Extrapyramidal symptoms in substance abusers with and without schizophrenia and in nonabusing patients with schizophrenia

Handedness as a neurodevelopmental marker in schizophrenia: Results from the FACE-SZ cohort

OBJECTIVES

High rates of non-right-handedness (NRH) including mixed-handedness have been reported in neurodevelopmental disorders. In schizophrenia (SZ), atypical handedness has been inconsistently related to impaired features. We aimed to determine whether SZ subjects with NRH and mixed-handedness had poorer clinical and cognitive outcomes compared to their counterparts.

METHODS

667 participants were tested with a battery of neuropsychological tests, and assessed for laterality using the Edinburg Handedness Inventory. Clinical symptomatology was assessed. Learning disorders and obstetrical complications were recorded. Biological parameters were explored.

RESULTS

The prevalence of NRH and mixed-handedness was high (respectively, 42.4% and 34.1%). In the multivariable analyses, NRH was associated with cannabis use disorder (p = 0.045). Mixed-handedness was associated with positive symptoms (p = 0.041), current depressive disorder (p = 0.005)), current cannabis use (p = 0.024) and less akathisia (p = 0.019). A history of learning disorder was associated with NRH. No association was found with cognition, trauma history, obstetrical complications, psychotic symptoms, peripheral inflammation.

CONCLUSIONS

Non-right and mixed-handedness are very high in patients with SZ, possibly reflecting a neurodevelopmental origin. NRH is associated with learning disorders and cannabis use. Mixed-handedness is associated with positive symptoms, current depressive disorder, cannabis use and less akathisia. However, this study did not confirm greater cognitive impairment in these patients.

Psychomotor Symptoms in Chronic Cocaine Users: An Interpretative Model

According to the latest estimates, there are around 24.6 million cocaine users worldwide, and it is estimated that around a quarter of the population worldwide has used cocaine at some point in their lifetime. It follows that such widespread consumption represents a major risk for public health. Long-term use of cocaine, in addition to being related to many cerebral and cardiovascular diseases, is increasingly associated with a higher incidence of psychomotor symptoms and neurodegenerative disorders. In recent years, numerous studies have shown an increased risk of antipsychotic-induced extrapyramidal symptoms (EPSs) in patients with psychotic spectrum disorders comorbid with psychostimulant misuse, particularly of cocaine. In the present paper, we describe the case of a young patient on his first entry into a psychiatric setting with previous cocaine misuse who rapidly presented psychomotor symptoms and was poorly responsive to symptomatic therapy consisting of benzodiazepines and anticholinergics, in relation to the introduction of various antipsychotics (first, second, and third generation). Furthermore, we propose neurobiological mechanisms underlying the hypothesized increased vulnerability to psychomotor symptoms in chronic cocaine abusers. Specifically, we supposed that the chronic administration of cocaine produces important neurobiological changes, causing a complex dysregulation of various neurotransmitter systems, mainly affecting subcortical structures and the dopaminergic and glutamatergic pathways. We believe that a better understanding of these neurochemical and neurobiological processes could have useful clinical and therapeutic implications by providing important indications to increase the risk–benefit ratio in pharmacological choice in patients with psychotic spectrum disorders comorbid with a substance use disorder.

Cognitive dysfunction and cerebral volumetric deficits in individuals with Alzheimer's disease, alcohol use disorder, and dual diagnosis

Epidemiological surveys suggest that excessive drinking is associated with higher risk of Alzheimer's disease (AD). The present study utilized data from the National Alzheimer's Coordinating Center to examine cognition as well as gray/white matter and ventricular volumes among participants with AD and alcohol use disorder (AD/AUD, n = 52), AD only (n = 701), AUD only (n = 67), and controls (n = 1283). AUD diagnosis was associated with higher Clinical Dementia Rating Scale Sum of Boxes (CDR-SB) in AD than in non-AD. AD performed worse on semantic fluency and Trail Making Test A + B (TMT A + B) and showed smaller total GMV, WMV, and larger ventricular volume than non-AD. AD had smaller regional GMV in the inferior/superior parietal cortex, hippocampal formation, occipital cortex, inferior frontal gyrus, posterior cingulate cortex, and isthmus cingulate cortex than non-AD. AUD had significantly smaller somatomotor cortical GMV and showed a trend towards smaller volume in the hippocampal formation, relative to non-AUD participants. Misuse of alcohol has an additive effect on dementia severity among AD participants. Smaller hippocampal volume is a common feature of both AD and AUD. Although AD is associated with more volumetric deficits overall, AD and AUD are associated with atrophy in largely distinct brain regions.

Dyskinesia is most centrally situated in an estimated network of extrapyramidal syndrome in Asian patients with schizophrenia: findings from research on Asian psychotropic prescription patterns for antipsychotics

BACKGROUND

Network analysis provides a new viewpoint that explicates intertwined and interrelated symptoms into dynamic causal architectures of symptom clusters. This is a process called 'symptomics' and is concurrently applied to various areas of symptomatology.

AIMS

Using the data from Research on Asian Psychotropic Prescription Patterns for Antipsychotics (REAP-AP), we aimed to estimate a network model of extrapyramidal syndrome in patients with schizophrenia.

METHODS

Using data from REAP-AP, extrapyramidal symptoms of 1046 Asian patients with schizophrenia were evaluated using the nine items of the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS). The estimated network of the ordered-categorical DIEPSS items consisted of nodes (symptoms) and edges (interconnections). A community detection algorithm was also used to identify distinctive symptom clusters, and correlation stability coefficients were used to evaluate the centrality stability.

RESULTS

An interpretable level of node strength centrality was ensured with a correlation coefficient. An estimated network of extrapyramidal syndrome showed that 26 (72.2%) of all possible 35 edges were estimated to be greater than zero. Dyskinesia was most centrally situated within the estimated network. In addition, earlier antipsychotic-induced extrapyramidal symptoms were divided into three distinctive clusters - extrapyramidal syndrome without parkinsonism, postural instability and gait difficulty-dominant parkinsonism, and tremor-dominant parkinsonism.

CONCLUSIONS

Our findings showed that dyskinesia is the most central domain in an estimated network structure of extrapyramidal syndrome in Asian patients with schizophrenia. These findings are consistent with the speculation that acute dystonia, akathisia, and parkinsonism could be the risk factors of tardive dyskinesia.

Methamphetamine Use and Antipsychotic-related Extrapyramidal Side-effects in Patients with Psychotic Disorders

Objective: Extrapyramidal side-effects (EPSE) are frequent in patients treated with antipsychotics and comorbid substance use disorders (SUDs). Methamphetamine has been shown to act as a dopaminergic neurotoxin. We aimed to determine whether EPSE occur more often in patients with psychotic disorders and co-occurring methamphetamine (MA) use disorders, and we examined the relationship between MA use, antipsychotic type, dose and EPSE. Methods: This study was a secondary analysis of data from three separate primary studies. Across all studies, psychiatric and SUD diagnoses were determined using the SCID-I for DSM-IV. EPSE were determined using the Simpson-Angus Scale (SAS) for Parkinsonism, the Barnes Akathisia Rating scale (BARS), and the Abnormal Involuntary Movement Scale (AIMS) for tardive dyskinesia. Participants were classified as having any EPSE if they scored above the cutoff on any of the EPSE scales (SAS, BARS, AIMS). We analyzed data using multivariable logistic regression analysis. Results: The sample included 102 patients with non-affective or affective psychotic disorders. Of the total sample, 65.7% were male, 54.9% had schizophrenia spectrum disorders, 20.5% bipolar type I disorder with psychotic features, 11.7% schizoaffective disorder and 12.7% had substance-induced psychosis. A diagnosis of a methamphetamine use disorder (abuse or dependence) was present in 25.5% of participants. EPSE occurred in 38.2% of patients and were significantly associated with MA use in the unadjusted and adjusted analysis, OR_adj = 4.01, 95% CI [1.07, 14.98], p = .039. Patients with MA dependence and MA use >3 years were significantly more likely to have EPSE. We found a significant interaction effect between MA use disorders and standardized antipsychotic dose on the occurrence of EPSE, OR_adj = 1.01, 95% CI [1.00, 1.01], p = .042, with MA users having a disproportionally higher likelihood of having EPSE compared to MA non-users as antipsychotic dosage increased. There were no significant associations of EPSE with comorbid alcohol, cannabis, or methaqualone use disorders. Conclusions: Patients with a MA use disorder were significantly more likely to have EPSE with evidence for a dose-response effect. Clinicians should carefully titrate antipsychotic dosage from lower to higher doses to avoid EPSE in patients with MA use disorders.

Specific impact of stimulant, alcohol and cannabis use disorders on first-episode psychosis: 2-year functional and symptomatic outcomes

BACKGROUND

Many studies have concluded that cannabis use disorder (CUD) negatively influences outcomes in first-episode psychosis (FEP). However, few have taken into account the impact of concurrent misuse of other substances.

METHODS

This 2-year, prospective, longitudinal study of FEP patients, aged between 18 and 30 years, admitted to early intervention programs in Montreal, Quebec, Canada, examined the specific influence of different substance use disorders (SUD) (alcohol, cannabis, cocaine, amphetamines) on service utilization, symptomatic and functional outcomes in FEP.

RESULTS

Drugs and alcohol were associated with lower functioning, but drugs had a greater negative impact on most measures at 2-year follow-up. Half of CUD patients and more than 65% of cocaine or amphetamine abusers presented polysubstance use disorder (poly-SUD). The only group that deteriorated from years 1 to 2 (symptoms and functioning) were patients with persistent CUD alone. Outcome was worse in CUD than in the no-SUD group at 2 years. Cocaine, amphetamines and poly-SUD were associated with worse symptomatic and functional outcomes from the 1st year of treatment, persisting over time with higher service utilization (hospitalization).

CONCLUSION

The negative impact attributed to CUD in previous studies could be partly attributed to methodological flaws, like including polysubstance abusers among cannabis misusers. However, our investigation confirmed the negative effect of CUD on outcome. Attention should be paid to persistent cannabis misusers, since their condition seems to worsen over time, and to cocaine and amphetamine misusers, in view of their poorer outcome early during follow-up and high service utilization.

Incidence and risk factors of acute akathisia in 493 individuals with first episode non-affective psychosis: a 6-week randomised study of antipsychotic treatment

INTRODUCTION

Acute akathisia is a neuropsychiatric syndrome with a negative effect on illness outcome. Its incidence in patients treated with antipsychotics has shown to be highly variable across studies.

OBJECTIVES

Our goals were to investigate prevalence, risk factors for the development of acute akathisia, and differences in incidence between antipsychotics in a sample of 493 first episode non-affective psychosis patients.

METHODS

This is a pooled analysis of three prospective, randomized, flexible-dose, and open-label clinical trials. Patients were randomized assigned to different arms of treatment (haloperidol, quetiapine, olanzapine, ziprasidone, risperidone, or aripiprazole). Akathisia was determined using the Barnes Akathisia Scale at 6 weeks after antipsychotic initialization. Univariate analyses were performed to identify demographic, biochemical, substance use, clinical, and treatment-related predictors of acute akathisia. Considering these results, a predictive model based of a subsample of 132 patients was constructed with akathisia as the dependent variable.

RESULTS

The overall incidence of akathisia was 19.5%. No differences in demographic, biochemical, substance use, and clinical variables were found. Significant incidence differences between antipsychotics were observed (Χ ² = 68.21, p = 0.000): haloperidol (57%), risperidone (20%), aripiprazole (18.2%), ziprasidone (17.2%), olanzapine (3.6%), and quetiapine (3.5%). The predictive model showed that the type of antipsychotic (OR = 21.3, p = 0.000), need for hospitalization (OR = 2.6, p = 0.05), and BPRS total score at baseline (OR = 1.05, p = 0.03) may help to predict akathisia emergence.

CONCLUSIONS

Among second generation antipsychotics, only olanzapine and quetiapine should be considered as akathisia-sparing drugs. The type of antipsychotic, having been hospitalized, and a more severe symptomatology at intake seem to predict the development of acute akathisia.

Psychosis After Switch in Opioid Maintenance Agonist and Risperidone-Induced Pisa Syndrome: Two Critical Incidents in Dual Diagnosis Treatment

BACKGROUND AND AIMS

Dual diagnosis commonly occurs among patients with an opioid use disorder. Treatment is ideally performed in an integrated fashion. We present a case that illustrates the complex and challenging psychiatric and medical therapy of such patients in the light of the literature.

CASE DESCRIPTION

We report on a 56-year-old patient with schizophrenia and opioid dependence who experienced both risperidone-induced Pisa syndrome and, 3 years later, acute psychosis after switching the opioid substitution medication from methadone to slow-release oral morphine due to QT prolongation.

CONCLUSIONS

With the current availability of a diversity of substitution opioids in Switzerland (methadone, buprenorphine, diacetylmorphine, sustained-release oral morphine), studies on differential effectiveness of these agents in opioid-dependent subpopulations with selective comorbidity profiles are desirable. The same is true for further investigation of the involvement of the opioid receptor system in schizophrenia. In clinical practice, any alteration of opioid medication in patients with dual diagnosis and a history of schizophrenia should be accompanied by close observation for psychotic symptoms.

Antipsychotic-induced parkinsonism is associated with working memory deficits in schizophrenia-spectrum disorders

In view of the significant cognitive deficits in schizophrenia and their impact on patients' social and occupational functioning, and considering that the influence potential influence of antipsychotic-induced extrapyramidal symptoms on cognition in schizophrenia remains poorly understood, the current study sought to identify the clinical, socio-demographic and neurologic predictors of the cognitive performance of schizophrenia patients. Eighty-two schizophrenia-spectrum (DSM-IV criteria) outpatients were recruited. Psychiatric symptoms were evaluated with the Positive And Negative Syndrome Scale and the Calgary Depression Scale for Schizophrenia. Extrapyramidal symptoms were evaluated with the Extrapyramidal Symptoms Rating Scale, while spatial working, planning abilities and visual paired associates learning were evaluated with the CAmbridge Neuropsychological Tests Automated Battery. The Stroop test was also administered. Multivariate hierarchic linear regression analyses were performed. We found that negative symptoms were associated with cognitive flexibility, planning, visual learning and working memory performance in schizophrenia. Age, sex, number of hospitalizations and antipsychotic type also emerged as significant predictors. More importantly, we found a significant association between antipsychotic-induced parkinsonism and working memory performance. The fact that negative symptoms and socio-demographic variables predicted cognitive performance in schizophrenia is consistent with the previous literature on the topic. The finding of an association between parkinsonism and working memory may have clinical implications, since working memory deficits are considered putative endophenotypes of schizophrenia and are known to impair patients' social and occupational functioning. Our results will need to be replicated in longitudinal studies involving larger samples of patients.

Predictors of community functioning in schizophrenia and substance use disorder patients

Community functioning is a broad term that encompasses various 'real world' measures of disability among schizophrenia patients. It includes outcomes such as independent living, social competence and behavioural problems-all of which are priorities for treatment among schizophrenia patients, mental health care providers, and family members. An important goal for rehabilitation programs is to identify predictors of community functioning which, in turn, could be used as targets for intervention. The present case-control study examined socio-demographic and substance use disorder (SUD) variables as well as psychiatric, extrapyramidal, and cognitive symptoms as predictors of community functioning in schizophrenia patients with (DD patients; n=31) and without comorbid SUDs (SCZ patients; n=31), and non-psychosis substance abusers (SUD patients; n=39). Psychiatric and extrapyramidal symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia and the Extrapyramidal Symptoms Rating Scale. Cognition was evaluated using the Cambridge Neuropsychological Test Automated Battery (speed of processing, explicit and working memory). In SCZ patients, community functioning was predicted by explicit memory performance. In DD patients, community functioning was predicted by substance abuse, depression and speed of processing. In SUD patients, community functioning was predicted by substance abuse, positive symptoms and education. Our results suggest that cognition should be among the top treatment priorities in SCZ patients, whereas the key treatment targets in DD patients should be substance abuse and depression. Future studies will need to replicate the current findings, using prospective research designs.

Movement disorders in patients with schizophrenia and a history of substance abuse

OBJECTIVE

The movement disorders acute dystonia, akathisia, Parkinsonian symptoms and tardive dyskinesia [extrapyramidal side effects (EPSs)] are recognized adverse effects of antipsychotic medication. Previous studies have indicated that substance abuse in patients with schizophrenia can worsen EPS. This study therefore investigated the relationship between drug and alcohol use and EPS in a group of patients with schizophrenia.

METHODS

Seventy patients with schizophrenia assessed for drug and alcohol use, global functioning, EPS and suicidality. Chlorpromazine equivalents were correlated to levels of EPS and substance abuse.

RESULTS

Current EPS were found in 65% of the sample despite three-quarters of the patients receiving second-generation antipsychotics. An even higher level of patients, 87%, was found to have a history of EPS. A long history of schizophrenia independently predicted presence of any EPS, particularly akathisia, controlling for history of substance abuse which was a non-significant predictor.

CONCLUSIONS

History or current use of alcohol or drug abuse did not predict EPS, except for alcohol abuse at the time of diagnosis which was associated with current akathisia. Length of illness was correlated with EPS, whereas suicidality was not linked to akathisia. Neither chlorpromazine equivalent antipsychotic dose nor whether the patient received first-generation or second-generation antipsychotic medication was significantly associated with EPS or substance abuse.

Sensation-seeking, social anhedonia, and impulsivity in substance use disorder patients with and without schizophrenia and in non-abusing schizophrenia patients

Substance use disorders (SUDs) are common in patients with schizophrenia and this comorbidity is associated with a poorer prognosis, relative to non-abusing patients. One hypothesis that has been advanced in the literature is that dual diagnosis (DD) patients may have a different personality profile than non-abusing schizophrenia patients. The present case-control study aimed to characterize levels of personality traits (sensation-seeking, social anhedonia, and impulsivity) in substance abuse/dependence patients with (DD group; n=31) and without schizophrenia (SUD group; n=39), relative to non-abusing schizophrenia patients (SCZ group; n=23), and healthy controls (n=25). Impulsivity was assessed using the Barratt Impulsivity Scale. Sensation-seeking was assessed using the Zuckerman Sensation Seeking Scale. Social anhedonia was assessed with the Chapman Social Anhedonia Scale. We found that sensation-seeking was significantly higher in DD and SUD, relative to SCZ patients. We found that social anhedonia was significantly elevated in DD and SCZ, relative to healthy controls. We found that impulsivity was significantly higher in DD, SCZ and SUD patients, compared to healthy controls. The results suggest that sensation-seeking is prominent in substance abuse/dependence (irrespective of schizophrenia), social anhedonia is prominent in schizophrenia (irrespective of substance abuse/dependence), and impulsivity is prominent in all three populations.

Is the deficit in pain inhibition in fibromyalgia influenced by sleep impairments?

It has been proposed that a deficit in inhibitory conditioned pain modulation (ICPM) underlies the pathophysiology of fibromyalgia (FM), but there is high variability in ICPM efficacy in this syndrome that remains poorly understood. Based on emerging data showing that age, anxiety, depression and sleep can modulate ICPM efficacy, the main objective of this study was to determine the clinical correlates of experimentally-induced pain perception in FM. Fifty FM patients and 39 healthy controls (HC) were tested. Anxiety, depression, sleep and FM symptoms were measured with questionnaires or interview-type scales. Experimental pain testing consisted of two tonic heat pain stimulations separated by a 2-minute cold pressor test (CPT). Thermal pain thresholds and tolerance were higher in HC compared to FM patients. Pain ratings during the CPT were lower in HC relative to FM patients. ICPM efficacy was stronger in HC compared to FM patients. Finally, sleep quality was the only factor significantly related to ICPM efficacy. To our knowledge, this is the first study to report this association in FM. Future studies will need to replicate this finding, to determine whether impaired sleep is primary or secondary to deficient pain inhibition, and to characterize the neurobiological mechanisms underlying this association.

Treatment of dual diagnosis disorders

PURPOSE OF REVIEW

Treatment of dual diagnosis [co-occurrence of a substance use disorder (SUD) in patients with mental illness] poses several challenges for mental health professionals. This article seeks to review the recent advances in dual diagnosis treatment with respect to pharmacotherapy and psychosocial approaches.

RECENT FINDINGS

Atypical antipsychotics are commonly used for comorbid schizophrenia and SUD. Whereas there is no difference between risperidone and olanzapine, clozapine appears to have a distinct advantage in reducing psychotic symptoms as well as substance abuse (including smoking). There is emerging evidence that quetiapine is beneficial in dually diagnosed patients, particularly using alcohol, cocaine and amphetamine. A combination of naltrexone and sertraline was found to be effective in patients with depressive disorder and alcohol dependence. Effectiveness of atomoxetine is yet to be established in patients with comorbid adult attention-deficit/hyperactivity disorder with respect to decrease in substance abuse. Integrated intervention is the choice of treatment for patients with dual diagnosis.

SUMMARY

In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.

Oral versus Long-Acting Injectable Antipsychotics in the Treatment of Schizophrenia and Special Populations at Risk for Treatment Nonadherence: A Systematic Review

Long-acting injectable antipsychotics (LAIs) should offer better efficacy and tolerability, compared to oral antipsychotics due to improved adherence and more stable pharmacokinetics. However, data on LAIs has been mixed, with some studies finding that they are more effective and tolerable than oral antipsychotics, and others finding the contrary. One possibility for the disparate results may be that some studies administered different antipsychotics in the oral and injectable form. The present systematic review examined the efficacy and tolerability of LAIs versus their oral equivalents in randomized and naturalistic studies. In addition, it examined the impact of LAIs on special populations such as patients with first-episode psychosis, substance use disorders, and a history of violence or on involuntary outpatient commitment. Randomized studies suggest that not all LAIs are the same; for example, long-acting risperidone may be associated with equal or less side effects than oral risperidone, whereas fluphenazine decanoate and enanthate may be associated with equal or more side effects than oral fluphenazine. They also suggest that LAIs reduce risk of relapse versus oral antipsychotics in schizophrenia outpatients when combined with quality psychosocial interventions. For their part, naturalistic studies point to a larger magnitude of benefit for LAIs, relative to their oral equivalents particularly among first-episode patients.

Evolution of Substance use, Neurological and Psychiatric Symptoms in Schizophrenia and Substance use Disorder Patients: A 12-Week, Pilot, Case-Control Trial with Quetiapine

Neurological and psychiatric symptoms are consequences of substance abuse in schizophrenia and non-schizophrenia patients. The present case-control study examined changes in substance abuse/dependence, and neurological and psychiatric symptoms in substance abusers with [dual diagnosis (DD) group, n = 26] and without schizophrenia [substance use disorder (SUD) group, n = 24] and in non-abusing schizophrenia patients (SCZ group, n = 23) undergoing 12-week treatment with the atypical antipsychotic, quetiapine. Neurological and psychiatric symptoms were evaluated with the Positive and Negative Syndrome Scale, the Calgary Depression Scale for Schizophrenia, the Extrapyramidal Symptoms Rating Scale, and the Barnes Akathisia Rating Scale. At endpoint, DD and SCZ patients were receiving significantly higher doses of quetiapine (mean = 554 and 478 mg/day, respectively), relative to SUD patients (mean = 150 mg/day). We found that SUD patients showed greater improvement in weekly dollars spent on alcohol and drugs and SUD severity, compared to DD patients. At endpoint, there was no significant difference in dollars spent, but DD patients still had a higher mean SUD severity. Interestingly, DD patients had significantly higher parkinsonism and depression than SCZ patients at baseline and endpoint. On the other hand, we found that SUD patients had significantly more akathisia at baseline, improved more than SCZ patients, and this was related to cannabis abuse/dependence. Finally, SUD patients improved more in Positive and Negative Syndrome Scale positive scores than DD and SCZ patients. Taken together, our results provide evidence for increased vulnerability to the adverse effects of alcohol and drugs in schizophrenia patients. They also suggest that substance abuse/withdrawal may mimic some symptoms of schizophrenia. Future studies will need to determine the role quetiapine played in these improvements.