Nonischemic ST-segment elevation induced by negative inotropic agents

The present study investigated whether regional ventricular dyskinesia (ie, systolic bulging) is a direct cause of ST-segment elevation in canine hearts in vivo. Regional ventricular dyskinesia was induced in 33 anesthetized open-chest dogs by injection of negative inotropic agents into the left anterior descending coronary artery (LAD) without disruption of coronary blood flow. Regional myocardial contraction was assessed in terms of the percent systolic shortening (%SS) and percent systolic bulging (%bulging), which were measured using ultrasonic crystals. The ST-segment elevation of the LAD-perfused area was measured with a unipolar electrode. Lidocaine, a sodium channel blocker, nicorandil, a potassium channel opener, propranolol, a beta-adrenergic blocker, or verapamil, a calcium channel blocker, was administered by intracoronary injection during maximal vasodilation induced by adenosine. All drugs induced dose-dependent ST-segment elevation in association with a parallel reduction in %SS and a parallel increase in %bulging. The absence of myocardial ischemia was confirmed by the absence of NADH fluorescence. It was concluded that regional ventricular dyskinesia had an important role in ST-segment elevation not associated with myocardial ischemia.

Phenylalanine kinetics are associated with tardive dyskinesia in men but not in women

RATIONALE

An association between tardive dyskinesia (TD) and severely impaired metabolism of the large neutral amino acid (LNAA), phenylalanine (Phe) was defined in a group of mentally retarded patients. Subsequently, an altered kinetics of Phe was associated with TD in men with schizophrenia based on plasma analyses subsequent to the ingestion of a protein meal.

METHODS

In the present study, a standardized oral challenge of pure Phe (100 mg/kg in 170 ml orange juice) was administered to psychiatric patients of both sexes (n = 312), with and without TD after an overnight fast. Plasma LNAA levels were assayed both fasting and 2 h subsequent to the ingestion of the challenge. The extent of the increase in plasma Phe levels 2 h following a standardized challenge is determined by the sum of the kinetic processes of plasma absorption, tissue distribution, metabolism and elimination.

RESULTS

The study hypothesis, that TD would be associated with significantly higher post-challenge plasma Phe indices of an absolute plasma Phe level and plasma Phe/LNAA ratio (a brain availability measure), was verified for the study men (n = 209), but not for the study women (n = 103).

CONCLUSIONS

The demonstrated altered kinetics of Phe in men with TD indicates a greater availability of Phe to the brain in these men. We suggest that the disorder may be related to the effects of this greater availability. Such effects could be the direct neurotoxic effects of Phe and its metabolites and/or the modulating effects of these compounds on the synthesis of the monoamine neurotransmitters. The fact that TD (Yes/No) group differences in post-challenge plasma Phe indices were not seen for the study women suggests the possibility of a sex difference in the biology of TD that we propose may be reflective of the young age of the study sample.

Clozapine efficacy in tardive dyskinesia in schizophrenic patients

Tardive dyskinesia (TD) is a long-term severe complication of antipsychotic treatment, with mean prevalence of 20-35%. The aim of this study was to evaluate effects of clozapine in severe TD. In an open trial seven patients with schizophrenia and severe TD were given clozapine for 6 months. Tardive dyskinesia severity was evaluated with AIMS and ESRS and schizophrenic psychopathology with PANSS. Clozapine mean dose at the end of the study was 392.86 mg/day. A mean reduction of 52% was observed in ESRS scores for TD. Two patients also had dystonic movements, and there was 50% reduction in one of them and complete remission in the other. There was also a 27% mean reduction in PANSS scores. Clozapine seems to be an alternative in the treatment of schizophrenic patients with severe TD.

Clinical manifestations of tardive truncal dystonia--abdominal movements: report of two cases

A variety of involuntary abdominal movements may result from peripheral insults or have a central origin. However, the spectrum of differential diagnoses can be broadened by this report of two patients whose involuntary abdominal movements were related to chronic use of haloperidol or sulpiride. Electromyographic studies revealed two patterns of muscle activity in these two patients. The first patient showed long-duration bursts of the thoracic and lumbar paraspinal muscles, causing repetitive backward tilting of the pelvis and downward shifting of the umbilicus. The second patient showed persistent contraction of the rectus and the external oblique abdominal muscles, causing sustained retraction of the abdominal wall and episodic jerking. Both patients improved dramatically after treatment with reserpine. We conclude that electromyographic study is useful in identifying truncal dystonia and abdominal dystonia, two variants of tardive syndrome.

The causes of sporadic and 'senile' chorea

BACKGROUND

Although 'senile' chorea is commonly listed in the differential diagnosis of chorea, the condition is poorly defined. Indeed, the existence of such an entity is debated. There are few contemporary prospective studies of sporadic chorea in the elderly.

METHODS

Detailed prospective study of patients presenting with undiagnosed chorea over a three year period to a Movement Disorder Clinic.

RESULTS

Twelve patients, aged 50 to 89 years, were identified. The final diagnoses were Huntington's disease, confirmed on genetic testing in six, antiphospholipid antibody syndrome in two, and hypocalcaemia, tardive dyskinaesia and basal ganglia calcification in each of the three remaining cases. Only one patient remained undiagnosed despite extensive investigation.

CONCLUSIONS

The majority of patients with 'senile' chorea actually have Huntington's disease even in the absence of a family history. Rarer causes of chorea still need to be considered in the elderly when Huntington's disease has been excluded by DNA analysis.

Negative symptoms, depression, and parkinsonian symptoms in chronic, hospitalised schizophrenic patients

BACKGROUND

Negative symptoms of schizophrenia are often confounded by overlapping depressive and parkinsonian symptoms. The role of medication as an aetiological factor in the development of these symptoms is an important issue for prevention and treatment.

METHODS

A total of 45 inpatients in chronic wards who met RDC criteria for schizophrenia were assessed with the Hamilton depression rating scale (HDRS) and negative symptom rating scale (NSRS) and the targeting abnormal kinetic effect scale (TAKE).

RESULTS

No significant correlation was found between the total scores on the vegetative superfactor of the HDRS and the NSRS. Duration of neuroleptic treatment was positively correlated with depressive symptoms (r=0.299, P < 0.05) and negative symptoms (r=0.443, P < 0.001). Dose of antipsychotic was also correlated positively with negative symptoms (r=0.260, P < 0.05). Age was negatively correlated with depressive symptoms as assessed by the HDRS (r=0.306, P <0.05).

CONCLUSION

The data suggest that depressive and negative symptoms can be separated in chronic schizophrenia, while pointing to a possible role of antipsychotic medication in the aetiology.

LIMITATIONS

The study was conducted in a small chronically hospitalised population treated with relatively high doses of antipsychotics. It is not clear that the results obtained here would be applicable to an acute patient population.

Effects of increasing doses of apomorphine during stereotaxic neurosurgery in Parkinson's disease: clinical score and internal globus pallidus activity. Short communication

We analysed the firing activity of internal globus pallidus cells in two Parkinson's disease patients undergoing stereotaxic surgery. Both patients showed an advanced rigid-akinetic syndrome with disabling levodopa induced dyskinesias. Apomorphine, intraoperatively administered at doses (1-2 mg) inducing a short but clear clinical improvement without involuntary movements, reduced the pallidal discharge rate by > 50% in both patients. An higher apomorphine dose (2.5 mg), tested in one hemisphere, blocked the firing activity with a time course independent from the occurrence of dyskinesias. These finding suggest that the reduction of internal pallidus excitability is one of the mechanisms underlying the efficacy of dopaminergic therapy, but also that changes in other basal ganglia stations are likely to be involved in dyskinesias.

The inter-relationships of tardive dyskinesia, parkinsonism, akathisia and tardive dystonia: the Curaçao Extrapyramidal Syndromes Study II

A study of the four extrapyramidal syndromes (EPS), tardive dyskinesia, parkinsonism, akathisia and tardive dystonia, was performed in the Netherlands Antilles, a well-defined catchment area with only one psychiatric hospital. The population under study (N = 194; mean age 53.1) was mainly Afro-Caribbean, and most patients were chronic. The severity of each EPS was measured with valid and reliable rating scales. The purpose was to study both the strength of the inter-relationships of EPS and the prevalence of combinations of EPS. The inter-relationships between the EPS were analyzed by means of logistic regression. The adjusted odds ratios between the various EPS revealed strong connections between the hyperkinetic syndromes (tardive dyskinesia, tardive dystonia and akathisia). Parkinsonism was found to be inversely related to tardive dyskinesia and to tardive dystonia. Almost 30% of the patients suffered from two or more EPS. The highest prevalence rates of combinations were: tardive dyskinesia combined with parkinsonism 12.9%, tardive dyskinesia combined with tardive dystonia 9.8%, and tardive dyskinesia combined with akathisia 5.2%. Our findings show a strong positive correlation between hyperkinetic forms of EPS. Furthermore, chronic psychiatric inpatients regularly suffer from combinations of EPS. Different treatment strategies are suggested for various combinations of EPS.

Effects of nifedipine, a calcium channel antagonist, on cognitive function in schizophrenic patients with tardive dyskinesia

We examined whether nifedipine, a calcium channel antagonist, added to a stable regimen of neuroleptic medication would affect cognition in patients with chronic schizophrenia or schizoaffective disorder who had tardive dyskinesia. Fifteen patients with tardive dyskinesia were treated with nifedipine (60 mg daily) or matching placebo for 4 weeks and then were crossed over from nifedipine to placebo or from placebo to nifedipine for another 4 weeks. At the end of each 4-week phase of the study, the patients performed a rotary pursuit test of procedural learning and a dementia scale assessing general cognitive abilities. Nifedipine improved performance in the rotary pursuit test and conceptual abilities in the dementia scale compared with placebo, but only for patients who first were exposed to the tests during the placebo condition. These results provide preliminary evidence that calcium channel antagonists might enhance learning and memory in schizophrenic patients with tardive dyskinesia.

[Respiratory dyskinesia induced by veralipride]

We describe the case of a patient whose menopause syndrome was treated with veralipride. After four months of this treatment she started to have bucco-lingual movements and marked dyspnea which caused difficult, irregular breathing and severe thoracic discomfort. After the drug was stopped there was progressive improvement and disappearance of the symptoms described. When the patient was taking a neuroleptic drug (veralipride) she developed bucco-lingual dyskinesia, considered to be the commonest late dyskinesia, together with marked respiratory dyskinesia. The latter is a type of dyskinesia seldom described, probably because it is only detected when it is severe enough to cause functional effects. It may pass unnoticed when the disorder is only slight or moderate. In the literature there are few references to disorders of movement induced by this drug, especially when compared with other benzamides which are frequently involved. However, in its mode of action there is a beneficial antigonadotropin activity together with an antidopaminergic effect which explains why they may cause such a reaction.

The use of risperidone in severely demented patients with persistent vocalizations

OBJECTIVE

The hypothesis being tested was that low doses of risperidone would diminish persistent, purposeless vocalizations in two severely demented geriatric women. A secondary hypothesis was that the severe tardive dyskinesia observed in one patient would improve after risperidone treatment.

DESIGN

An intrasubject on-off-on design was employed.

SETTING

A chronic care facility in Canada.

SUBJECTS

Two inpatients with DSM-IV (American Psychiatric Association) diagnosis of combined Alzheimer vascular dementia.

MEASURES

Nursing assessment of frequency of vocalizations. Extrapyramidal System Rating Scale (ESRS) and Folstein Mini Mental State Examination (MMSE).

RESULTS

With risperidone treatment, the vocalizations diminished to less than 20% of baseline ratings. For the patient with dyskinesia, ESRS dyskinetic movement scores decreased (baseline = 27; after risperidone 8 weeks = 16). No change was observed for the MMSE.

CONCLUSIONS

The findings support the main hypothesis. The secondary hypothesis was also supported. Further studies of larger numbers of subjects are required to substantiate these preliminary findings.

Cognitive dysfunction in chronic schizophrenia followed prospectively over 10 years and its longitudinal relationship to the emergence of tardive dyskinesia

Basic cognitive function was assessed at initial and at 5- and 10-year follow-up assessments among 41 primarily middle-aged in-patients manifesting the severest form of schizophrenia; additionally, the presence and severity of tardive dyskinesia was evaluated on each occasion. Overall, there was a modest but significant deterioration in cognitive function over the decade, particularly among older men. Longitudinally, patients with persistent tardive (orofacial) dyskinesia continued to show poorer cognitive function than those consistently without such movement disorder, though within neither group did cognitive function change over the decade. Those patients demonstrating prospectively the emergence of orofacial dyskinesia showed a marked deterioration in their cognitive function over the same time-frame within which their movement disorder emerged, but this decline did not progress further thereafter. There appears to exist some modes, progressive deterioration in cognitive function even late in the chronic phase of severe schizophrenic illness which appears to derive primarily from patients showing de novo emergence of tardive orofacial dyskinesia.

Life-threatening tardive dyskinesia

We present the case of a patient with severe tardive dyskinesia that led to dehydration. Clinicians need to recognise that tardive dyskinesia is a potentially life-threatening condition, and familiarise themselves with its management.

Does pursuit abnormality in schizophrenia represent a deficit in the predictive mechanism?

Although an abnormality of smooth pursuit eye movement has been consistently noted in schizophrenia, the underlying ocular motor pathophysiology is unknown. It is unclear whether the abnormality represents deficits in processing of information provided by the moving target, generation of pursuit eye movements, or other ocular motor and related cognitive processes. To evaluate the ability to process information provided by a moving target, saccadic accuracies were studied in step-ramp and single step tasks. Schizophrenic (with and without tardive dyskinesia [TD]) and normal subjects made equally accurate initial corrective saccades to the moving target. Thus, when the target jumped and then smoothly moved (creating a position and a velocity error on the retina), the patients were able to process retinal motion information and generate a normally accurate saccadic response. After the initial corrective saccade, both groups followed the target with a combination of pursuit eye movements and occasional catch-up saccades. During this period, the retinal velocity error is minimal because the eye approximates the target motion, and the major source of target motion information both for the smooth pursuit and saccadic responses is extra-retinal (i.e., predictive mechanism). The accuracies of catch-up saccades were significantly lower in the schizophrenic patients than in the normal subjects. During this period, overall pursuit performance, measured by pursuit gain, was also significantly worse in the patients. Accuracies of subsequent catch-up saccades, but not initial corrective saccades, significantly predicted the pursuit gain. Low pursuit gain was associated with high numbers of saccades per time spent in pursuit, which were similar in both schizophrenic subgroups (i.e., with and without TD), but were only significantly higher in the patients with TD than in the normal subjects. These preliminary data suggest that schizophrenic patients are able to process retinal motion information but have difficulties in using extra-retinal motion information to generate an appropriate saccadic response.

[Tardive dyskinesia: an increased risk of neuroleptics in elderly women]

Tardive dyskinesia is a side-effect of antipsychotic drugs. Elderly women with depression are at risk even on a low dosis. A case is presented in which a typical depression was treated with high dosis haloperidol resulting in orofacial dyskinesia and a less frequently seen grunting. Correct diagnosis, indication, dosis monitoring and regular evaluation of possible side-effects are the most important factors to prevent these serious invalidating conditions.

Polymorphic drug metabolism in schizophrenic patients with tardive dyskinesia

The metabolism of many neuroleptics cosegregates catalyzed by the polymorphic cytochrome P450 CYP2D6. The population can be phenotyped into extensive metabolizers (EM) and poor metabolizers (PM) with respect to this enzyme's activity. PM are likely to achieve higher than average concentrations of neuroleptic drugs in plasma, with an increased risk of extrapyramidal side effects, possibly including tardive dyskinesia. Sixteen white schizophrenic patients who had developed tardive dyskinesia during long-term neuroleptic treatment were phenotyped with debrisoquine and genotyped by CYP2D6-specific DNA amplification and EcoRI restriction fragment length polymorphism analysis. Only 1 (6%) of the 16 patients had a PM genotype, 8 (50%) were homozygous, and 7 (44%) were heterozygous EM. None had a CYP2D6 genotype indicative of ultrarapid debrisoquine hydroxylation capacity. The patients were also phenotyped with mephenytoin, a probe drug for another polymorphic cytochrome P450, CYP2C19. One patient was a PM of S-mephenytoin, which corresponds to the frequency found in healthy white volunteers. In conclusion, there was no overrepresentation of PM of debrisoquine or of S-mephenytoin among the 16 patients with neuroleptic-induced tardive dyskinesia. However, the PM of debrisoquine had the highest score on the Simpson-Angus Rating Scale and the second highest on the Abnormal Involuntary Movement Scale, despite a very low neuroleptic dose. Also, the debrisoquine MR correlated significantly with the SARS score (rs = 0.685, p < 0.05, N = 10), indicating a relationship between the degree of impaired CYP2D5 activity and the severity of extrapyramidal side effects during neuroleptic treatment.

Oral and genital tardive pain syndromes

We report the development of chronic painful oral or genital sensations in 11 patients with tardive akathisia, tardive dyskinesias, or tardive dystonia. In each case, the pain syndrome became a source of profound distress for the patient, overshadowing all other concurrent neuropsychiatric symptoms, and requiring treatment. Agents effective in treating tardive dyskinesia and tardive akathisia, such as catecholamine depletors, proved effective in reducing the painful sensations. Our observations support the concept of tardive pain as a complication of chronic neuroleptic exposure.

Successful treatment of respiratory dyskinesia with picoTesla range magnetic fields

Respiratory dyskinesia, a syndrome characterized by an irregular respiratory rate, tachypnea, and grunting, is a serious complication of chronic neuroleptic therapy. It frequently occurs in elderly women and is commonly associated with clinical features of Tardive dyskinesia (TD). Respiratory dyskinesia initially was considered to be a rare complication of chronic neuroleptic treatment, but more recent reports indicate that respiratory abnormalities are common in patients treated with antipsychotic medications. The appropriate management of patients with respiratory dyskinesia has not been determined as the underlying pathophysiology is incompletely understood. We present a schizophrenic patient on long term antipsychotic therapy who presented with respiratory dyskinesia associated with symptoms of TD and tardive Tourette's syndrome which emerged coincident with an abrupt withdrawal of neuroleptic therapy. In this patient, external application of picoTesla range magnetic fields (MF) produced rapid attenuation in the severity of respiratory and motor dyskinesias. As the pineal gland is considered a magnetosensor and since exposure of experimental animals and humans to external MF alters melatonin secretion, we then propose that the beneficial effects of MF involve the mediation of the pineal gland which has been implicated previously in the pathophysiology of drug-induced movement disorders including TD.

Respiratory dysrhythmias in patients with tardive dyskinesia

Tardive dyskinesia (TD) is a disorder characterized by abnormal involuntary movements and associated with neuroleptic therapy. To determine whether the respiratory muscles are involved in this condition, we compared the breathing pattern of ten patients with TD with ten patients with chronic schizophrenia receiving neuroleptic therapy without evidence of TD, and ten age-matched normal control subjects during resting tidal breathing, forearm pronation-supination (a maneuver designed to elicit the abnormal movements of TD), and breathing to a set frequency. Breathing patterns were also assessed in seven patients with TD during a progressive incremental exercise test and an overnight polysomnogram. Patients with TD had an irregular tidal breathing pattern, with a greater variability in both tidal volume and time of the total respiratory cycle (TTOT). Both groups of patients receiving neuroleptic therapy had a rapid shallow breathing pattern when performing forearm pronation-supination compared with control subjects. There were no differences between any of the subject groups when breathing to a set frequency. The patients with TD had a normal response to progressive exercise and inspiratory time and TTOT values were less variable during non-rapid eye movement sleep compared with wakefulness. We conclude that patients with TD have irregular rapid shallow breathing which is less variable during sleep and does not limit their exercise performance.

Tardive dyskinesia and associated cognitive disorders: a convergent neuropsychological and neurophysiological approach

This study sought to assess whether tardive dyskinesia (TD) related differentially to two types of cognitive functioning in schizophrenia. Thirteen schizophrenics with severe formal thought disorders (+FTD) were matched for age, sex, education, chronicity, dosage, hospital care, with 13 schizophrenics selected for absence of or minimal formal thought disorders (-FTD). TD and neuroleptic dosage were analyzed in relation to cognitive and motor tests of the Luria-Nebraska (L-N) battery and to attentional evoked potentials (EPs). EPs were recorded at electrodes Fz, Cz, and Pz, in a dichotic signal detection task (oddball paradigm), during attention and inattention conditions. Group differences on attentional EPs replicated published results with flatter and smaller positive waves in +FTD patients and larger late negative waves (FzN4-N7) in -FTD patients. Controlling for dosage, the following were the best groups discriminators. +FTD schizophrenics presented more severe dyskinesia in the orofacial area and poorer verbal scores on L-N. Severe TD correlated with smaller N1 amplitudes. +FTDs also presented distinct attentional EP deficits with abnormally small P3a, a correlate of deficient categorization and orienting. Neuroleptic dosage was not directly correlated to any single motor or cognitive measure, nor to TD indices. The hypothesis of a differential association of TD with distinct attentional/cognitive disorders was generally supported.

Factors related to the severity of tardive dyskinesia

This study was undertaken to clarify factors associated with severity of tardive dyskinesia (TD). It was hypothesized that dopaminergic changes associated with neuroleptic medication may interact with unknown vulnerabilities contributing to the manifestation of TD. Fifty-four psychiatric patients residing on the acute and intermediate care wards of a Veterans Administration hospital participated. Thirty schizophrenic and 24 manic patients, under 60 years of age, were assessed for TD using the Abnormal Involuntary Movement Scale. Cognitive tests were used to form verbal and nonverbal composite indices. The results of multiple regression analyses revealed a modest linear relationship between TD and nonverbal function (p < .03) after controlling for duration of hospitalization, years of illness, motor speed, and age. This relationship was noted for both manic and schizophrenic patients. The results of this study suggest that nonverbal dysfunction is related to severity of TD.