Neurological consequences of psychotropic drug withdrawal in schizophrenic children

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVE

Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics.

DATA SOURCES

We searched the databases CENTRAL, Pubmed, and EMBASE with no restriction to the beginning of the searched time period and until October 1, 2019 (PROSPERO registration no. CRD42019119148).

STUDY SELECTION

Of the 18,043 screened studies, controlled and cohort trials that assessed withdrawal symptoms after discontinuation of oral antipsychotics were included in the random-effects model. Studies that did not implement placebo substitution were excluded from analyses. The primary outcome was the proportion of individuals with withdrawal symptoms after antipsychotic discontinuation. We compared a control group with continued antipsychotic treatment in the assessment of odds ratio and number needed to harm (NNH).

DATA EXTRACTION

We followed guidelines by the Cochrane Collaboration, PRISMA, and MOOSE.

RESULTS

Five studies with a total of 261 individuals were included. The primary outcome, proportion of individuals with withdrawal symptoms after antipsychotic discontinuation, was 0.53 (95% CI, 0.37-0.70; I² = 82.98%, P < 0.01). An odds ratio of 7.97 (95% CI, 2.39-26.58; I² = 82.7%, P = 0.003) and NNH of 3 was calculated for the occurrence of withdrawal symptoms after antipsychotic discontinuation.

CONCLUSION

Withdrawal symptoms appear to occur frequently after abrupt discontinuation of an oral antipsychotic. The lack of randomized controlled trials with low risk of bias on antipsychotic withdrawal symptoms highlights the need for further research.

Amisulpride withdrawal dyskinesia: a case report

BACKGROUND

The effects of antipsychotic drug withdrawal have been inadequately studied. Case reports have described dyskinesia occurring in patients with several antipsychotics withdrawn, but studies on amisulpride withdrawal dyskinesia are lacking.

CASE PRESENTATION

A 63-year-old man, who was diagnosed with schizophrenia at age 49, received amisulpride treatment since age 62. The dosage of amisulpride was reduced from 200 to 50 mg/day because of occurrence of akathisia during one admission. Severe withdrawal dyskinesia, mixed with dystonia and akathisia, was noted immediately after the dosage reduction. The abnormal involuntary movement showed improvement 2 weeks later when the dosage was increased to 100 mg/day.

CONCLUSIONS

Withdrawal dyskinesia and other abnormal involuntary movements could be noted in a patient with reduction of amisulpride dosage or sudden termination. Withdrawal dyskinesia may subsequently lead to persistent tardive dyskinesia. Therefore, withdrawal-emergent dyskinesia should be promptly identified, and appropriate medical interventions should be given early.

An update on tardive dyskinesia: from phenomenology to treatment

Tardive dyskinesia (TD), characterized by oro-buccal-lingual stereotypy, can manifest in the form of akathisia, dystonia, tics, tremor, chorea, or as a combination of different types of abnormal movements. In addition to movement disorders (including involuntary vocalizations), patients with TD may have a variety of sensory symptoms, such as urge to move (as in akathisia), paresthesias, and pain. TD is a form of tardive syndrome-a group of iatrogenic hyperkinetic and hypokinetic movement disorders caused by dopamine receptor-blocking agents. The pathophysiology of TD remains poorly understood, and treatment of this condition is often challenging. In this update, we provide the most current information on the history, nomenclature, etiology, pathophysiology, epidemiology, phenomenology, differential diagnosis, and treatment of TD.

Nonprimary dystonias

Dystonias can be classified as primary or secondary, as dystonia-plus syndromes, and as heredodegenerative dystonias. Their prevalence is difficult to determine. In our experience 80-90% of all dystonias are primary. About 20-30% of those have a genetic background; 10-20% are secondary, with tardive dystonia and dystonia in cerebral palsy being the most common forms. If dystonia in spastic conditions is accepted as secondary dystonia, this is the most common form of all dystonia. In primary dystonias, the dystonic movements are the only symptoms. In secondary dystonias, dystonic movements result from exogenous processes directly or indirectly affecting brain parenchyma. They may be caused by focal and diffuse brain damage, drugs, chemical agents, physical interactions with the central nervous system, and indirect central nervous system effects. Dystonia-plus syndromes describe brain parenchyma processes producing predominantly dystonia together with other movement disorders. They include dopa-responsive dystonia and myoclonus-dystonia. Heredodegenerative dystonias are dystonic movements occurring in the context of other heredodegenerative disorders. They may be caused by impaired energy metabolism, impaired systemic metabolism, storage of noxious substances, oligonucleotid repeats and other processes. Pseudodystonias mimic dystonia and include psychogenic dystonia and various orthopedic, ophthalmologic, vestibular, and traumatic conditions. Unusual manifestations, unusual age of onset, suspect family history, suspect medical history, and additional signs may indicate nonprimary dystonia. If they are suspected, etiological clarification becomes necessary. Unfortunately, potential etiologies are legion. Diagnostic algorithms can be helpful. Treatment of nonprimary dystonias, with few exceptions, does not differ from treatment of primary dystonias. The most effective treatment for focal and segmental dystonias is local botulinum toxin injections. Deep brain stimulation of the globus pallidus internus is effective for generalized dystonia. Antidystonic drugs, including anticholinergics, tetrabenazine, clozapine, and gamma-aminobutyric acid receptor agonists, are less effective and often produce adverse effects. Dopamine is extremely effective in dopa-responsive dystonia. The Bertrand procedure can be effective in cervical dystonia. Other peripheral surgery, including myotomy, myectomy, neurotomy, rhizotomy, ramizectomy, and accessory nerve neurolysis, has largely been abandoned. Central surgery other than deep brain stimulation is obsolete. Adjuvant therapies, including orthoses, physiotherapy, ergotherapy, behavioral therapy, social support, and support groups, may be helpful. Analgesics should also be considered where appropriate.

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.

Modeling withdrawal syndrome in zebrafish

The zebrafish (Danio rerio) is rapidly becoming a popular model species in behavioral neuroscience research. Zebrafish behavior is robustly affected by environmental and pharmacological manipulations, and can be examined using exploration-based paradigms, paralleled by analysis of endocrine (cortisol) stress responses. Discontinuation of various psychotropic drugs evokes withdrawal in both humans and rodents, characterized by increased anxiety. Sensitivity of zebrafish to drugs of abuse has been recently reported in the literature. Here we examine the effects of ethanol, diazepam, morphine and caffeine withdrawal on zebrafish behavior. Overall, discontinuation of ethanol, diazepam and morphine produced anxiogenic-like behavioral or endocrine responses, demonstrating the utility of zebrafish in translational research of withdrawal syndrome.

The management of tics

A tic is a stereotyped repetitive involuntary movement or sound, frequently preceded by premonitory sensations or urges. Most tic disorders are genetic or idiopathic in nature, possibly due to a developmental failure of inhibitory function within frontal-subcortical circuits modulating volitional movements. Currently available oral medications can reduce the severity of tics, but rarely eliminate them. Botulinum toxin injections can be effective if there are a few particularly disabling motor tics. Deep brain stimulation has been reported to be an effective treatment for the most severe cases, but remains unproven. A comprehensive evaluation accounting for secondary causes, psychosocial factors, and comorbid neuropsychiatric conditions is essential to successful treatment of tic disorders.

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.

Focus on lower risk of tardive dyskinesia with atypical antipsychotics

BACKGROUND

Tardive dyskinesia (TD) is one of the most serious iatrogenic neurological complications of the first-generation antipsychotics. Identifying the risk factors for TD is important to minimize the risk of this potentially irreversible movement disorder in susceptible populations.

METHODS

A Medline search was conducted for the literature on risk factors for TD with the first-generation antipsychotics, as well as the emerging literature of the lower risk of TD with the second-generation antipsychotics.

RESULTS

Several demographic, phenomenological, comorbidities and treatment variables have been reported to be associated with higher risk of TD. On the other hand, significantly lower rates of TD have been reported with the second-generation atypical antipsychotics, even in high risk groups such as the elderly.

CONCLUSIONS

The use of the second-generation antipsychotics as first-line treatment of psychosis appears to have lowered the overall prevalence of acute movement disorders as well as TD, and have led them to become the standard of care in part because of their safer extrapyramidal profiles.

Classification and treatment of tardive syndromes

BACKGROUND

Tardive syndromes are a group of delayed-onset abnormal involuntary movement disorders induced by a dopamine receptor blocking agent. There are several phenomenologically distinct types of TS.

REVIEW SUMMARY

The term tardive dyskinesia has been used to refer to the TS that presents with rapid, repetitive, stereotypic movements mostly involving the oral, buccal, and lingual areas. Tardive dystonia can be focal, segmental, or generalized. It commonly affects the face and neck followed by the arms and trunk. It usually results in retrocollis when it involves the neck and trunk arching backwards when it involves the trunk. Tardive akathisia is characterized by a feeling of inner restlessness and jitteriness with an inability to sit or stand still. Other tardive syndromes include tardive tics, myoclonus, tremor, and withdrawal-emergent syndrome. It remains unclear whether tardive parkinsonism truly exists. The only way to prevent TS is to avoid its etiologic agents. Chronic use of dopamine receptor blocking agents should be limited as much as possible to patients with chronic psychoses. In general, for mild TS, reducing the neuroleptic dose, switching to an atypical agent, or discontinuing antipsychotic treatment altogether in the hope of facilitating remission is recommended. For moderate to severe TS, tetrabenazine or reserpine may be the most effective agent. Neuroleptics should be resumed to treat TD in the absence of active psychosis only as a last resort for persistent, disabling, and treatment-resistant TD.

CONCLUSIONS

The severity of the TS and the absolute need for antipsychotic therapy often dictate the treatment approach for this disorder.

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.

Pisa syndrome in an adolescent on neuroleptic medication

To our knowledge Pisa syndrome in childhood or adolescence has not previously been described. The syndrome developed in an adolescent girl following administration of neuroleptic medication for psychotic features, and was transiently thought to be abnormal illness behaviour. This case emphasises the need for early diagnosis and rapid effective treatment.

Postural myoclonus associated with long-term administration of neuroleptics in schizophrenic patients

Postural myoclonus associated with long-term administration of neuroleptics was demonstrated in schizophrenic patients. Sixty patients who had been taking neuroleptics for more than 3 months were investigated for myoclonus and the relationships between postural myoclonus and age, duration of illness, duration of medication, current daily dose, cumulative dose, occurrence of abnormal finger movement, parkinsonism, and tardive dyskinesia were evaluated. Twenty-three patients (38%) showed postural myoclonus when holding the hands forward with the elbow joints flexed at about 90%. Male patients showed a higher incidence of myoclonus than female patients. Patients with myoclonus had been given significantly higher doses of neuroleptics than those without myoclonus. There was a significant correlation between the occurrence of myoclonus and abnormal finger movement. Electromyographic recordings in 7 patients with prominent myoclonus revealed that arrhythmic jerks occurred in the extensor carpi radialis and posterior deltoid muscles and that the jerks on the left and right side were not synchronized. Clonazepam reduced the frequency of the myoclonic activity.

Pediatric psychopharmacology

This article is a brief and selected overview of pediatric psychopharmacology, a field which links medicine, behavioural sciences, and neurosciences to child psychiatry. It will summarize current knowledge and recent advances related to the indications, effects, limitations and research issues of psychostimulants, antidepressants, antipsychotics, anxiolytics, anticonvulsants and diets used in the treatment of child and adolescent psychiatric disorders.

Risks of neuroleptic drugs in children

We surveyed members of the Child Neurology Society to examine their attitudes about use of neuroleptic drugs in children and their experiences with neuroleptic-induced movement disorders. Sixty percent of the membership responded to our questionnaire. Of these responders, over 99% agreed that there were clinical indications for neuroleptics in children, but their criteria varied. Only a minority of the responders routinely incorporated drug holidays in the therapeutic plans of children treated with neuroleptics. The majority had not had clinical experience with patients who developed chronic movement disorders associated with neuroleptic treatment, but 35% (140/410) had encountered patients whose symptoms they considered typical of tardive dyskinesia. However, some of these patients did not meet strict criteria for diagnosis of this movement disorder. The results suggest that neuroleptic-induced movement disorders occur with significant frequency in children and that more detailed prospective studies of the risks and benefits of these drugs in children are warranted.

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.

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.

A neural systems theory of schizophrenia and tardive dyskinesia

Some systems ideas applied to individual persons are used to try to explain symptoms of schizophrenia and a syndrome of uncontrolled fragments of movement which sometimes occurs as a side effect of chronic, antipsychotic drug therapy. The behavior of normal organisms may be conceptualized in three echelons of control, with each successively higher echelon organizing, by selective disinhibition, semiautonomous, spontaneous fragments of activity which comprise the next lower echelon. It is hypothesized that schizophrenia involves a deficiency of inhibition by the frontal cortex, first echelon, on the corpus striatum, second echelon. This results first in insufficiently integrated fragments of behavior, and second in premature associative linkages among active elements. First echelon control develops as a normal person matures and gradually loses some of the playful activities of childhood. It is hypothesized that by disrupting certain aspects of activity in the corpus striatum, neuroleptic drugs reduce schizophrenic symptoms but also reduce the capacity of the second echelon to inhibit and integrate the smaller behavioral fragments wired into lower parts of the brain, third echelon. This results in uncontrolled movements. Though many researchers already favor the hypothesis that neuroleptic drugs act on the corpus striatum, the broader theory presented here is new and depends in large part on general living systems considerations. Emphasis is on conceptual decomposition of the integrated behavior of a whole organism into less complex subsystems. Individually, these have neither too much nor too little complexity to yield a plausible model. Some experimental predictions and predictions about possible therapies are made from the theory.

Maintenance antipsychotic therapy: is the cure worse than the disease?

The serious long-term complications of maintenance antipsychotic therapy led the authors to undertake a critical review of outpatient withdrawal studies. Key findings included the following: 1) for a least 40% of outpatient schizophrenics, drugs seem to be essential for survival in the community; 2) the majority of patients who relapse after drug withdrawal recompensate fairly rapidly upon reinstitution of antipsychotic drug therapy; 3) placebo survivors seem to function as well as drug survivors--thus the benefit of maintenance drug therapy appears to be prevention of relapse; and 4) some cases of early relapse after drug withdrawal may be due to dyskinesia rather than psychotic decompensation. The authors urge clinicians to evaluate each patient on maintenance antipsychotic therapy in terms of feasibility of drug withdrawal and offer practical guidelines for withdrawal and subsequent management.