Propranolol in the treatment of tardive akathisia: a report of two cases

The authors present two patients suffering from tardive akathisia. They also review the available literature on the subject. Propranolol was found to be an effective treatment of tardive akathisia in both patients. The implications of this finding are discussed.

Acute generalized myoclonus following buspirone administration

The authors present a case of a 62-year-old woman who was hospitalized with severe medical problems that included congestive heart failure secondary to mitral stenosis and atrial fibrillation, coronary artery disease, chronic renal failure, and a recent history of a right cerebral lacunar infarction. She also had a 2-year history of anxiety and depression, manifested in the hospital by frequent crying spells, sleeplessness, and ruminating about her illnesses. The patient received buspirone 5 mg three times a day for her anxiety and depression. Approximately 12 hours after her first dose, she developed dramatic myoclonus, dystonias, and akathisia. She was given 25 mg of intramuscular diphenhydramine and 1 mg of intramuscular benztropine mesylate, which resulted in little relief; however, 1 mg clonazepam caused both the myoclonic jerks and dystonias to resolve completely.

Beta-adrenoceptor antagonists in neuropsychiatry: an update

Although beta-adrenoceptor antagonists such as propranolol have been used in neuropsychiatry for more than 20 years, their indications, extent of efficacy, and place in therapy remain unclear. In this overview, which concentrates on the recent literature, four indications for use of the drugs are reviewed, with particular reference to efficacy, mode of action, and clinical utility. The indications are anxiety disorders, including performance anxiety; schizophrenia; aggressive behavior; and akathisia. The author concludes that beta-blockers are useful in some forms of anxiety disorder, perhaps those characterized by somatic symptoms and by performance anxiety, and that akathisia seems to be responsive to those drugs. However, the use of high doses of beta-blockers in schizophrenia remains unestablished, and insufficient data are available with respect to their use in aggressive behavior.

Subtle and underrecognized side effects of neuroleptic treatment in children with Tourette's disorder

A variety of side effects developed in children treated with neuroleptics for Tourette's disorder. Of 208 children, 34 manifested dose-related symptoms of dysphoria, nine experienced a worsening of symptoms of Tourette's disorder that was attributed to akathisia, five became hostile and aggressive, three developed "fog states" that disappeared with discontinuation of neuroleptics or treatment with primidone, and three experienced symptoms of tardive dyskinesia that resolved with time. This data base of neuroleptic-treated children with Tourette's disorder demonstrates a variety of subtle and underrecognized side effects that may not be as readily discernible in children receiving neuroleptics for a primary psychiatric disorder.

Effects of alpha 2-receptor blockade in addition to tricyclic antidepressants in therapy-resistant depression

It was investigated whether yohimbine, a primarily alpha 2-receptor blocking agent, may have an antidepressant effect when given in addition to tricyclic antidepressants. After at least two unsuccessful preliminary antidepressant treatments for a minimum of 4 weeks each, patients received, in addition to tricyclics, yohimbine in increasing doses for 7 days. None of the five patients investigated demonstrated any improvement in depressive symptomatology and four of the five suffered from such side effects as severe anxiety, inner restlessness, psychomotor agitation, and tremor. During intravenous administration of 2.5 and 20 mg yohimbine, significant increases in norepinephrine values and systolic blood pressure were observed. It was concluded that a combination of yohimbine and tricyclic antidepressants seems to have little indication due to yohimbine's lack of efficacy and the high incidence of side effects in the treatment of severely depressed inpatients.

Buspirone-induced jitteriness in three patients with panic disorder and one patient with generalized anxiety disorder

Three patients with a history of panic disorder and one patient with a history of generalized anxiety disorder were treated with buspirone and experienced an increase in their anxiety levels, agitation, and restlessness and also developed pressured speech and racing thoughts. These symptoms completely resolved after buspirone was discontinued. Jitteriness may have been due to an unusual adrenergic sensitivity in these patients.

The response of depressed inpatients to isocarboxazid

Fifty-six inpatients with unipolar depression completed treatment with isocarboxazid. In comparing the differences between responders and nonresponders, it was found that psychomotor retardation, pathological guilt, daily persistence of unremitting symptoms, phobic anxiety, dexamethasone suppression test nonsuppression, and neuroticism were significantly more common among nonresponders. Reactivity of mood, blaming others, and extraversion were more common in responders. Total endogenous depression scores on the Newcastle 1, Newcastle 2, and Michigan scales were also significantly higher in nonresponders. Attained platelet monoamine oxidase inhibition was similar in both groups.

The jitteriness syndrome in panic disorder patients treated with antidepressants

The jitteriness syndrome (jitteriness, shakiness, increased anxiety, and insomnia) can develop with low doses of tricyclic antidepressants in patients who are sensitive to these drugs. The authors review the antidepressant treatment of 180 patients. Only those with panic attacks had jitteriness, usually during the first week of treatment. Desipramine was associated with a much higher frequency of jitteriness than was imipramine. Tolerance to jitteriness occurred with continued treatment, but fewer patients with jitteriness responded to treatment, apparently because of difficulties in increasing the dose. Characteristics of the jitteriness syndrome in panic disorder patients are consistent with noradrenergic hypotheses of panic anxiety. The clinical and theoretical implications of these findings are discussed.

Postburn delirium associated with use of intravenous lorazepam

A case of delirium with persecutory delusions is reported, which occurred three days after a previously healthy male suffered burns over 30% of his total body surface area. Routine evaluation was negative for other etiology of delirium, and the symptoms spontaneously remitted within seven hours with no sequella. We found that the benefits and potential side effects of intravenous lorazepam are similar to but of longer duration than those of intravenous diazepam. The effects of intravenous lorazepam should be recognized in the differential diagnosis of postburn delirium in patients given this medication.

Review: drug induced akathisia in medical and surgical patients

Drug-induced akathisia is a significant and common iatrogenic disorder. It involves both a subjective component of a disturbing sense of compulsion to move and an objective component of motor restlessness. Akathisia is being seen with increasing frequency in medical and surgical patients. This is due to the increased use of anti-emetics or novel adjuncts to pain control as well as more widespread use of the major psychoactive drugs throughout medicine. This review focuses on diagnostic features of the disorder as well as on possible treatment approaches. In addition, the disorder demonstrates the close anatomic and functional relationship between cortical and subcortical dopaminergic pathways. Akathisia is thus both an increasingly significant clinical problem and a fascinating glimpse at the relationship between brain function and behavior.

Noradrenergic effects in tardive dyskinesia, akathisia and pseudoparkinsonism via the limbic system and basal ganglia

1. This paper proposes that the neuropsychiatric symptoms of tardive dyskinesia, akathisia and pseudoparkinsonian tremor are modulated by a noradrenergic pathway that projects from the locus coeruleus to the limbic system. 2. The proposed pathway is found to the consistent with neuroanatomical and neurochemical data in the literature. 3. The proposed pathway is found to be clinically consistent with observations by ourselves and others on the efficacy of clonidine and beta-adrenoreceptor blockers like propranolol for treating akathisia and pseudoparkinsonian tremor. It is also consistent with reports by ourselves and others that some patients with tardive dyskinesia benefit from treatment with propranolol or clonidine. 4. Noradrenergic modulation of the limbic system by way of the locus coeruleus accounts for a number of clinical observations, such as the worsening of tardive dyskinesia by stress, the greater risk for tardive dyskinesia in patients with affective disorder, the time-of-onset of tardive dyskinesia, and the coexistence of tardive dyskinesia and pseudoparkinsonism. 5. The functional significance of beta-adrenoreceptors in the basal ganglia is considered from an evolutionary perspective. 6. The model proposed in this article appears to have considerable heuristic value because it may further our understanding of Gilles de la Tourette syndrome and attention deficit disorder (hyperkinesis).

Dysphoria associated with methylphenidate infusion in borderline personality disorder

Two patients with borderline personality disorder experienced dramatic dysphoric episodes after acute administration of intravenous methylphenidate in a double-blind manner. These dysphoric episodes were similar to those which occurred spontaneously under conditions of psychological stress. Case histories and the behavioral and cardiovascular effects of the infusions are described. The pharmacology of methylphenidate is discussed in order to elucidate possible mechanisms mediating the observed responses to this drug.

Severe akathisia causing neuroleptic failure: an indication for lithium therapy in schizophrenia?

Several neuroleptics recurrently failed to ameliorate psychosis in three schizophrenic patients. Failures were caused by recurrent intractable akathisia, unresponsive to diazepam and trihexyphenidyl. Lacking this extrapyramidal side effect, lithium carbonate was tried and proved an effective antipsychotic. It is suggested that in schizophrenic psychosis lithium is a rational therapeutic option in cases of neuroleptic intolerance and failures due to akathisia.