Clinical nonrecognition of neuroleptic-induced movement disorders: a cautionary study

Extrapyramidal side effects are a major limitation in the use of neuroleptics, and tardive dyskinesia is a special public health problem. Accurate clinical diagnosis of extrapyramidal syndromes is necessary for effective management. The authors compared clinicians' recognition of the major extrapyramidal syndromes in 48 psychotic inpatients with independent blind diagnoses by clinical researchers using standardized ratings. The major finding was a high rate of clinical underrecognition of all major extrapyramidal syndromes, especially tardive dyskinesia. The authors discuss the clinical predictors of nonrecognition of extrapyramidal side effects and recommend improved training in their detection.

Antidepressant-related akathisia

Five neuroleptic-free patients exhibited syndromes that were indistinguishable from idiopathic or neuroleptic-induced akathisia in association with antidepressant administration. While antidepressant-related akathisia may be produced by any of a variety of antidepressants, the susceptibility of each individual patient to the development of this disorder may be limited to only one or a few of these agents. A considerably rarer syndrome than neuroleptic-induced akathisia, antidepressant-related akathisia appears to respond to established pharmacologic treatments for neuroleptic-induced akathisia.

Comparison of propranolol, sotalol, and betaxolol in the treatment of neuroleptic-induced akathisia

In earlier open studies, beta-blockers were found to be effective in the treatment of neuroleptic-induced akathisia. In the present study, 16 patients with severe neuroleptic-induced akathisia successively received low doses of three beta-blockers--propranolol, sotalol, and betaxolol. There was rapid and complete improvement in seven of 16 patients (and partial improvement in three patients) treated with betaxolol. The efficacy of propranolol and betaxolol and failure of sotalol in treating neuroleptic-induced akathisia suggest a central mechanism of action.

Low- and conventional-dose maintenance therapy with fluphenazine decanoate. Two-year outcome

We evaluated the effectiveness and the side effects of what we defined as low (5-mg) and conventional (25-mg) doses of fluphenazine decanoate administered every two weeks in a double-blind comparison. Subjects were 66 patients who fulfilled DSM-III criteria for schizophrenic disorder. Evaluation of the survival with each dose revealed no significant difference at one year, but significantly better survival was seen with the 25-mg dose (64%) than the 5-mg dose (31%) at two years. There was no significant difference in survival when the clinician was permitted to make a dosage adjustment up to 10 mg in the low-dose group and 50 mg in the higher-dose group when the patient demonstrated evidence of a symptomatic exacerbation. Patients assigned to the higher dose appeared to feel more uncomfortable during the early months of the study, as indicated by significantly higher scores on subscales of the Hopkins Symptom Checklist-90R and higher side effect scores for retardation and akathisia. Implications for clinical practice are discussed.

Akinesia and postpsychotic depression: a difficult differential diagnosis

Detailed clinical case descriptions highlight the potential symptomatic overlap between the syndromes of akinesia and postpsychotic depression in neuroleptic-treated patients. The cases demonstrate that both syndromes may resemble major depression phenomenologically. However, the syndromes are not identical in medication response. Thus, differential medication response may potentially be a useful tool in teasing apart the various postpsychotic depressionlike states in the course of schizophrenia or schizoaffective disorder.

Low serum iron status and akathisia

26 patients were studied to assess the association between iron deficiency and akathisia. 13 akathisic patients were matched with 13 non-akathisic controls. Serum iron and percentage saturation were significantly decreased in the akathisic group, whereas total iron-binding capacity was significantly increased. A negative correlation between serum iron and akathisia rating (rs = -0.42) was also found.

Physostigmine reversal of drug-induced paradoxical excitement

Paradoxical excitement associated with intravenous conscious-sedation in a patient undergoing dental surgery was successfully reversed with 1.0 mg physostigmine. Physostigmine is felt to have exerted this effect by 2 mechanisms: the re-establishment of homeostasis in the CNS via augmented cholinergic pathways with the net result being thalamacocortical excitation, and cholinergically-mediated increase in cerebral blood flow increasing the rate of redistribution of the intravenous sedative agents used. The most commonly encountered side-effects of physostigmine used to reverse parodoxical excitement, emergence delirium, or prolonged narcosis are bradycardia, nausea, and/or vomiting. The incidence of these side-effects is low in doses, below 2.0 mg/70 kg. body weight.

Worsening of Tourette's disorder due to neuroleptic-induced akathisia

Of 100 patients with Tourette's disorder, six demonstrated unequivocal worsening after their neuroleptic doses were increased. Akathisia was described in the records of all six patients and seemed to be the cause of the deterioration.

Treatment of akathisia with lorazepam. An open clinical trial

Sixteen patients with neuroleptic-induced akathisia were treated with lorazepam. A marked improvement in symptoms was observed in 9 of the patient and moderate improvement in 5. Symptoms remained unchanged in 2 patients. The drop in the akathisia score from a pretreatment value of 1.81 to 0.5 after 7 days and to 0.32 after 14 days was statistically significant. Symptoms did not improve significantly during observation of the spontaneous course. No severe side effects were observed. The physiologic mechanisms of action of lorazepam on the akathisia syndrome are discussed.

Akathisia: the syndrome of motor restlessness

Akathisia is a common but frequently unrecognized complication of antipsychotic medication. Affected individuals report an inner discomfort which they attempt to relieve by increased motor activity. This disorder often causes dramatic changes in behavior which may be misinterpreted as signs that more, rather than less, medication is required. Diphenhydramine therapy is often effective in new-onset akathisia. Anticholinergic agents may also be of value.

Clonidine in neuroleptic-induced akathisia

Six hospitalized patients with neuroleptic-induced akathisia were treated with clonidine under single-blind conditions. Akathisia and anxiety at maximum clonidine dose were significantly lower than at baseline, although it was difficult to differentiate specific therapeutic effects from sedation.