will have enough information to prove the real science involved.

9-C WHAT MIGHT BE DONE BY THOSE WHO WANT TO USE THE CONCEPTS OF PROSOCIALIZATION IN TREATMENT.

9-C1 Patient types. Anyone who has some type of barrier to entering into normal conversational patterns. Individuals with autism, “shyness”, some substance abusers., catatonics, stuttering, brain injury, “loners” , dissociative individuals, victims of post traumatic stress, and even some individuals who might be called sociopathic or antisocial personalities might consider using these medications. Their use is far from well-worked out however, so both physicians and patients need to be cautious,

9-C2 Use by non-physicians – It often occurs that the concerned individual, generally the parent of the autistic child, acts alone to deal with the problem. There are two extremes seen in this problem.

9-C2.a The correct understanding of the parent is that the physician has failed to recognize the problem or to offer any treatment. (This is the frustration seen by the parent who seeks a high level medical consult with multiple tests but is
given no real diagnosis and offered no treatment.)

9-C2.b The intense emotionally driven belief of the parent that there must be something out there that they can find to reverse this terrible thing and they spend frenzied hours seeking it.

9-C2.c Sometimes the parents’ drive leads to positive results, sometime the drive leads to an irrational crusade that engulfs the life of the patient, the caregivers and all else that gets involved. Sometimes the parent is simply frustrated. This section is presented with the hope that it encourages rational attempts at treatment and does not create situations which are totally irrational.

9- D Lay individuals working without a doctor.

9-D1 Sleep can sometimes be improved with antihistamines, melatonin.

9-D2 Substances which can be used. If there is no significant rage, self-abuse, or hyperactive behavior, just signs of social withdrawal, one might use the following for prosocialization effects.

9-D2.a L-Glycine. Start off with low doses. (1/2 teaspoon) It causes irritation of the gut and is poorly absorbed. It succeeds in only a few.

9-D2.b D-Serine. If it available in your country, start with low doses – probably working up from two consecutive days, to four, to daily. There is no evidence that it has been tried in autism.

9-D2.c DSG This is a health food available and used in autism in the USA. Some stories of rapid improvement in socialization. It might act like l-glycine as a prosocialization agent, and is certainly easier to take. However, the percentage of individuals that obtain benefits does not seem as high as with l-glycine.

9-D2.d Dextromethorphan There is also the possibility that dextromethorphan would be beneficial, it is available in pure form as Delsym cough syrup. It may or may not require an enzyme-blocking medication such as

9-D2.e Alternate treatments. There are of course the better-known indirect non-traditional treatments such as gluten free diet. It might be rational to try those which make sense to the individual’s particular problem - for example gluten free diet is individuals with bowel or skin allergy problems. Also, with any attempted treatment, there should be considered a trial stopping it if there is no benefit seen especially if the treatment is highly intrusive into the daily function of those involved.

9-D2.f Atypical antipsychotic. You can also ask physicians to prescribe low doses of an atypical and antipsychotic since this is a treatment that makes sense to most doctors.

9-D3 Suggestions for physicians with no previous training or experience with autism.
Often the reality of geography and finances make it necessary that some autistic individuals are cared for by a doctor whose best qualification if that he or she is willing to try to help. The following is a rough outline of a treatment scheme presuming that the autistic patient is a younger child.

9-D3.a Stabilize sleep. Consider use of clonidine for adrenaline over-reactivity, quetiapine/Seroquel to deal with nighttime “inner world” arousal and,
for cyclic sleep problems – can also use valproate/Depakote for cycle sleep disturbance that is cyclic. Consider Melatonin if the there very irregular day-night sleep patterns. If necessary use more than one.

9-D3.b Treat major problems not necessarily related to autism

9-D3.b1 Treat rage and aggression. Learn how to monitor pulse and blood pressure to allow for use of beta-blockers, alpha-blockers, alpha 2 agonists. Even if establishing a lower basal pulse rate and BP does not immediately help, such therapy make subsequent therapy more effective.

9-D3.b 2 Naltrexone. Be willing to give a trial of Naltrexone whether it is for giddy disinhibition, self-abuse, or “autism”. Often a two week trial titrating up to1 mg/lb/day
is generally enough to determine its benefit.

9-D3.b 3 History suggesting bipolar disorder or significant psychosis. May need to place on mood stabilizer such as Depakote, carbamazepine, or Lithium. If there is psychosis, place on non-activating atypical (quetiapine/ Seroquel, olanzapine/Zyprexa.), Sometimes a typical antipsychotic (haloperidol/ Haldol) is necessary. (Many clinicians obtain the antipsychotic effect of a typical antipsychotic by using a high dose of an atypical.) Very severe psychotic aggression in a socially isolated individual may require clozapine/ Clozaril.

9-D3.e Treatment of ADHD and anxiety. Children with Autism can seem to have symptoms of either of these disorders as manifestations of more complex difficulties. Sometimes actual ADHD symptoms will respond to stimulants and anxiety disorder to benzodiazepines; however, both classes of drugs can caused the reaction of over activation and disinhibited social reactions. One should use these two classes cautiously and allow several weeks before considered the treatment successful, since both can show an initial positive effect and later on caused behavioral difficulties.

9-D3.f Decide to treat obsession or social withdrawal first. If OCD is very dominant and the socialization deficit not too significant, one might decide to start treating OCD first, Generally start with very low doses of an SSRI to guard against the side effect of hyperarousal, which is not uncommon in the autistic, I often start with 5 mg fluoxetine/ Prozac 2x a week and work up very slowly. If thee is a question of possible overactivity , I would use trazodone instead.

9-D3.g Start a low dose of a prosocializing med. Use small doses for two successive days to start a trial. Note that mecamylamine/ Inversine is water soluble. It is relatively easy to make solutions with very low doses per teaspoon.
.
9-D3.h Do not place the patient on an atypical plus a mood stabilizer and then keep raising the doses seeking behavioral control..

9-D4 Suggestions for Specialist physicians when standard techniques do not provide adequate stability.

9-D4.1 Consider the need for anti-adrenergics -- trying a beta-blocker for rage and clonidine for sleep.

9-D4.2 Consider trial of naltrexone/ ReVia.

9-D4.3 Determine if there has been over-activation by the atypicals that have been used. If so, consider use of clozapine/ Clozaril or a typical.

9-D4.4 Consider the use of low dose activating atypical -- as a trial for improving socialization in an individual who did not tolerate higher doses of atypicals because of agitation.

9-D4.5 In special circumstances consider trial of the unique prosocializing medications – e.g. in autistically driven self-abuse.

9-D4.6 Do not set a limit to the number of agents used to establish a stabilizing regime.

9-D5 SOMETHING FOR ALL NEED TO ADD TO THEIR THINKING.
Individuals who do not demonstrate negative behaviors such as rage or self abuse – especially young ones – are the best candidates for prosocialization medications – and they are the least likely to be considered for the use of psychotropic medications. There is no tradition for the use of medication is very young individuals whose only “illness” is diminished socialization, bu beneficial medications seem to be available,. If we do not try to use them, we may be condemning a whole new generation to a life of socially withdrawn dull existence.

9  SUMMARY: This paper seeks to present the concept of the presence of socialization factor as part of the functioning brain. This concept has two parts. Part 1 –the “socialization factor” and its inhibition, Part 2 – the “primitive psychotic drives” which are the extremes of brain functions that influenced the growth of the individual’s socialization experience.

The “socialization factor” has qualities not typical of standard brain functions. It is unique in that it can be dormant for an extended time then suddenly function; its treatment is unique in that a number of widely divergent neuro-chemical systems seem to affect it; and treatment is also unique in that a time-limited treatment may cause a prolonged benefit. It may be that the socialization factor is a dissociative reaction; it may be intimately connected with the MNDA glutamate system; or both statements may be true. “Prosocialization medications”, which include atypical antipsychotics, various Glycine agonists, glutamate antagonists, and the nicotinic antagonist mecamylamine, can stimulate the emergence of increased socialization but can also produce severe behavioral disruptions in some individuals. These disruptions have demonstrated qualities which suggested part B of this theory – the presence of “primitive psychotic drives.”

“Primitive psychotic drives.” apparently represent the expression of the extremes of psychotic-like socialization drives which are dissociatively suppressed during normal brain function, but seem to be the force behind the two major psychiatric breaks—the autistic, socially-isolating psychosis of the schizophrenic break and the socially intrusive disinhibited dysfunction of the manic break. These two primitive drives parallel the first two infantile developmental phases conceived by the child psychiatrist, Margaret Mahler – the autistic phase and the symbiotic phase.

Determining whether there is a true relationship between the clinical observations presented and such foundationally novel theories will require extensive controlled clinical study. Indeed, the observations and theories on which the concept of the socialization factor is formulated are incomplete, hard to substantiate, and quite subject to skepticism. However, the material presented does contain observations by myself and others that are not easily explained using other models of psychopathology. Thus this paper is set forth with the hope that others will seek to develop experience dealing with the area of behavior which has been termed the “socialization factor” and that the concept of “prosocialization treatment” will be expanded to reach the large number of patients that it promises to help.

9-A1.a) Summary of prosocialization medicines.
Most individuals who are socially and conversationally repressed will respond somewhat to the so-called prosocialization medications.
9- A 1.b) The initial doses should be small.
9- A 1.c) If benefits are seen, the dose should remain stable for a time to allow the individual to become accustomed to this level of activity.\
9- A 1.d) Some individuals do not respond to the milder prosocialization meds but do respond to the more activating ones.
9-A1.e) Treatment with mood stabilizers and higher dose atypicals may be needed to prevent manic like over-arousal.
9-A1.f) Treatment with standard antipsychotics, and atypicals may be needed to
prevent breakthrough psychosis.
9-A1. g) Despite protective medications, some individuals persistently have
regression to a manic-like or psychotic state when given prosocialization
meds.
9-A1.h) Response to some prosocialization medications may persist after the
medication has been stopped.
9-A1.i) Highly socially inhibited individuals may respond quickly to
prosocialization medications, but then lose the response.
9-A1.j Response to one prosocializing med only roughly predicts the possible
response to another.

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