Efficacy of betaxolol in neuroleptic-induced akathisia

Betaxolol, a beta 1-selective antagonist, produced marked improvement in eight patients with neuroleptic-induced akathisia. No further improvement was seen with subsequent propranolol treatment. These findings, along with the results of prior studies of betaxolol and metoprolol, suggest that blockade of central beta 1-receptors may be sufficient for efficacy in akathisia.

Successful treatment of tardive akathisia with moclobemide, a reversible and selective monoamine-oxidase-A inhibitor. A case study

Tardive akathisia (TA) is a well-documented side-effect of neuroleptic treatment. The underlying mechanism is poorly understood, and treatment is unsatisfactory. In this case report, TA that occurred in the course of a tardive dyskinesia (TD) was successfully treated with the monoamine-oxidase-A inhibitor moclobemide. With respect to the mechanism of action, it may be hypothesized that dopaminergic supersensitivity in the mesocortical region is counteracted by enhanced inhibition of primarily noradrenergic neurotransmission.

Effect of caffeine intake on psychotic in-patients

Psychotic in-patients who consume caffeine may present complications in the course of their illness. Two cases are described which illustrate the clinical profile of such patients, whose caffeine-associated complications are often misdiagnosed.

Acute extrapyramidal syndromes in neuroleptic-treated elders: a pilot study

The incidence, morbidity, and risk factors for acute extrapyramidal syndromes (EPS) such as akathisia and drug-induced parkinsonism (DIP) in neuroleptic-treated elders have not been systematically explored. This study presents data on 17 elderly patients who were prospectively examined for up to 4 weeks for acute EPS, functional and cognitive status, and behavioral disturbances. Seventy-one percent of subjects developed DIP, and 18% developed akathisia. Predictors of DIP included pre-neuroleptic treatment parkinsonian signs and neuroleptic dose, despite use of low doses of neuroleptics. Development of acute EPS was associated with failure to improve behaviorally. New-onset urinary incontinence was the most common functional abnormality.

Neuroleptic use, parkinsonian symptoms, tardive dyskinesia, and associated factors in child and adolescent psychiatric patients

OBJECTIVE

The authors' goal was to determine the prevalence of and risk factors for neuroleptic-induced movement disorders in a group of psychiatrically hospitalized children and adolescents.

METHOD

They evaluated the presence or absence of parkinsonism, tardive dyskinesia, and akathisia in 104 children and adolescents who were in residence in or admitted over a 6-month period to a state-operated child psychiatric center. They applied a standardized, structured assessment procedure used in research on adult and geriatric psychiatric patients and the mentally retarded.

RESULTS

The prevalence of parkinsonism among the 61 subjects at risk was 34% and was significantly associated with longer neuroleptic treatment periods immediately before evaluation. The prevalence of treatment-emergent tardive dyskinesia among the 41 subjects at risk was 12% and showed no association with quantitative neuroleptic treatment variables. However, patients with tardive dyskinesia were significantly more likely to have a family history of mental illness and significantly less likely to have a history of assaultive behavior. A pattern of complex pharmacological responses for parkinsonism and tardive dyskinesia, some of which are not typical of those most commonly reported in adults, was seen in this group of young patients.

CONCLUSIONS

The study data highlight the acute sensitivity of the neuroleptic-treated child and adolescent to the development of parkinsonism, the possible role of certain patient characteristics in the vulnerability to develop tardive dyskinesia, and the possibility that neuroleptic-induced side effects experienced by children and adolescents differ in some ways from those experienced by adults. The data further strongly support the need for systematic monitoring of neuroleptic-treated child and adolescent patients for a full range of side effects.

Amphetamine poisoning in infant: report of two cases

Amphetamine poisoning is rare in children. Here we report two male infants with acute poisoning due to accidental amphetamine ingestion. One infant had a family history of drug abuse and the other was due to poor supervision of the parents. Although typical clinical symptoms and signs (including restlessness, hyperactivity, hypertension, tachycardia and tachypnea....etc.) were found, both were completely recovered after treatment. The principle of management of amphetamine poisoning are presented.

Low serum iron in patients with neuroleptic-induced akathisia and dystonia under antipsychotic drug treatment

The concentration of iron was determined in the serum of 35 patients; 10 with akathisia, 8 with dystonia and 17 without akathisia or dystonia. The patients exhibiting akathisia or dystonia had significantly lower serum concentration of iron than the patients without akathisia or dystonia. Neuroleptic-induced akathisia or dystonia may be facilitated by the low serum iron.

A clinical and polysomnographic comparison of neuroleptic-induced akathisia and the idiopathic restless legs syndrome

Neuroleptic-induced akathisia (NIA) is motor restlessness caused by dopamine receptor blocking antipsychotic agents. Nine patients with NIA and 11 patients with idiopathic restless legs syndrome (RLS) were studied polysomnographically. The sleep disturbances were milder in NIA than idiopathic RLS but increased numbers of awakenings and decreased sleep efficiencies were common to both groups. In addition, RLS patients demonstrated prolonged sleep latencies. Periodic movements in sleep (PMS) were present in only 5 of 9 patients with NIA but in all 11 patients with idiopathic RLS. In no NIA patient did we see the multiple, large amplitude, violent, resting myoclonic jerks of the legs that we saw during wakefulness in some of our more severe cases of idiopathic RLS. NIA patients tended to experience inner restlessness and idiopathic RLS patients tended to experience leg paresthesias as an antecedent to motor restlessness. Idiopathic RLS patients had symptoms that were worse at night and in repose far more frequently than patients with NIA. NIA and idiopathic RLS have similarities and differences. Because both NIA and idiopathic RLS are characterized by motor restlessness and sleep disturbances, the pharmacodynamics of antipsychotic medications may give clues as to both the cause and treatment of idiopathic RLS.

Smoking and movement disorders in psychiatric patients

Previous studies have suggested that tardive dyskinesia may occur more frequently in patients who smoke. Further evidence of an interaction between smoking and movement disorders includes the low lifetime exposure to cigarettes found in Parkinson's disease patients. In this study 126 patients with chronic psychiatric illnesses were blindly evaluated for tardive dyskinesia, neuroleptic-induced parkinsonism, and akathisia. Patients who smoked received significantly higher doses of neuroleptics but did not have significantly more frequent or more severe tardive dyskinesia or parkinsonism. Female smokers did have significantly more akathisia. These results are discussed with regard to interactions between smoking, central dopaminergic tone, and the psychopathology of extrapyramidal syndromes. The effect of smoking on neuroleptic blood levels as well as clinical symptomatology is also discussed.

The present status of akathisia

Akathisia is a common and distressing side effect of antipsychotic and some other psychotropic medications. This paper reviews the current state of knowledge of its clinical features, pathophysiology, and treatment. Restless legs syndrome and akathisia associated with Parkinson's disease are discussed in so far as they help understand drug-induced akathisia. The complexity of the disorder, and the difficulty in characterizing and quantifying it, may explain why researchers have relatively neglected akathisia for so long. The recent upsurge of research interest promises the hope of a better understanding of its pathophysiology so that effective therapy may result.

Fluoxetine versus trazodone: efficacy and activating-sedating effects

BACKGROUND

The efficacy and safety of fluoxetine (N = 65; median sustained dose, 20 mg/day) and of trazodone (N = 61; median sustained dose, 250 mg/day) were compared in a trial in outpatients with major depressive episode. The incidence and temporal patterns of activation and sedation were also assessed.

METHOD

Men and women who met DSM-III criteria for nonpsychotic major depressive episode (but with a current episode greater than or equal to 4 weeks) and had a 21-item Hamilton Rating Scale for Depression (HAM-D21) score greater than 20 were selected. After single-blind placebo was administered for 1 week, eligible patients were randomized to double-blind fluoxetine or trazodone treatment for up to 6 weeks. Efficacy (HAM-D21, Clinical Global Impressions Scales for Severity and Improvement, Patient Global Impressions Scale for Improvement, Guild Memory Test) and adverse events were evaluated weekly.

RESULTS

The HAM-D21 score improved within both treatment groups (p less than .001). The groups were similar with respect to endpoint mean HAM-D21 improvement. For individual adverse events that developed or worsened during therapy, more fluoxetine-treated patients reported rhinitis and tremor (p less than or equal to .05), while more trazodone-treated patients reported somnolence and dizziness (p less than or equal to .05). More combined events suggesting activation (agitation, anxiety, nervousness, insomnia) were reported with fluoxetine than with trazodone (15.4% vs. 3.3%, p less than or equal to .05), while more combined events suggesting sedation (somnolence, asthenia) were reported with trazodone than with fluoxetine (42.6% vs. 21.5%, p less than or equal to .05). Discontinuation rates for activation and sedation did not differ between treatments. Numerically, more sedation (21.5%) than activation (15.4%) was reported with fluoxetine.

CONCLUSIONS

There was little clinical difference between treatments with regard to efficacy and safety. The occurrence and temporal patterns of activation and sedation differed within and between treatments.

[Behavioral and neuropathological analyses of rats with intrahippocampal lesions]

Rats with intrahippocampal lesions produced by infusion of colchicine showed an impairment of learning ability and a decrease in local choline acetyl-transferase activity. In addition, these rats showed bizarre excitable behavior from 3 days after infusion for about an average of 10 days. This included daytime arousal, and easy jumping and squeak reactions against external stimuli as compared to the sham-operated control rats. Moreover, three-dimensional behavioral analysis disclosed: (i) the lesioned rats showed an increase ambulation compared to the control rats, (ii) a more centrally oriented sequence of wandering, while the control rats tended to display peripheral movement around the wall of the test cage, and (iii) they showed a decrease movement associated with rearing compared to the control rats. Neuropathologically, pyramidal neurons and fascia dentata of the lesioned hippocampus showed degeneration from 3 days with a marked astrocytic reaction. In addition, transient over expression of synaptophysin-immunoreactive material was seen in early stage of degeneration and this corresponded ultrastructurally to the presence of swollen synaptic boutons containing numerous non-core synaptic vesicles. These findings appeared to represent in part an abnormal excitement seen in patients with organic brain lesions, in which the excitement has been considered to correspond with neuronal death. Thus, the hippocampus-lesioned rats may provide an animal model to analyse the abnormal behaviors associated with neuronal death.

Post-triathalon delirium

This is a case presentation of acute delirium in a previously healthy man. It was originally discussed during Morbidity and Mortality Conference at The George Washington, Georgetown Residency Program in Emergency Medicine, December 1989.

Prevalence and severity of akathisia in patients on clozapine

The atypical antipsychotic clozapine is reported to have unique therapeutic effects and to produce minimal extrapyramidal side effects. However, in a blind survey, akathisia was observed to be similar in prevalence and severity in patients treated with clozapine and those receiving standard neuroleptic antipsychotic drugs. In addition, as with standard antipsychotic drugs, the presence of akathisia in patients receiving clozapine was associated with a worse overall clinical outcome. The results suggest that akathisia may be a common side effect of all antipsychotic drugs, that akathisia may be produced by a mechanism distinct from other locomotor effects of these medications, and that patients receiving clozapine, like patients receiving standard antipsychotic drugs, should be monitored for akathisia.

A placebo-controlled trial of nadolol in the treatment of neuroleptic-induced akathisia

BACKGROUND

Although propranolol has been documented to be useful in treatment of neuroleptic-induced akathisia, preliminary anecdotal reports on the efficacy of nadolol in treatment of this condition are contradictory.

METHOD

To evaluate the efficacy of nadolol in treatment of this condition, a double-blind, placebo-controlled trial was conducted in 20 psychiatric inpatients. Patients with akathisia of at least moderate severity were randomly assigned to receive nadolol 40 to 80 mg/day or placebo. Patients were rated daily for 4 days, then every other day for 15 days by means of the Extrapyramidal Symptom Rating Scale.

RESULTS

No significant differences were found between or within groups in subjective restlessness scores. In objective akathisia scores, there were no significant differences between groups; however, beginning at Day 9, both groups showed significant improvement compared with Day 1. There was no difference between groups in number of responders.

CONCLUSIONS

The authors' data do not support the efficacy of nadolol in the treatment of neuroleptic-induced akathisia and do not provide support for a peripheral site of action for beta-blockers in treatment of this condition.

Plasma levels of fluphenazine in patients receiving fluphenazine decanoate. Relationship to clinical response

The levels of fluphenazine and fluphenazine sulphoxide in schizophrenic patients who were randomly assigned to receive either 5 mg or 25 mg of fluphenazine decanoate every two weeks were monitored. Patients treated with 25 mg of fluphenazine decanoate required three months to reach a steady-state plasma level, indicating that those patients who are being converted from oral to depot fluphenazine should continue to receive oral supplementation during the first three months of treatment with fluphenazine decanoate. Plasma levels of fluphenazine sulphoxide were lower than levels of fluphenazine. At six and nine months following randomisation, there was a statistically significant relationship between lower fluphenazine plasma levels and an increased risk of psychotic exacerbations. A relatively weak relationship was found between fluphenazine plasma levels and akinesia, but non-significant relationships between fluphenazine levels and other neurological side-effects including akathisia, retardation, and tardive dyskinesia. Monitoring the plasma levels may be helpful to clinicians who are attempting to treat stabilised patients with the lowest effective dose of fluphenazine decanoate.

Tardive dyskinesia and positive symptoms of schizophrenia

Positive symptoms and movement disorders were rated in 44 schizophrenic inpatients. A significant negative correlation was demonstrated between tardive dyskinesia and positive symptoms. Possible explanatory mechanisms are discussed.