[A case report of cyclic psychosis]

Cycloid psychoses have a special position in psychiatric classification. Usually they are listed among atypical psychoses, located between the group of schizophrenias and affective psychoses. Nevertheless, there are indications for nosological differentiation of cycloid psychoses from other psychotic conditions. The case of cycloid psychosis of a 38 year old woman with two severe psychotic episodes of mixed, paranoid and affective symptomatology is described. Among the characteristic features of psychotic episodes were acute onset, severe but short course of the episodes and the lack of residual/defect symptoms at outcome. On the basis of this case the differential diagnosis of cycloid psychoses is discussed.

Orthostatic challenge during neuroleptic test dose: a possible predictor of short-term outcome

Cardiovascular measurements were used as indicators of autonomic arousal during an orthostatic challenge test without medication and after a test dose of 150 mg perazine in 20 acute schizophrenic patients. Unmedicated schizophrenics showed elevated heart rates and elevated systolic and diastolic blood pressure in comparison to healthy volunteers. After a test dose of 150 mg perazine, responders (using BPRS outcome criteria after 23 days) showed a pronounced orthostatic heart rate reaction in comparison to nonresponders. Results are discussed in relation to arousal theories and central dopaminergic activity in schizophrenia.

Initial improvement as a criterion for drug choice in acute schizophrenia

Several investigators have found that the initial improvement of acute schizophrenia after some days of neuroleptic treatment is correlated in a statistically significant way to the outcome after four weeks. In all these studies the question arises as to whether the correlation between early response and subsequent outcome is due to a specific response to a certain neuroleptic, or whether patients who respond early simply have a better prognosis. In order to isolate the specific drug effect from prognostic influences we performed a controlled double-blind study in 50 newly admitted schizophrenic inpatients. All patients were treated over three days with 15 mg haloperidol i.v., following which they were classified as 'early responders (ER)' (markedly improved or improved) or as 'early nonresponders (EN)' and then randomly assigned to group 1 (3 x 5 mg haloperidol p.o./d) or to group 2 (3 x 100 mg perazin p.o./d). If there was a specific drug effect on the correlation between early response and subsequent outcome a therapeutic superiority of perazin in EN and no superiority in ER was expected. Independently of the treatment condition the mean BPRS score had decreased from 61.2 (Sx = 12.1) to 38.1 (Sx = 13.9) at the end of the study. ER and EN were evenly distributed in the haloperidol and perazin group. The analysis of variance revealed no significant interactions of the factors 'treatment condition' x 'duration' x 'early response' (p = 0.27) and 'treatment condition' x 'early response' (p = 0.88) on the outcome (BPRS, CGI). This means that the initial hypothesis of this study has to be rejected.(ABSTRACT TRUNCATED AT 250 WORDS)

Schizophrenic patients treated with high dose phenothiazine or thioxanthene become deficient in polyunsaturated fatty acids in their thrombocytes

Total fatty acids were analysed in thrombocytes of schizophrenic patients treated with a "high dose" or "low dose" monotherapy of neuroleptic drugs phenothiazine or thioxanthene. The ratio of the very long chain fatty acid hexacosanoic acid to the long chain fatty acid docosanoic acid (C26:0/C22:0) increased in the "high dose" and "low dose" groups as compared to healthy untreated controls (P less than 0.05). The polyunsaturated fatty acid arachidonic acid decreased in the "high" and "low dose" groups (P less than 0.01 and P less than 0.05). The polyunsaturated fatty acids alpha-linolenic acid, eicosapentaenoic acid and docosahexaenoic acid were not detectable in most of the "high dose" schizophrenic patients, however, they were found in the "low dose" group and in the controls. There was a negative correlation between the daily dosage of phenothiazine and the percentages of the polyunsaturated fatty acids arachidonic acid and alpha-linolenic acid+eicosapentaenoic acid+docosahexaenoic acid in thrombocytes (r = -0.87, P less than 0.01 and r = -0.81, P less than 0.01). Two patients of the "high dose" group with an especially high and long lasting monotherapy of neuroleptics were nearly devoid of polyunsaturated fatty acids in their thrombocytes. Untreated schizophrenic patients exhibited a fatty acid pattern in their thrombocytes not markedly different from that of the healthy untreated control group. We conclude that neuroleptic drugs phenothiazine or thioxanthene can alter the fatty acid pattern of thrombocytes.

[Electroconvulsive therapy in treatment of acute life threatening catatonia in toxic epidermal necrolysis (Lyell syndrome)]

Toxic epidermal necrolysis (Lyell syndrome) developed in a 43-year woman treated with carbamazepine, perazine, and sulpiride for recurrent manic bipolar disorder. Five days after withdrawal of all psychotropic medication her psychiatric illness was exacerbated and a syndrome of lethal catatonia developed which was promptly treated with unilateral electroconvulsive therapy (ECT). Rapid remission of lethal catatonia after the first ECT treatment and of her affective disorder within days was achieved. According to clinical observations of the preneuroleptic era, early improvement of lethal catatonia following ECT may have been supported by concurrent high dose corticosteroid therapy for toxic epidermal necrolysis.

Early serum levels of neuroleptics do not predict therapeutic response in schizophrenia

Thirty-six acute schizophrenics were included in a 28-day open treatment study with the neuroleptic perazine. Peak serum levels of parent drug and its main inactive metabolite desmethyl-perazine were assessed 2 hours after an oral test dose given at the beginning of the study. Whereas peak levels of perazine were not significantly different in treatment responders and nonresponders, desmethyl-perazine was significantly higher in nonresponders. The ratio between desmethyl-perazine and perazine was not predictive of (non-) response to neuroleptic treatment in schizophrenia.

[Clinical effectiveness of zotepine in treatment of negative schizophrenic symptoms. Results of an open and a double-blind controlled trial]

The clinical action of Zotepine was examined in an open and in a randomised double-blind controlled study in in-patients displaying a productive or minus pattern of symptoms within the framework of a schizophrenic disease or schizoaffective psychosis. The present paper discusses only the results achieved in treating schizophrenic minus patterns of signs and symptoms. In Study I 20 schizophrenic patients were treated with two different Zotepine dosages. Group 2 (n = 12) showed at an average daily dose of 168 +/- 15 mg (150-190 mg) a significant improvement (p less than 0.05) of the anergy subscore in the BPRS scale as well as a significant improvement of the subscores affective flattening, anhedonia/asociality and attentional imparvement in the SANS scale, compared with Group 1 (n = 8) with an average daily dose of 270 +/- 37 mg (240-340 mg). This improvement developed already during the first two weeks of the treatment. In Study II the antipsychotic action of Zotepine compared to that of perazine was studied under double-blind conditions. The average daily dose in the Zotepine group (n = 20) was around 241 +/- 70 mg (106-396 mg), in the perazin group (n = 19) at 348 +/- 09 mg (214-575 mg). With regard to the BPRS subscore anergy and all the subscores of the SANS scale, there was a distinct improvement without significant group differences. Both substances were comparably well tolerated.

[Effectiveness and tolerance of zotepine in a double-blind comparison with perazine in schizophrenic patients]

40 inpatients suffering from a schizophrenia (ICD-9) were treated with either zotepine or perazin. The study was continued for a period of 28 days. Assessment of clinical efficacy was effected via BPRS, AMDP, CGI and SANS; tolerance was assessed by means of Simpson's scale. In addition, EEG, ECG and laboratory controls were conducted. The overall therapeutic efficacy was good, and it was not possible to distinguish one group from the other, i.e. both substances were equally effective, judged by means of the psychopathometric tools that were at our disposal. In 11 patients of the zotepine group and in 9 patients of the perazin group, slight extrapyramidal symptoms were observed. No clinically relevant changes were seen in EEG, ECG and laboratory controls in both groups.

[Zotepine versus perazine in patients with paranoid schizophrenia: a double-blind controlled trial of its effectiveness]

The dibenzothiepine zotepine is a new potential "atypical" neuroleptic exhibiting powerful antiserotonergic and antidopaminergic properties. The efficacy of zotepine was evaluated in a double-blind controlled trial versus the tricyclic neuroleptic perazine in 41 patients suffering mainly from the paranoid-hallucinatory type of schizophrenia. The key outcome variable was the extent of mental disturbance as defined by the total score of the BPRS. Additional outcome variables were GAS and CGI. In addition, adverse reactions and extrapyramidal side effects were assessed according to the FSUCL scale and the Gerlach and AIMS rating scale, respectively. Additional variables recorded were blood pressure, heart rate and routine laboratory parameters as well as electrocardiogram and electroencephalogram. In the first two days, standard equivalent doses of both drugs were administered. Thereafter, doses were administered as required. The efficacy of both substances was compared after 7, 14 and 28 days of treatment. Both drugs showed a similar antipsychotic efficacy. Under zotepine treatment a 55% improvement of the BPRS total score was observed while perazine led to a 41% BPRS score reduction. After 7 days the zotepine group was significantly more improved than the perazine group, possibly due to a dosing effect in the perazine group. In the zotepine group, fewer adverse reactions and a better benefit/risk index were observed although the differences between the two treatment groups did not reach levels of statistical significance. There were no drug-specific abnormal laboratory findings. Thus, in the present study there was no significant difference between zotepine and perazine with respect to antipsychotic efficacy and side-effect rates. However, zotepine showed a trend to a better benefit/risk index at the end of treatment.

[Comparative studies of the effects of perazine, fluphenazine, trifluoperazine, chlorpromazine and haloperidol on primary and deficit symptoms of paranoid schizophrenia]

In order to evaluate the influence of some neuroleptics on unproductive symptoms of schizophrenic process, first hospitalized patients with paranoid schizophrenia underwent monotherapy with perazine, fluphenazine, trifluoroperazine, chlorpromazine, and haloperidol. All the drugs eliminated the productive activity of the disease process within 2 months in both women and men aged 18-40 years. However, drugs showed different qualitative and quantitative effects on unproductive symptoms of schizophrenic process; this fact allows the suggestion regarding the particular usefulness of drugs in the out-patient care.

Auditory evoked potentials as possible predictors of outcome in schizophrenic outpatients

As part of a follow-up study on long-term neuroleptic treatment, 36 schizophrenic out-patients under neuroleptic treatment were studied in an 'auditory oddball' event-related potential paradigm after a 3-month stabilization phase following clinical discharge. In the first cross-sectional analysis, we evaluated the influences of age and gender and tried to find auditory evoked potential (AEP) variables, which might be promising as potential predictors of the course of illness. Compared with healthy age-matched controls, the patients showed smaller N1/P3-amplitudes. Males and females showed only minor AEP-differences, the amplitude N1/P2 being slightly higher in females. Age correlated positively with the latency P3 and negatively with the latency P2R. The interpeak latency P3-P2R showed the highest correlation with age. Test/re-test reliability was measured and variables with r less than 0.60 were rejected. The amplitudes N1/P2 and N1/P3 showed the highest test/re-test correlations. The more severely disturbed patients (global assessment scale [GAS]-score less than 65) had shorter interpeak latencies P2F-N1F than the less disturbed patients (GAS greater than or equal to 65). Patients with a high rate of relapse tended to have shorter interpeak latencies P2F-N1F than patients with low rates of relapse. Our results indicate that the interpeak latency P2F-N1F has an acceptable test/re-test reliability (C3: r = 0.72; C4: r = 0.80) and is related to clinical variables characterizing the course and outcome of illness. This leads to the hypothesis that a short interpeak latency, P2F-N1F, might be a predictor of poor prognosis.

[Perazine-induced agranulocytosis--case report]

This complication normally arises between the 5th and 10th weeks of treatment and is most commonly seen in middle-aged and elderly women. The risk is estimated to be between 0.04% and 2%, depending on the type of medication and the method of assessment. The present report describes a 16-year-old boy who developed agranulocytosis after 4 weeks of treatment with perazine. The problem was complicated by acute toxoplasmosis. After perazine was discontinued the neutrophils recovered within 5 days; the boy did develop fever, but the infectious disease had a mild course. This case report once again confirms the importance of regular blood control during the early phases of treatment with psychopharmacological agents.

Autonomic nervous system differences as predictors of short-term outcome in schizophrenics

Skin conductance and heart rate of 19 drug-free acute schizophrenic patients were measured before neuroleptic therapy was started. The patients were divided into two groups according to therapeutic outcome. The Discriminant Analysis revealed a difference in the ANS activity pattern between the group with low improvement and the group with a more favorable outcome. The low improvement group showed a paradoxical ANS reactivity pattern: relatively lower activity in skin conductance level under demand (attention task) and relatively higher activity, as reflected by the cardiovascular response to neutral stimuli (orienting stimuli), which suggests poor adaptation of ANS arousal to the environment in these schizophrenics. This finding agrees with those reported in other short-term outcome studies that considered differences in ANS activity in a schizophrenic population. The authors' findings indicate that these differences in the ANS response in schizophrenics should be included in future biochemical and pharmacotherapeutic investigations on schizophrenia.

Can changes in eye-contacts predict therapeutic outcome in schizophrenic patients undergoing neuroleptic treatment? Results of a preliminary study

The proportion of interview time spent in eye-contacts was studied before the onset of and during neuroleptic treatment in a group of 24 male schizophrenic patients. A significant increase in eye-contacts after 14 days distinguished responders to neuroleptic treatment, while a tendency towards the same effect distinguished patients treated with haloperidol from those treated with perazine. Only in the subgroup of responders was there a significant relationship between increase in eye-contacts and reduction of psychopathologic symptoms, regardless of whether these values were compared for the same treatment days or whether early changes in eye-contacts were compared with final outcome of treatment after 28 days. Since the patient subgroups were rather small, the results should still be considered preliminary. A prospective study including more parameters of visual interaction, a larger patient sample, and a longer observation period is required.

A case of perazine-induced enteritis--allergy or pseudoallergy?

Almost all adverse reactions to neuroleptic drugs in the gastro-intestinal system can be explained by their peripheral cholinergic blocking action with subsequent inhibition of intestinal tone and peristalsis. As a rare condition, severe diarrhoea due to enteritis may occur. A case with this complication is presented, the etiology and pathogenetic factors are discussed.

[Perazine-induced agranulocytosis--case report and discussion]

A 22-year-old female patient developed agranulocytosis 26 days after starting single agent treatment with perazine. In accordance with the clinical and hematological picture this agranulocytosis is classified as antibody mediated with destruction of peripheral neutrophils. After cessation of perazine treatment and proper therapy of infection the patient recovered within two weeks. The diagnosis of agranulocytosis should be suspected in anyone on neuroleptic treatment who develops fever, malaise or objective evidence of an infection and in neutropenic patients the adequate treatment should be started immediately.

The outpatient clinic for patients under chronic lithium or neuroleptic treatment as a phase-IV research tool

Psychiatric drug treatment often means life-long therapy Controlled long-term drug trials in psychiatric patients over periods of more than three years, however, do not exist. Organisational and ethical reasons prohibit placebo controlled or even standard drug controlled trials over periods of one decade and more. The present paper illustrates the methodology and scientific significance of well-documented long-term follow-up studies by example of the structure and scientific results of two outpatient clinics: (1) a schizophrenic outpatient clinic taking care of approximately 200 patients of whom a subgroup has been treated with perazine for now 18 years on the average; (2) a lithium clinic taking care of approximately 100 actively participating patients.--It is suggested that this kind of "naturalistic" open trials, set up in accordance with conditions normally occurring in psychiatric practice, are a necessary complement to other controlled methodologes.

No correlation between neuroleptic-induced increase of beta-endorphin serum level and therapeutic efficacy in schizophrenia

In 23 acute, unmedicated, schizophrenic patients, psychotic behaviour and beta-endorphin serum level were measured before and during four weeks of neuroleptic therapy. Prior to drug treatment, beta-endorphin level of all patients was within the normal range. Neuroleptic therapy induced marked elevations of beta-endorphin in eight subjects; statistical analysis revealed a slight but significant increase for the whole group. This endocrine effect was not correlated with therapeutic efficacy of neuroleptic treatment.

Prediction and evaluation criteria in perazine therapy of acute schizophrenics. Pharmacokinetic data

Twenty-eight patients with acute schizophrenic illness received an oral daily dose of 200-800 mg perazine (Taxilan) for 4 weeks. Weekly plasma level determinations showed a constant perazine concentration from day 7 to day 28, whereas the equilibrium level of its metabolite desmethyl perazine was only achieved at day 14; on an average it amounted to twice the level of perazine. Additional measurements were carried out 2 and 4 h after administration of the morning dose on day 14. The maximal increase of the perazine concentration was usually reached after 2 h; though it varied between 7 and 240% of the morning level, a close correlation existed between minimal and maximal levels. The perazine fraction not bound to plasma proteins was found to be 3.1-5.5% on day 21. The percent improvement in target syndromes during 4 weeks of neuroleptic therapy, as documented with the AMDP system, was most marked in those patients who had perazine levels in the 100-230 ng/ml range at day 28; patients with lower or higher levels improved significantly less. Curvilinear relationships also appeared to exist between improvement and free perazine concentration as well as maximal level on day 14. With regard to total scores on the Brief Psychiatric Rating Scale or scores of higher-order factors, no significant relationship between improvement and perazine level was found. The desmethyl perazine concentration did not exhibit a significant relationship to the therapeutic result. The pharmacokinetic parameters investigated seem to have a limited influence on the clinical outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction and evaluation criteria in perazine therapy of acute schizophrenics. Methodological considerations, sample population, and research variables

In an open study of schizophrenic patients treated with perazine (Taxilan), a multidimensional approach comprising the following three areas was chosen: 1. psychopathology (AMDP, BPRS); 2. psychophysiology (habituation of skin resistance reaction, pulse rate); 3. pharmacokinetics (perazine-desmethylperazine plasma levels). Looking beyond the known global effect of the neuroleptic drug, interactions between these three areas were studied. Furthermore, methodological questions concerning possible predictor variables for treatment outcome were examined. Finally, an improved method for analyzing psychopathological data was employed. The methodological framework of the study, the examination techniques, and patient population are presented.

Prediction and evaluation criteria in perazine therapy of acute schizophrenics: psychopathological results

In a pharmacopsychiatric pilot study 28 patients with an acute schizophrenic illness were treated for 4 weeks with perazine (Taxilan). Research goals in the psychopathological investigation were: (1) to assess the range of efficacy, target symptoms and syndromes of perazine and to compare these results with previous studies; (2) to compare the quality, interrater reliability, and practicability of two instruments of psychopathological assessment (AMDP and BPRS) for measuring change during treatment; (3) to apply new mathematical methods for finding statistically significant changes in symptomatology on the item level as well as on the levels of syndrome and total score; (4) to test whether pre-treatment prediction based on psychopathological evaluation or psychophysiological data is possible. The target symptoms and syndromes of perazine were the "positive" schizophrenic syndromes, above all thought disturbances and delusional phenomena. This result was consistent with a former perazine investigation. The BPRS proved to be a practicable and reliable instrument for a more global evaluation of change in psychopathology. The AMDP seemed to be especially useful for evaluating the homogeneity of a sample and showing differentiated psychopathological profiles. On this scale, changes in symptomatology became statistically apparent more clearly and more quickly on the syndrome level rather than on the level of single items. As to interrater reliability, both scales perform well. Dichotomizing the original scaling may mean a loss of information from both scales (AMDP and BPRS) in their evaluation of change. Hence it seems necessary to introduce new mathematical procedures (e.g., Friedman and Dunn-Rankin tests) into pharmacopsychiatric research.(ABSTRACT TRUNCATED AT 250 WORDS)