Effects of prolonged phenothiazine intake on psychotic and other hospitalized children

Treatment of Tardive Dyskinesia: A General Overview with Focus on the Vesicular Monoamine Transporter 2 Inhibitors

Tardive dyskinesia (TD) encompasses the spectrum of iatrogenic hyperkinetic movement disorders following exposure to dopamine receptor-blocking agents (DRBAs). Despite the advent of atypical or second- and third-generation antipsychotics with a presumably lower risk of complications, TD remains a persistent and challenging problem. Prevention is the first step in mitigating the risk of TD, but early recognition, gradual withdrawal of offending medications, and appropriate treatment are also critical. As TD is often a persistent and troublesome disorder, specific antidyskinetic therapies are often needed for symptomatic relief. The vesicular monoamine transporter 2 (VMAT2) inhibitors, which include tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice for most patients with TD. Deutetrabenazine-a deuterated version of tetrabenazine-and valbenazine, the purified parent product of one of the main tetrabenazine metabolites, are novel VMAT2 inhibitors and the only drugs to receive approval from the US FDA for the treatment of TD. VMAT2 inhibitors deplete presynaptic dopamine and reduce involuntary movements in many hyperkinetic movement disorders, particularly TD, Huntington disease, and Tourette syndrome. The active metabolites of the VMAT2 inhibitors have high affinity for VMAT2 and minimal off-target binding. Compared with tetrabenazine, deutetrabenazine and valbenazine have pharmacokinetic advantages that translate into less frequent dosing and better tolerability. However, no head-to-head studies have compared the various VMAT2 inhibitors. One of the major advantages of VMAT2 inhibitors over DRBAs, which are still being used by some clinicians in the treatment of some hyperkinetic disorders, including TD, is that they are not associated with the development of TD. We also briefly discuss other treatment options for TD, including amantadine, clonazepam, Gingko biloba, zolpidem, botulinum toxin, and deep brain stimulation. Treatment of TD and other drug-induced movement disorders must be individualized and based on the severity, phenomenology, potential side effects, and other factors discussed in this review.

The Use of Psychotropic Medication for People with Severe Disabilities and Challenging Behavior: Current Status and Future Directions

People with severe disabilities who engage in challenging behavior are often prescribed psychotropic medication as a form of intervention. Although the goal of the medication is to reduce challenging behavior, limited empirical evidence is available to support the use of psychotropic intervention for people with severe disabilities. However, across a range of drug classes basic research suggests that many psychotropic medications selectively affect dimensions of behavior that could be of benefit in reducing challenging behavior. Currently, researchers cannot demonstrate whether most drugs prescribed to reduce challenging behavior are effective or predict when adverse side effects will emerge from their use. In this article we review the basic literature on behavioral pharmacology and integrate those findings with existing applied research to update JASH readers regarding the status of psychotropic medication. From this review, we present a set of suggestions that include: (a) improving research practices, (b) increasing the diversity of individuals involved in decision-making processes regarding medication use, and (c) developing consumer-friendly strategies for monitoring drug effects.

Tardive dyskinesia and withdrawal emergent syndrome in children

Tardive dyskinesia (TD) is a well-recognized and sometimes permanent adverse effect of treatment with dopamine receptor-blocking drugs (DRBDs), also referred to as neuroleptics. This iatrogenic disorder has been well characterized in adults, but not extensively studied in children. Withdrawal emergent syndrome (WES) is another pediatric movement disorder related to the use of DRBDs. TD and WES are among the most feared adverse effects of DRBD treatment, and have important medical and legal implications. We review published studies of children under the age of 18 years who were exposed to DRBD to determine the clinical spectrum and estimate the possible prevalence of TD and WES. We particularly wish to draw attention to the phenomenology, clinical course and treatment of these childhood-onset disorders. Although avoiding DRBDs is the best strategy for minimizing the risk of TD and WES, physicians who evaluate children exposed to DRBDs must be vigilant and recognize the early symptoms and signs of these syndromes to provide appropriate clinical management.

Prevalence of movement disorders in adolescent patients with schizophrenia and in relationship to predominantly atypical antipsychotic treatment

OBJECTIVE

To examine prevalence of movement disorders (MDs) such as tardive dyskinesia (TD), parkinsonism or akathisia in an adolescent population with schizophrenia and in relationship to predominantly atypical antipsychotic treatment.

METHOD

Ninety-three patients (aged 19.6+/-2.2 years) were ascertained in this cross-sectional/retrospective study. 76 patients (81.7%) received atypical, 10 (10.8%) typical antipsychotics and 7 (7.5%) combinations of atypical/typical antipsychotics. MD symptoms were assessed using Tardive Dyskinesia Rating Scale (TDRS), Abnormal Involuntary Movement Scale (AIMS), Extrapyramidal Symptom Scale (EPS), Barnes Akathisia Scale (BAS).

RESULTS

Movement disorder symptoms were found in 37 patients (39.8%) fulfilling strict/subthreshold criteria for TD (5.4/11.8%), parkinsonism (2.2/25.8%) or akathisia (1.1/11.8%), respectively. Patients treated with typical antipsychotics displayed a significantly higher EPS-score (P=0.036) and a tendency towards a higher BAS-score (P=0.061) compared to patients with atypical antipsychotics. Treatment durations with typical/atypical antipsychotics showed trends towards advantages of atypical antipsychotics with regard to parkinsonism/akathisia symptoms (P=0.061; P=0.054), but not with regard to TD symptoms (P=0.003), possibly due to confounding effects.

CONCLUSION

Under treatment with atypical antipsychotics MD symptoms are less prevalent and less pronounced than under typical antipsychotics. We speculate that the finding of relatively high prevalence rates of subthreshold MD symptoms may be, at least partially, explained by previous or combined therapy with typical antipsychotics.

Metoclopramide-induced tardive dyskinesia in an infant

We describe a 1-year-old girl who developed orofaciolingual stereotypy at age 2 months after a 17-day treatment with metoclopramide for gastroesophageal reflux. The stereotypy, documented by sequential videos, persisted for at least 9 months after the drug was discontinued. This patient represents the first documented case of tardive dyskinesia in an infant. We also review previous reports of tardive dyskinesia in children.

The current status of tardive dyskinesia

OBJECTIVE

This paper aims to provide an overview of the current knowledge on neuroleptic-induced tardive dyskinesia (TD) in relation to its clinical features, risk factors, pathophysiology and management.

METHOD

The published literature was selectively reviewed and assessed.

RESULTS

Tardive diskinesia is a common neurological side-effect of neuroleptic medication, the cumulative incidence of which increases with increasing duration of treatment. Its clinical manifestations are diverse and subsyndromes have been described. Many risk factors for TD are now recognised, but increasing age remains pre-eminent as a risk factor. The pathophysiology of TD is not completely understood. Of the neurotransmitter hypotheses, the dopamine receptor supersensitivity hypothesis and the gamma-aminobutyric acid insufficiency hypothesis are the main contenders. There is increasing recognition that TD may in fact be caused by neuroleptic-induced neuronal toxicity through free radical and excitotoxic mechanisms. The occurrence of spontaneous dyskinesias in schizophrenic patients and even healthy subjects suggests that neuroleptics act on a substratum of vulnerability to dyskinesia. As no effective treatment for TD is available, the primary emphasis is on prevention. Many drugs can be tried to reduce symptoms in established cases. The increasing use of atypical neuroleptics has raised the possibility of a lower incidence of TD in the future.

CONCLUSIONS

After four decades of clinical recognition, the pathophysiology of TD is still not understood and no effective treatment is available. Its prevention with the optimal usage of currently available drugs and regular monitoring of patients on long-term neuroleptic treatment remain the best strategies to reduce its impact.

Abnormal involuntary movements in neuroleptic-naive children and adolescents

OBJECTIVE

To determine the prevalence of and identify risk factors for abnormal involuntary movements in a well-characterized community sample of neuroleptic-naive children and adolescents.

METHOD

The Abnormal Involuntary Movement Scale (AIMS) was administered to 390 subjects aged 3-17 years who were in foster care. Additional instruments were used to assess intellect and behaviour problems.

RESULTS

A total 12.6% of subjects had at least 1 rating of "mild" movements on AIMS; these included 4.1% with at least 2 ratings of "mild" or 2 of "moderate" severity. Significant risk factors for movement disorder were younger age, lower IQ, and more severe behaviour problems. The abnormal movements were usually orofacial, and the affected subjects were generally unaware of these movements.

CONCLUSION

The base prevalence of abnormal involuntary movements must be considered in children and adolescents assessed for medication in order to determine the true rate of motor side effects.

New strategies for old problems: tardive dyskinesia (TD). Review and report on severe TD cases treated with clozapine, with 12, 8 and 5 years of video follow-up

Tardive dyskinesia (TD) is the most feared and troublesome extrapyramidal side-effect of prolonged neuroleptic (NL) treatment. We present a review of TD. Its pathophysiology remains elusive, although extrapyramidal symptoms (EPS) increase the liability for TD. Nowadays, therefore, avoidance of all EPS remains the best preventive strategy, as it is not possible to predict which liable patients will develop TD, or of what type or severity. TD frequently includes dystonic features, and is more disabling when these dystonias are present. Clozapine (CLZ) has been reported to be effective in suppressing nearly 60% of TD syndromes, specially those with dystonic features. Based on the few reports in the literature on CLZ and TD by the early 1980s, we started to videotape the first severe TD patient treated with CLZ in 1984. We present the first three case reports of severe TD, with prominent disabling dystonic features, treated with CLZ and videotaped since pretreatment and then periodically for 12, 8 and 5 years of follow-up, respectively. The patients' current diagnosis, gender and age are: Case 1, DSM-IV Schizophrenia Residual Type, male, 39 years; Case 2, DSM-IV Polysubstance Related Disorder, Borderline Personality Disorder, female, 28 years; Case 3, DSM-IV Schizoaffective Disorder, male, 40 years. Two of them presented with a recurrence of TD because of CLZ interruption within the first 2 months of treatment, with no further breakthrough to date. The first two cases have complete remission of TD; the third case is still improving after 5 years of CLZ treatment, with only minor dystonic features persisting that constitute no impairment for work or daily routines at present. All patients, independent of their psychiatric primary diagnosis, have shown significant and progressive improvement in both motor and psychosocial aspects. None of them has been rehospitalized. Long-term treatment and follow-up is required to avoid TD recurrence and to assure full assessment of treatment effectiveness. Ideally, periodic video recording with standardized examination is advisable for long-term follow-up and outcome assessment. At present, CLZ could be regarded as the drug of choice for patients with TD, specially for those with disabling and or dystonic features and who require ongoing NL therapy. The use of novel antipsychotic agents for TD treatment and prevention, with their low EPS liability, is promising, but has yet to be tested.

Tardive dyskinesia and pregnancy and delivery complications

Twelve children and adolescents with movements suggestive of tardive dyskinesia (TD) were compared to 49 non-TD patients while receiving neuroleptic treatment. A multiple regression analysis revealed the diagnosis of TD to be significantly associated with a history of pregnancy and delivery complications (PDCs), suggesting that these events may increase the risk of the development of treatment emergent TD.

Heterogeneity of tardive dyskinesia. A multivariate analysis

To determine whether tardive dyskinesia (TD) is a single abnormal movement syndrome or multiple syndromes involving different anatomical areas, we examined 228 out-patients diagnosed with TD at the Connecticut Mental Health Center in New Haven. Application of factor analysis to the seven anatomical severity scores of the Abnormal Involuntary Movement Scale yielded three statistically independent factors involving abnormal movements primarily of the jaw-tongue, face-lips, and extremities-trunk. Using logistic regression to predict the severity of these factors, we found that the severity of the orofacial scores was positively associated with age, schizoaffective or affective disorder, and living alone, while severity of non-orofacial movement was positively associated with current neuroleptic dose, non-use of psychiatric medication, and living alone. Our findings suggest that orofacial and non-orofacial dyskinetic movements may involve distinct clinical syndromes of TD, each having a different set of prognostic and, possibly, aetiological determinants.

Ontogeny of striatal unit activity and effects of single or repeated haloperidol administration in rats

Development of striatal unit activity recorded from chloral hydrate anesthetized, neonatal rats was characterized electrophysiologically following acute or repeated haloperidol administration. No spontaneously active single units were detected in 8 day old pups. Spontaneous activity was recorded by 17 days of age, although the number of active cells, firing frequency and the variety of firing patterns were less diverse than those observed in 28 day olds. There were also age related differences in striatal unit responses to haloperidol. A significant increase in activity was induced by acute haloperidol administration only in 28 day old animals. No tolerance to the acute effects was demonstrated. Both 17 and 28 day olds responded to repeated haloperidol injections, followed by a 24 h recess, with an increase in striatal activity. These results may assist our understanding of the effects of human fetal, neonatal and/or adolescent exposure to neuroleptics.

Infantile autism and the temporal lobe of the brain

Studies are reviewed that support the hypothesis that infantile autism results from a neuropathology of the temporal lobes of the brain. First, there are parallels between symptoms noted in autism and those found in the Kluver-Bucy and amnesic syndromes. Second, there is a similarity between developmental dysphasia and autism. Third, the formation of cross-modal associations may be deficient in autistic children, a symptom resembling aspects of Geschwind's disconnection syndromes. Finally, a large number of organic factors have been associated with the development of autism, some of these having specific implications for temporal lobe involvement. It is concluded that the main autistic symptoms are most consistent with a neurological model involving bilateral dysfunction of the temporal lobes. Individual differences in the extent of bilateral involvement and/or other coexistent neuropathologies could contribute to the heterogeneity of the autistic population.

Transient Gilles de la Tourette syndrome after chronic neuroleptic withdrawal

A retarded 16-year-old male developed symptoms consistent with Gilles de la Tourette syndrome within one month of withdrawal from chronic neuroleptic treatment. The symptoms began to subside after six months and he was symptom-free after seven months. This suggests that symptoms of Gilles de la Tourette syndrome which appear after withdrawal of chronic neuroleptic therapy may be due to transient hypersensitivity of dopamine receptor sites.

Selectivity of treatment modalities

Consensus as to diagnostic definitions and criteria in Child Psychiatry is recent. Traditional "treatment" has been direct psychotherapy of child patient and mother. Despite growing precision of etiologic concepts and expansion of therapeutic approaches, many centres continue to define therapy in terms of their available techniques rather than the actual needs of the child. A brief review and definition of the major clinical syndromes is given. A glossary of the therapeutic modalities and their description is provided. Selection of treatment interventions is discussed in terms of diagnosis, severity, strengths of child patient, and the environmental modifications possible. Case illustrations are given. Periodic reassessment is essential to reselect therapeutic goals and determine choice as well as simultaneity versus sequentiality of therapeutic interventions.

The differential diagnosis of tardive dyskinesia

The evaluation, diagnosis, and treatment of involuntary hyperkinetic movements can be a difficult challenge. A thorough history, including past and present drug use, and a complete physical, neurological, and psychiatric examination, accompanied by appropriate laboratory tests, are often necessary to make the correct differential diagnosis of dyskinesias. Movement disorders in psychiatric patients are usually related to neuroleptic medicines. Extrapyramidal syndromes related to starting these drugs include dystonia, akathisia, and parkinsonism, whereas dyskinesia occurs late in the course of the treatment. Involuntary movements may, however, be idiopathic, be caused by many other drugs, or occur as part of psychoses, hereditary neurodegenerative diseases, or other medical illnesses.

Psychopharmacological treatment of psychotic children. A survey

Controlled investigations on the psychopharmacological treatment of psychotic children are reviewed. Children with infantile autism might benefit from psychopharmacological medication when they grow older, e.g. above the age of 7 years. Learning might be facilitated when the psychoactive medication is able to inhibit psychotic preoccupations and idiosyncratic reactions. Schizophrenic and manic-depressive psychoses are rarely seen in childhood. A subgroup of the children with infantile autism might develop schizophrenic symptoms. Schizophrenia and manic-depressive psychosis in children are treated as in adults. Special caution must be paid to the toxic effects of imipramine.