Clinical and instrumental assessment of neuroleptic-induced parkinsonism in patients with tardive dyskinesia

We evaluated 21 right-handed psychiatric patients with tardive dyskinesia (TD) for the presence and laterality of neuroleptic-induced tremor and rigidity. The goals of the study were to assess the frequency and coexistence of TD and neuroleptic-induced parkinsonism (NIP) using instrumental and clinical measurements and to evaluate the hypothesis that when TD and NIP coexisted in the same patient, they were more likely to appear in opposite limbs. Results indicated that a high percentage of TD patients had coexisting rigidity and tremor on the basis of both clinical ratings and instrumental procedures; however, only instrumental procedures were useful in identifying tremor and rigidity asymmetries. We found that TD and tremor or rigidity did not lateralize to opposite limbs, thus weakening the hypothesis that TD and NIP stemmed from reciprocal pathophysiological mechanisms.

The motor disorders of mental handicap. An overlap with the motor disorders of severe psychiatric illness

Among 236 in-patients in one hospital for the mentally handicapped, there was a significant relationship between the amount of motor disorder (rated using a comprehensive check-list) and the severity of mental handicap, the presence of associated psychiatric disorder and the use of neuroleptic medication. The population was fairly evenly divided between those currently, previously and never having received neuroleptic medication. All categories of motor disorder, including abnormal movements, were present in all three subgroups. Neuroleptic medication appeared to modify the expression of motor disorder rather than producing it de novo. The range and frequency of motor disorders was comparable with that in patients with severe psychiatric illness. A common cerebral basis for the motor disorders of patients with mental handicap and severe psychiatric illness is suggested.

Tardive dyskinesia in bipolar affective disorder: a catchment area study

The prevalence of tardive dyskinesia in a consecutive series of 69 patients with bipolar affective disorder admitted to a catchment area service was found to be 19%. Prevalence increased with age and was related to the age of onset of bipolar disorder and number of previous episodes. Patients with tardive dyskinesia were significantly slower on a simple test of cognitive function (Trails B).

The relationship of pineal calcification to subtypes of tardive dyskinesia in bipolar patients

Recent studies have suggested that bipolar patients may be at high risk for developing tardive dyskinesia (TD) if exposed to chronic neuroleptic therapy. It has been suggested that reduced melatonin secretion may favor the development of TD in bipolar and schizoaffective patients. Since pinealectomized rats have been reported to develop increased incidence and severity of abnormal chewing movements, and as depression is associated with reduced melatonin secretion, the increased risk of TD in bipolar patients may be associated with diminished melatonin secretion. Evidence suggestive of an inverse correlation between pineal calcification and reduced melatonin secretion, led me to study the relationship between pineal calcification on CT scan and the severity of axial (truncal) and limb and orofacial dyskinesias in bipolar patients with TD. The incidence of pathologically enlarged pineal calcifications (i.e., greater than 1 cm in diameter) in the bipolar patients was 25 times greater than the reported incidence in the literature among nonpsychiatric patients. In addition, there was a significant difference in scores of axial dyskinesias between patients with pineal calcification of less than 1 cm in diameter compared to those with pineal calcification of greater than 1 cm in diameter (F = 3.24; p = .04, one-way ANOVA). There was no significant association between scores of limb and orofacial dyskinesias and pineal calcification. These findings suggest a meaningful association between the presence of enlarged pineal calcification, and axial dyskinesias in bipolar patients. Further studies using direct plasma melatonin measurements are required to more precisely define the association between TD and melatonin secretion in bipolar patients.

The relationship between ECT responsiveness and subtypes of tardive dyskinesia in bipolar patients

Despite intensive research, the mechanisms of action of electroconvulsive therapy (ECT) remain elusive. In addition, there are no known biological factors predicting ECT responsiveness in bipolar patients. A study was conducted to investigate the relationship between ECT responsiveness and tardive dyskinesia (TD), a common side effect of neuroleptic therapy, and its subtypes (i.e., orofacial and limb-axial dyskinesias) in a group of 18 bipolar patients. There was a significant difference in orofacial dyskinesia scores between ECT responders and non-responders (p less than 0.005), while there was no significant association in scores of limb-axial dyskinesia between ECT responders and non-responders. These findings suggest an association between ECT responsiveness and the presence of orofacial dyskinesias in bipolar patients with TD and add further support to the notion that TD is a heterogeneous disorder comprising at least two subtypes with distinct underlying pathophysiological mechanisms.

Tardive dyskinesia in bipolar disorders: possible role of pineal melatonin

Several clinical studies have suggested that patients with affective disorders, are at high risk for developing tardive dyskinesia (TD). An intriguing aspect of the relationship between TD and affective disorders involves mood dependent alterations in severity of TD. In most reported cases, depressive episodes are associated with exacerbation of TD, while manic episodes are accompanied by attenuation of TD. Current neurochemical hypotheses of TD do not explain adequately the relations of TD to depression or the mood dependent variations in the severity of TD. I propose that alterations in the secretory activity of pineal melatonin during manic and depressive episodes may explain better both the higher risk of TD in patients with affective disorders and the mood-dependent fluctuations in severity of TD. Consideration of pineal melatonin functions may further our understanding of the pathophysiology of TD in patients with affective disorders.

Seborrhea and persistent tardive dyskinesia

The following communication concerns two schizophrenic patients with Tardive dyskinesia (TD) in whom fluctuations in the severity of the dyskinesias were accompanied by changes in the severity of the seborrheic skin lesions. Since seborrheic dermatitis may be associated with increased plasma melanocyte-stimulating hormone (MSH) level, these observations suggest an association between the severity of TD and increased pituitary MSH release. In addition, TD may be associated with hypothalamic-pituitary dysfunction of MSH autoregulation.

Dopaminergic supersensitivity and vomiting among schizophrenic patients

The prevalence of vomiting among schizophrenic inpatients was determined over a 6-week period; 8 of 19 patients (42%) experienced at least one episode of vomiting and 3 (16%) experienced 4 episodes. A hypothesis that this may be a dopaminergic supersensitivity phenomenon is proposed, but no association with tardive dyskinesia, another putative supersensitivity phenomena, could be demonstrated. The authors suggest that vomiting among schizophrenic patients is usually underestimated and may at times be a serious clinical problem.

Carbamazepine-induced tics

Although a variety of dyskinesias are known to develop during anticonvulsant therapy, carbamazepine-induced tics are rarely recognized. We report three patients with an underlying movement disorder (Huntington's disease, tardive dyskinesia, and Tourette's syndrome) who experienced the onset or exacerbation of tics after the introduction of carbamazepine. These cases confirm the phenomenon of carbamazepine-induced tics and suggest that basal ganglia neuropathology may be an important predisposing factor. The dopaminergic effects of carbamazepine may be responsible for the induction of tics.

Functional impairment in tardive dyskinesia: medical and psychosocial dimensions

The author presents 22 patients with tardive dyskinesia who were referred to him through consultation. Several patients had functional impairment caused by their movement disorder. Impaired gait was noted in 6 patients, speech impediment in 3 and thoughts of suicide in 1. Psychosocial difficulties were reported in 12 patients. The author concludes that tardive dyskinesia can lead to difficulties in patients who are suffering from the severe form.

Mortality rate of schizophrenic patients with tardive dyskinesia during 10 years: a controlled study

We examined mortality rates (MR) during 10 years between schizophrenic inpatients with and without tardive dyskinesia (TD). The TD group had a significantly higher MR (41%), as compared with the control group (20%). However, we could not reveal critical factors to explain why the TD patients had the higher MR.

Schizophrenia in the elderly: what nurses need to know

People age 65 and older with schizophrenia comprise a small but growing number of the mentally ill that nurses, especially those who work in nursing homes, care for. Elderly schizophrenics are a heterogeneous group. They are subject to all of the chronic and acute illnesses common to elderly persons. In addition, their medical problems are frequently overlooked and are difficult to treat. As many as 50% of them have tardive dyskinesia, which has potentially fatal consequences, especially in the elderly.

Blink reflex in dyskinetic and nondyskinetic patients with Parkinson's disease

An electrophysiological study of the blink Reflex was undertaken in 40 dyskinetic and 20 nondyskinetic patients with Parkinson's disease, who were matched for age, stage of disease, duration of illness and amount and nature of antiparkinsonian medication. We found that latencies of R2 responses (both ipsilateral and contralateral) were prolonged in the dyskinetic group compared to the nondyskinetic group. Moreover, the late response was more easily inhibited by conditioning stimulation in dyskinetic patients. This behavior of late response in dyskinetic parkinsonians may be attributed to the reinstatement of dopaminergic suppressive control over the segmental multisynaptic systems belonging to the reflex.

Spastic dysphonia and denervation signs in a young man with tardive dyskinesia

Pathophysiological theories of tardive dyskinesia (TD) suggest the possibility of structural changes in the central nervous system of patients with TD. This report describes a case of choreoathetoid dyskinesia and spastic dysphonia associated with clinical and electromyographic signs of muscle denervation. The findings of this case suggest that the neurological syndrome originates within basal ganglia nuclei but may also extend to the peripheral neuromuscular system.

[Motor complications in patients with Parkinson disease treated with levodopa]

Motor complications appearing in 180 patients with Parkinson's disease who received levodopa for a long period are reviewed. The most frequently observed motor disorders were wearing off fluctuations and dyskinesias of "dose benefit". Most patients who presented a decrease in the response to levodopa developed signs during the course or findings in complementary tests which were incompatible with the diagnosis of Parkinson's disease. In the present study, the duration of the treatment with levodopa and the duration of the disease varied in parallel in such a way that it was not possible to individualize the relative importance of both factors in the development of the observed motor complications.

Antipsychotic-withdrawal akathisia versus antipsychotic-induced akathisia: further evidence for the existence of tardive akathisia

The authors present a study in which 33 chronic schizophrenic patients who, when withdrawn from antipsychotic drug treatment for more than 2 weeks, presented with concurrent signs of akathisia and tardive dyskinesia; however, signs of akinesia, facial masking, rigidity, or dystonia were not concurrent with the patients' akathetic presentation. In a subsequent study phase, these patients were treated with antipsychotics for up to 6 weeks. The dyskinetic signs that had been dramatically more severe in those patients exhibiting akathisia following withdrawal from antipsychotic medication continued for up to 6 weeks following the renewal of antipsychotic drug therapy. These findings help to confirm a relationship between tardive dyskinesia and a persistent akathisia of later onset known as tardive akathisia.

A comparison of clinical and pathological features of young- and old-onset Parkinson's disease

We compared 46 patients having onset of Parkinson's disease before age 45 years with 52 having onset after age 70. Young-onset cases more often presented with muscular stiffness (43%) and old-onset with difficulty walking (33%). One-third of young-onset cases had off-period dystonia, mostly affecting the legs, but no dystonia was recorded in old-onset cases. Presentation with rest tremor occurred in 41% of young-onset and 63% of old-onset. There were no differences in the number of affected relatives, endocrine disease, personality characteristics, dementia, or dyskinesia. A pathological study of 12 young-onset and 22 old-onset cases showed 24% greater nigral cell loss in the young, but no differences in the basic Lewy body pathology. Median disease duration in young cases was 5 years longer in the clinical study and 12 years longer in the pathological study. These studies show that the Parkinson's disease process is similar in young- and old-onset cases.

[The treatment of psychopathologic disorders associated with tardive dyskinesias]

Tardive dyskinesia, an extrapyramidal syndrome consisting of involuntary hyperkinetic movements, is a serious side effect induced by the administration, usually on a long-term basis, of neuroleptic therapy mostly for psychotic disorders. Therefore, psychopathologic disturbances, florid or residual may coexist with the appearance and persistence of tardive dyskinesia. Thus, the exact nature of the psychopathology observed with the presence of tardive dyskinesia and its origin is difficult to delineate and to assess. Indeed, the psychopathological findings observed can possibly originate from the initial psychiatric disorder itself from the intrinsic effect of the neuroleptic medication on psychic processes, may be specifically related to tardive dyskinesia, or be the result of all these factors. Cognitive, thymic or psychotic disturbances have been closely associated with tardive dyskinesia, but their systematic studies is still scarce. Based on these findings, some tentative therapeutic considerations will be outlined, keeping in mind that exact nature and origin of these disturbances still remains to be elucidated, that no really specific and generally effective treatment of tardive dyskinesia has been found.

Administration of butaperazine and plasma methionine-enkephalin levels in schizophrenic and affective disorder patients with tardive dyskinesia

The levels of plasma methionine-enkephalin in male chronic schizophrenic and affective disorder patients with or without tardive dyskinesia (TD) were in a range similar to those of sex-matched adult control volunteers. Administration of butaperazine resulted in significant changes (increases) of neuropeptide plasma concentration only in the affective disorder with TD subgroup, reaching statistical significance over their own baseline at 8, 10.5, and 24 hours, and at baseline (0 hr), 8-, and 48-hour intervals when compared with the affective disorder patients without TD.