Organic brain dysfunction and cognitive deficits in young schizophrenic patients with tardive dyskinesia

Tardive dyskinesia (TD) has been associated with cognitive deficits, especially in older psychiatric patients on neuroleptic medication. This study investigated the relationship between presence of TD, organic brain dysfunction (OBD), and cognitive deficits in young psychiatric outpatients maintained on minimal doses of oral neuroleptics, with anticholinergics prescribed only on as-needed basis. Sixty-four patients, aged 20-39 years, were evaluated for the presence of abnormal movements, localizing and nonlocalizing physical signs, and deficits in memory, ability to shift, and sustained attention. Sixteen patients showed definite signs of TD. Significant associations were found between TD and OBD, and between cognitive deficits and OBD, but not between TD and cognitive deficits. Significant regression predictors of TD were the interaction between OBD and previous dystonia, as well as duration of neuroleptic treatment. These findings suggest that some potential risk factors for TD already identified in the literature also apply to younger patients with relatively shorter exposure to neuroleptics. However, the results indicate that the relationship between movement disorders and cognitive deficits may be more apparent in older patients.

Arm tremor, tardive dyskinesia, and mental retardation

The arm tremor of adults diagnosed as having mental retardation and/or tardive dyskinesia was examined through an analysis of the acceleration properties of several arm postures. The degree of arm acceleration was increased in all groups compared to a control group without mental retardation. The tardive dyskinesia and/or mentally retarded groups also showed a shift to a lower modal frequency of physiological tremor. Results showed that both time domain and frequency properties of the tremor acceleration signal are necessary to distinguish between groups. The neuroleptic medication appears to engender a dual and opposing influence on performance in the arm tremor task for the mentally retarded group. The medication reduces behavioral variability as indexed by analyses of arm acceleration over time (time domain) but lowers the modal frequency of physiological tremor.

A quantitative study of levodopa-induced dyskinesia in Parkinson's disease

The present study addressed the question of whether the emergence and severity of levodopa-induced dyskinesia was related to the therapeutic benefits derived from levodopa. Eight PD patients with clinically observed levodopa-induced dyskinesia were studied prior to and for two hours following a single dose of Sinemet (carbidopa/levodopa). Quantitative instrumental procedures were used to assess upper extremity dyskinesia, rigidity and bradykinesia. Results indicated that all patients exhibited significant reduction in their parkinsonism within 45 minutes following treatment. Reduction in bradykinesia, but not rigidity appeared to coincide with the emergence of dyskinesia. There was a significant relationship between severity of dyskinesia and the degree of improvement in movement velocity but not rigidity. Further analyses revealed that this relationship depended largely on the age of the patient. These findings are discussed as they pertain to a unified model of basal ganglia movement disorders which places dyskinesia and bradykinesia at opposite extremes along a continuum.

Diabetes and development of tardive dyskinesia

Diabetes mellitus has been identified as a possible risk factor for tardive dyskinesia. The authors examined 160 elderly individuals who were beginning neuroleptic treatment; 24 had diabetes and 136 did not. After 43 weeks of neuroleptic exposure, the cumulative incidence rates of tardive dyskinesia were 54.1% (SE = 5.6%) for the diabetics and 25.6% (SE = 16.1%) for the nondiabetics.

Brain atrophy and intellectual impairment in tardive dyskinesia

Fourteen chronic schizophrenic patients with tardive dyskinesia (TD) and 13 without TD were given psychological tests and CT scans. The low density rate (LDR), i.e., the ratio of the X-ray absorption (corresponding nearly to that of cerebrospinal fluid) of a brain lesion to the X-ray absorption of the whole brain, was used as an index of brain atrophy (HN-method). The LDR of the left hemisphere of the TD patients was significantly higher than that of non-TD patients in the basal nucleus and lateral ventricle, and the LDR of the right hemisphere for the TD patients was significantly higher than that of non-TD patients in the basal nucleus. The Hasegawa Dementia Rating Scale (HDRS) and Bender-Gestalt Test (BGT) for the TD patients were significantly lower than those for the non-TD patients. Our study revealed that brain atrophy was greater in TD than in non-TD patients and tended to be more pronounced in the left hemisphere, and that the degree of intellectual impairment was greater in the TD patients than in the non-TD group. The results suggest that schizophrenic brains with TD tend to be more easily damaged than those without TD, that this tendency predominates on the left side, and that intellectual impairment in TD is related to brain atrophy.

An animal model for coexisting tardive dyskinesia and tardive parkinsonism: a glutamate hypothesis for tardive dyskinesia

There is now ample evidence for long-term malfunctioning within five different brain GABAergic pathways in a monkey model for tardive dyskinesia (TD). Three of these GABA connections (GPe-STN, CP-SNr, and CP-GPi) are chronically downregulated during neuroleptic treatment and after some years they do not seem to regain their normal activity, even when the neuroleptics are discontinued. The persistent downregulation of these three GABA connections, evidenced by depressions of terminal GAD activity and GABA levels, appears to be a conceivable mechanism behind tardive parkinsonism (TP), often reported to coexist with TD in the clinic. The TD patients' well-known lack of awareness of their symptoms may be due to their parkinsonian "sensory neglect." Another two GABA malfunctioning connections were found in our monkey model: SNr-VA/VL and GPi-VA/VL. These pathways are upregulated during chronic neuroleptic treatment, partly due to an elevated glutamate release within subthalamofugal pathways. This chronic glutamatergic hyperactivity may have acted via an excitotoxic mechanism and consequently both GPi and VA/VL had a low synaptic activity in our dyskinetic monkeys, as measured by 2-deoxyglucose uptake, even 4 months after the last neuroleptic dose. It is hypothesized that TD may be due to an excitotoxic lesion of the inhibitory GABAergic VA/VL afferents, while TP has to do with persistent malfunctioning of downregulated SNr and GPi afferents.

Correlations between kinematic and rating scale measures of tardive dyskinesia in a developmentally disabled population

This paper reports a study that examines the relations between Dyskinesia Identification System: Condensed User Scale (DISCUS) scores and a battery of postural and movement kinematic measures in a group of adults diagnosed as being developmentally disabled and screened as having tardive dyskinesia. The results showed that finger tremor measures correlated with the tongue tremor and pill rolling items of DISCUS, whereas the postural stability scores correlated with the toe movement item of DISCUS and the total DISCUS score. There was also a high stability in subject kinematic performance from trial to trial over the postural and movement tests. The pattern of correlations between the DISCUS items and movement kinematic measures is consistent with the proposition that tremor is a centrally rather than peripherally driven phenomenon, although many factors contribute to emergent tremors. These findings provide construct and content validity for the DISCUS as a screening device for tardive dyskinesia and suggest that certain posture and movement kinematic measures could be sensitive measuring methods for tardive dyskinesia in developmentally disabled populations.

The profile of cognitive impairment in elderly dyskinetic subjects

Cognitive performance was assessed in 107 psychiatric patients whose age exceeded 59 years and who did not carry the diagnosis of organic mental syndrome. In this sample, tardive dyskinesia (TD) was associated with greater impairment in each of the seven cognitive domains assessed. These data do not address the etiology of TD but raise questions regarding the use of antipsychotics in young patients with cognitive impairment. Insofar as TD is an expression of basal ganglia dysfunction, these data also emphasize the critical role of relatively caudal brain structures in cognition and emotional expression.

Sub-syndromes of tardive dyskinesia and some clinical correlates

Syndromes of dyskinetic movements in subjects (N = 70) with chronic schizophrenia were investigated, using principal components analysis of AIMS ratings. Consonant with previous research, three discrete groupings were found, namely dyskinetic movements of lips-jaw-tongue, limb-truncal and facial movements. These were then related to demographic, psychological and movement disorder variables. The limb-truncal, but neither the lips-jaw-tongue nor facial movements components, were associated with negative symptoms and cognitive impairment.

[Acute dyskinesia as the cause of jaw dislocation]

A case of an acute dyskinesia of a young, schizophrenic woman caused by neuroleptic therapy is reported. The acute dyskinesia was the reason for a complete luxation in the jaw-joint. The patient showed phenomenons (brain-atrophy, cognitive dysfunction, negative symptoms) which are discussed to be connected with acute dyskinesia. They also are a danger-signal regarding the beginning of a tardive dyskinesia.

Psychotropic drug-related rhabdomyolysis

OBJECTIVE

The objective of this review is to discuss the pathophysiology and potential etiologies of rhabdomyolysis in psychiatric patients, with an emphasis on psychotropic drug-induced rhabdomyolysis.

DATA SOURCES

References were obtained through an on-line search of MEDLINE, using English-language and human literature only.

STUDY SELECTION

Because the topic is a potential drug-induced adverse effect, no controlled studies are available. Most of the literature are case reports and series of case reports.

DATA EXTRACTION

The quality of case reports was assessed using the Food and Drug Administration guidelines for assessing the causality of a potential adverse drug reaction.

DATA SYNTHESIS

The results of this review are based on qualitative data and indicate that rhabdomyolysis in psychiatric patients can be from multiple etiologies, including agitation, dehydration, and intramuscular injections, as well as an adverse effect of psychotropic medications. Although the deficiencies of this type of data are recognized, it is the only type of data often available to assess the etiology and causality of an uncommon adverse event.

CONCLUSIONS

Rhabdomyolysis in psychiatric patients can be caused by many factors, both drug- and non-drug-related. Rhabdomyolysis is more likely to occur when patients are faced with a combination of risk factors. When combinations of factors are present (e.g., aggression and restraints, intramuscular injections, and extrapyramidal effects), or when muscle trauma from an individual factor is sufficiently traumatic, muscle necrosis may occur to the point that rhabdomyolysis ensues.

The acute effects of a loading dose of phenylalanine in unipolar depressed patients with and without tardive dyskinesia

The effects of a loading dose of 100 mg/kg phenylalanine (PHE) were assessed in three groups of DSM-III-R diagnosed unipolar depressed patients: patients with tardive dyskinesia (TD) (n = 11); patients exposed to neuroleptics (NLs) but without TD (n = 10); and patients never exposed to NLs (n = 10). No significant differences were obtained in fasting and 2 hour postloading PHE plasma levels between the groups. A statistically significant correlation was found between Abnormal Involuntary Movements Scale total scores and postloading PHE plasma levels (p less than .05). Three TD patients showed unusually large increases in PHE plasma levels and PHE:large neutral amino acid ratios. Abnormalities in PHE metabolism may contribute to the development and severity of TD in some NL-treated unipolar depressed patients.

[Respiratory disorders caused by tardive dyskinesia in psychogeriatric patients]

Three case reports of antipsychotically induced tardive dyskinesia with prominent respiratory symptoms in elderly behaviourally disturbed patients are presented, followed by a discussion of the clinical picture and treatment of this relatively ill-known condition. It is not uncommon for the respiratory symptoms of tardive dyskinesia to be misdiagnosed as a pulmonary or psychogenic disorder. As an overall satisfactory treatment of tardive dyskinesia does not exist at present, reinstitution or increasing the dose of antipsychotics is sometimes the only effective way to suppress severe dyskinesia.

Relationship of symptomatology of schizophrenia and tardive dyskinesia

The role of drug factors and patient factors in the development of tardive dyskinesia (TD) was examined in 31 TD patients and 31 non-TD patients matched by age and sex. TD patients achieved significantly lower total scores on the anxiety-depression factor of Brief Psychiatric Rating Scale (BPRS) (5.2 +/- 1.4 vs. 6.5 +/- 2.2; less than P) and significantly higher total scores on the activation factor (6.4 +/- 2.2 vs. 5.3 +/- 2.5; less than P). The finding that TD patients were less depressed may be explained by a hypermonoaminergic state developing in TD. Based on the findings of this study it is suggested that catatonic schizophrenic patients are more vulnerable to the development of TD.

Is diltiazem effective in treating the symptoms of (tardive) dyskinesia in chronic psychiatric inpatients? A negative, double-blind, placebo-controlled trial

Calcium channel blockers, antiarrhythmic drugs, such as verapamil and diltiazem, may decrease the symptoms of tardive dyskinesia. The efficacy and safety of administering 60 mg diltiazem hydrochloride, four times daily for a period of 3 weeks, was studied in a random, double-blind, crossover trial in which the drug was compared with placebo in 17 neuroleptic-treated, chronic psychiatric inpatients of both genders with (tardive) dyskinesia. The severity of the dyskinesia was assessed using the Abnormal Involuntary Movement Scale. Neither diltiazem nor placebo produced a significant decrease in the severity of the dyskinesia. Diltiazem did not influence the psychiatric state of the patients, nor did it have a significant effect on either the blood pressure or electrocardiographic parameters. No significant adverse drug reactions were elicited.

Tardive dyskinesia and diabetes mellitus

Two studies examine the prevalence of tardive dyskinesia (TD) in neuroleptic-treated diabetic patients. Study 1 compared 38 diabetic patients with 38 nondiabetic patients treated for psychotic disorders with low to moderate doses of neuroleptics (mean chlorpromazine equivalents = 300 mg/day) for an average of 18 years. Study 2 compared 24 diabetic and 27 nondiabetic patients treated for an average of 2.6 years with a mean 31 mg/day of metoclopramide for gastrointestinal disease. Patients were examined for TD using standardized scales by raters blind to all treatment and illness variables. In both studies, there were no differences between the diabetic and nondiabetic groups in age, sex, type of psychiatric illness, and dose and duration of neuroleptic treatment or severity of parkinsonism. In both studies, the diabetic patients had significantly greater prevalence and severity of TD. No measures of diabetes severity were associated with TD in either study. Possible pathophysiologic mechanisms for the increased prevalence of TD in neuroleptic-treated patients with diabetes will be discussed.

Risk factors for neuroleptic-induced movement disorders

Chronic neuroleptic therapy may be associated with the development of diverse movement disorders including Tardive dyskinesia (TD), Parkinsonism, dystonia, and akathisia in a subset of schizophrenic patients. It is presently unknown why only a proportion of neuroleptic-treated patients develop these movement disorders. In the following communication, we present a series of studies which demonstrate that the development of these movement disorders may be facilitated by certain risk factors including disturbances in pineal melatonin functions, diabetes mellitus, cognitive deficits, suicidal behavior, and disturbances in the functions of the choroid plexus. Recognition of these biological factors may prove useful in: (a) further understanding of the pathophysiology of these disorders, and (b) identifying patients at risk for these movement disorders.

Three-year follow-up of older schizophrenics: extrapyramidal syndromes, psychiatric symptoms, and ventricular brain ratio

Longitudinal evaluation of psychiatric patients often yields information that cross-sectional study does not. We previously examined 31 older (age greater than 55) chronic schizophrenics for prevalence of extrapyramidal side effects, severity of psychiatric symptoms, and ventricular brain ratio (VBR). We reexamined 22 of these patients after 2-4 years. Tardive dyskinesia (TD) and drug-induced parkinsonism (DIP) were common (mean prevalences were 52% and 62%, respectively) and often occurred together (38%). The overall prevalences of the disorders did not change significantly with time, although there was some individual fluctuation in diagnosis. Severity of TD was constant, but severity of DIP decreased, probably because neuroleptic doses were significantly decreased. Magnitude of DIP was positively correlated with VBR and severity of negative symptoms of schizophrenia. The correlation of DIP and negative symptoms occurred primarily because of the similarity between masked facies and blunted affect. VBR did not change over the follow-up period. Negative symptoms of schizophrenia were prevalent, moderately severe, and quite stable over time in this cohort. Positive symptoms were less severe but highly variable between examinations.

Persistent and progressive parkinsonism after discontinuation of chronic neuroleptic therapy: an additional tardive syndrome?

Drug-induced parkinsonism is usually reversible, except in a small percentage of elderly patients. We describe two relatively young patients, who developed drug-induced parkinsonism during chronic treatment with neuroleptics for a psychotic disorder. Parkinsonism persisted, and markedly and progressively deteriorated after discontinuation of neuroleptic drugs. One patient had tremor as the most prominent sign and the other had mainly an akinetic-rigid syndrome. Neither had ever developed tardive dyskinesia. Both responded to levodopa therapy. Persistent drug-induced parkinsonism in our, and other reported on, elderly patients may be due to unmasking of preexisting subclinical idiopathic Parkinson's disease by neuroleptics. Theoretically, these drugs may precipitate degeneration of vulnerable, nigrostriatal neurons by generating cytotoxic free radicals or by attrition, due to accelerated neuronal firing rates.

Neuroradiological covariates of drug-induced parkinsonism and tardive dyskinesia in schizophrenia

Computed tomographic (CT) studies have demonstrated structural brain abnormalities including cortical atrophy and enlarged lateral ventricles in a subset of schizophrenic patients including those with abnormal involuntary movements. In the following series of studies, we present our findings pertaining to neuroradiological covariates of drug-induced Parkinsonism and Tardive dyskinesia in schizophrenic patients. In these studies we have explored the relationship of Parkinsonism and Tardive dyskinesia to pineal and choroid plexus calcification. In addition, we also investigated the relationship of pineal calcification to schizophrenia, and specifically to the paranoid and nonparanoid subgroups. In a further series of studies, we investigated the neuroradiological covariates of disorders of gait and posture as well as tremor in schizophrenic patients with drug-induced Parkinsonism. In addition, we explored the relationship of Tardive dyskinesia and its subsyndromes to CT scan measurements of cortical and subcortical atrophy in schizophrenia. Our findings highlight the significance of the pineal gland in the pathophysiology of schizophrenia and drug-induced movement disorders. Furthermore, these studies underscore the heterogeneity of Parkinsonism and Tardive dyskinesia.