Intravenous benztropine and propranolol challenges in tardive akathisia

We challenged five patients suffering from tardive akathisia (TA) with intravenous benztropine (2 mg), propranolol (1 mg) and placebo (saline) using a random, double-blind cross-over design to examine the effects of the drugs on the subjective, objective and global manifestations of neuroleptic-induced akathisia. Benztropine produced a marginally significant, and propranolol a significant improvement in the overall manifestations of the disorder. The patients demonstrated a considerable placebo effect and marked variation in their responses to the drugs. The implications of these findings for the pathophysiology of TA in relation to acute akathisia and tardive dyskinesia are discussed.

Psychotic symptoms preceding ocular deviation in a patient with tardive oculogyric crises

This report describes a patient with schizophrenia who developed episodes of ocular dystonia as a delayed side effect of neuroleptic medication. Each episode was preceded and accompanied by marked agitation, stereotypic behaviour and exacerbation of hallucinations. Both the psychotic and dystonic symptoms responded to anticholinergic medication. The theoretical and practical implications of this observation are discussed.

"Rubral" tremor induced by a neuroleptic drug

"Rubral" tremor is a rare movement disorder that occurs typically with midbrain damage. It is defined by its presence at rest, with sustained posture, and with movement. Whether it is a single-tremor disorder or a combination of two distinct tremors is debated. This report chronicles a severe neuroleptic induced "rubral" tremor in a patient who had had a stable posttraumatic ataxia. The dramatic response to benztropine and bromocriptine is illustrated in the videotape.

Continuous performance tests in schizophrenic patients: stimulus and medication effects on performance

Medicated (n = 17) and unmedicated (n = 17) schizophrenic patients were compared to a normal control group (n = 19) on their performance on auditory and visual versions of the Continuous Performance Test (CPT). Within each stimulus modality, performance was examined on lexical and nonlexical target stimuli. Neuromotor competence was assessed on the basis of motor speed and proficiency. Normal subjects made fewer errors of all types than schizophrenic patients. Unmedicated patients made significantly more errors on nonlexical stimuli than medicated patients, with medication status found not to be associated with stimulus modality effects. Motor proficiency was associated with CPT performance in the medicated patients, but not the unmedicated ones, although this difference in correlations did not account for the group differences between these patients. The authors discuss the implications of these data for the type of cognitive and attentional functions that are affected by medication in schizophrenia.

The effect of benztropine on haloperidol-induced dystonia, clinical efficacy and pharmacokinetics: a prospective, double-blind trial

Twenty-nine inpatients with major psychotic disorders were treated for 14 days with a clinician-determined dose of haloperidol and with either benztropine or placebo given by double-blind random assignment on days 1 through 7. No differences were noted in haloperidol mean dose, haloperidol blood levels, or BPRS scores during the first seven days between benztropine (N = 14) and placebo (N = 15) groups. Benztropine-treated patients demonstrated increased dry mouth and diminished sweat and a non-significantly lower rate of dystonia compared to placebo (14% vs. 33%). Dystonic patients were significantly younger than nondystonic patients, but did not differ in haloperidol mean dose or plasma concentration. The effect of benztropine on the incidence of dystonia was consistent with other studies, which, when analyzed together, demonstrate the efficacy of anticholinergic prophylaxis. The relatively low incidence of anticholinergic side effects, coupled with the lack of effect on haloperidol blood levels or antipsychotic efficacy, suggest that moderate doses of benztropine in conjunction with haloperidol are a rational approach for the treatment of acute psychosis in young patients.

Comparison of 6- with 9-week trials of adjunctive imipramine in postpsychotic depression

Outcome at 6 weeks versus outcome at 9 weeks was compared in 23 patients with syndromally defined episodes of postpsychotic depression who underwent a trial of adjunctive imipramine added to their continuing treatment with fluphenazine decanoate and benztropine. The global outcome after 9 weeks was found to be superior. The implications of this finding for the treatment of secondary depressions in patients with schizophrenia and schizoaffective disorder is discussed.

Recall memory deficit in schizophrenia. A possible manifestation of prefrontal dysfunction

Patients with schizophrenia have memory deficits when compared to other neuropsychiatric and normal samples, but the mechanism by which the deficits arise is obscure. In the present study, 13 older, less educated normal subjects, and 31 inpatients with schizophrenia were administered the Selective Reminding test. In addition, the schizophrenic patients received the Mini Mental State Exam and the Brief Psychiatric Rating Scale. While normal subjects performed at a higher level on various measures of recall, a significant effect of repeated trials was present for each group for each measure, indicating that both groups learned. Normal subjects also outperformed the patients on a test of recognition memory. However, the patients exhibited a significantly greater disparity between recognition and recall than did the normal subjects, suggesting they were better able to acquire new information than to retrieve it ('forgetting to remember'). Moreover, anergia, a factor measure on the Brief Psychiatric Rating Scale, correlated significantly with recall, but not recognition memory, in the patient group. The data are suggestive of prefrontal-type cognitive and behavioral deficits in schizophrenia.

The dose-response relationship for memory impairment by anticholinergic drugs

Twelve stabilized chronic schizophrenic outpatients receiving maintenance treatment with fluphenazine decanoate plus anticholinergic antiparkinsonian drugs underwent two challenge sessions receiving, in random sequence and double-blind, injections of either benztropine or glycopyrrolate (a peripherally active anticholinergic agent that penetrates the CNS poorly, used as an active placebo). Performance on free recall testing was significantly worse after benztropine than after glycopyrrolate. It has previously been shown that routine clinical doses of anticholinergic antiparkinsonian drugs impair verbal learning relative to a drug-free baseline. Our results suggest that memory impairment continues to further increase as anticholinergic drugs are pushed to the upper limit of the acceptable clinical range.

Anticholinergic prophylaxis of acute haloperidol-induced acute dystonic reactions

Young adults treated with a high potency neuroleptic such as haloperidol are at high risk of developing dystonic reactions. In this retrospective study, 15 of 16 young adult patients treated only with haloperidol had such reactions within 60 hours of beginning the drug, while none of the seven patients treated with haloperidol plus prophylactic benztropine mesylate developed dystonia. Although methodologic considerations limit the generalization of these results, they are consistent with other reports and suggest that initial anticholinergic prophylaxis is warranted in young patients treated with high potency antipsychotics. All dystonic reactions in these patients occurred within 2 1/2 days, justifying the consideration of discontinuing prophylaxis (which also causes side effects) after 1 week.

Antiparkinsonian medication withdrawal in the treatment of tardive dyskinesia: a report of three cases

Three patients are presented in whom TD either disappeared (2 cases) or improved (one case) after discontinuing antiparkinsonian medication without changing the concurrent neuroleptic treatment. In addition, two of the patients presented some "complications" secondary to the TD in the form of frequent falling, psychosocial impairment and suicidal ruminations. The implications of these findings are discussed in the light of the current literature.

Three cases of akathisia and "acting out"

Three cases of akathisia are described in which the manifestations of motor restlessness were subtle enough to be easily missed, but in which the resultant propensities to behavioral "action" nonetheless contributed to significant difficulties for the patients. Appropriate medication adjustments, including adequate treatment with antiparkinsonian agents or suitable lowering of neuroleptic dosage, were beneficial. Subtle manifestations of akathisia of this sort may occur more frequently than is commonly recognized.

Anticholinergic challenge and neuroleptic withdrawal. Changes in dyskinesia and symptom measures

Benztropine mesylate (intravenous [IV] and oral) challenge was compared with brief neuroleptic withdrawal on dyskinesia ratings and symptom measures. Thirty-six neuroleptic-treated patients underwent a placebo-controlled acute IV challenge with 2 mg benztropine and a placebo-controlled two-week trial of oral benztropine mesylate (2 mg three times a day), followed by a double-blind placebo-controlled neuroleptic withdrawal involving four weeks of dose tapering and six weeks of placebo treatment. Benztropine given IV had no significant effect. Orally administered benztropine, however, led to statistically significant increases in dyskinesia and dysphoric mood. The brief neuroleptic withdrawal significantly increased dyskinesia scores and dysphoria and resulted in early termination of therapy in 12 of 36 patients (33%) due to symptom exacerbation. There was a striking absence of correlation between dyskinesia change measures brought about by benztropine and changes following neuroleptic withdrawal. Therefore anticholinergic challenge does not appear to be a fruitful procedure for identifying patients with covert dyskinesia.

The withdrawal of benztropine mesylate in chronic schizophrenic patients

In this double-blind, four-week study, 28 chronic schizophrenic patients receiving neuroleptic medication plus the antiparkinsonian drug, benztropine mesylate, were either switched to placebo or maintained on benztropine. Patients withdrawn from benztropine reliably increased their overall scores on the Wechsler Memory Scale in comparison with the drug group. Sub-test scores suggest that deficits in attention and concentration were induced by treatment with benztropine. Psychotic decompensation appeared to develop simultaneously with extrapyramidal symptoms (EPS) in some patients, but only 14.2 per cent of the placebo group experienced extrapyramidal symptoms severe enough to require resumption of benztropine therapy. It is suggested that antiparkinsonian agents should be prescribed only if and when EPS occur.

Meige syndrome: relief on high-dose anticholinergic therapy

A patient with Meige syndrome associated with spasmodic torticollis was treated with benztropine mesylate (Cogentin) at doses of 12-16 mg daily. Marked suppression of both oromandibular dystonia and the torticollis was obtained. Mild impairment of recent memory was the major side effect. Peripheral anticholinergic side effects were controlled by the concomitant administration of ambenonium chloride (Mytelase) 15 mg daily.

Differential liabilities of haloperidol and thioridazine for inducing apomorphine hypersensitivity

In an animal model of tardive dyskinesia, sensitivity to apomorphine-induced stereotyped behavior reflects increased dopamine receptor activity induced by chronic neuroleptic treatment. Four groups of Sprague-Dawley rats received haloperidol (H) 0.5 mg/kg, haloperidol 0.5 mg/kg + benztropine 2.0 mg/kg (H + B), thioridazine (T) 25 mg/kg, or saline (S) ip daily for 18 days, were withdrawn for 21 days, and then received another 10 days of drug. Drug-induced catalepsy was measured daily during the second phase of drug treatment. Sensitivity to apomorphine 0.125 mg/kg and 0.250 mg/kg was assessed during the first and second weeks of withdrawal from each phase of drug treatment. Catalepsy scores for H, H + B, and T groups showed an unexpected progressive increase over treatment days. Following withdrawal from the first drug phase, only H and H + B rats showed enhanced apomorphine stereotypy. H rats were hypersensitive for both weeks of testing while H + B rats were only hypersensitive for the first week. All rats showed changes in apomorphine sensitivity after withdrawal from the second drug phase. H and H + B rats showed significant enhancement of stereotypy at both apomorphine dose levels and at both weeks of testing. T rats showed a significant enhancement but only at the higher apomorphine dose level and only during the first withdrawal week. S rats had a significant enhancement of apomorphine-induced stereotypy during the second withdrawal week. We conclude that H, H + B, and T have differential liability for inducing dopamine receptor hypersensitivity, with haloperidol being most effective and thioridazine being least effective.

Treatment of drug-induced dystonic reactions

Thirty-two cases of drug-induced dystonic reaction were treated by the author with diphenhydramine or benztropine mesylate, intramuscularly or intravenously, in a prospective, nonrandomized fashion. Recovery time with the two drugs was compared. Benztropine mesylate lessened recovery time in this case series. An epidemiological study of drug-induced dystonic reactions found that most of the patients were drug abusers. The commonest offensive agent in this case series was haloperidol. The most common dystonic reactions seen were buccolingual and torticollic.

A new method for treating "headaches"

The author describes a 10-week study designed to gain some understanding of how to treat patients who have suffered for a long time with headaches that have not been alleviated by many attempts at treatment. Fourteen patients whose chief complaint was this kind of headache were given varying amounts of perphanazine and amitriptyline with the direct suggestion that these drugs would be helpful. This treatment appeared successful for 10 of the 14 patients at 6-month and 3-year follow-up.

Therapeutic antagonism between anticholinergic antiparkinsonism agents and neuroleptics in schizophrenia. Implications for a neuropharmacological model

Systematic data from three studies suggest that anticholinergic antiparkinsonism agents, when added to ongoing neuroleptic treatment in schizophrenics, have the effect of arresting or reversing therapeutic changes, and when given alone to untreated patients, tend to further worsen their psychosis. The countertherapeutic effects of anticholinergic drugs are reflected particularly in parameters which represent features of schizophrenic psychosis most consistently responsive to neuroleptics. It is proposed that these anticholinergic effects are central in origin and point to the involvement of cholinergic mechanisms in the expression of schizophrenic psychosis and its improvement with neuroleptic medication.

High vs standard dosage fluphenazine HCL in acute schizophrenia

This rater blind project compared the efficacy and safety of using an oral rapid or neuroleptization method (maximum 80 mg./day) versus fixed standard dosage (20 mg./day) fluphenazine, a commonly used neuroleptic. There were 32 hospitalized, acutely decompensated schizophrenic patients in the experiment; the study period for each patient was a maximum of 7 days. The data were collected using the Benjamin Proverb Test and rating scales for psychopathology and adverse effects. Data analysis by means of the analysis of covariance demonstrated few significant differences between the 2 treatment methods: both methods produced a similar reduction in psychopathological symptoms and incidence of adverse effects. The authors conclude that the rapid neuroleptization method is not superior to the fixed standard dosage method in treating acute schizophrenia.