The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia

Catatonia in an acute adult inpatient population in mental health units in Khartoum, Sudan: A cross-sectional study

BACKGROUND

Catatonic syndrome is a mental health issue, as well as a medical, neurological, and toxic condition. There are few published data on catatonic syndrome in African countries and none in Sudan, the third-largest African country.

AIM

To assess the prevalence and presenting symptoms of catatonic syndrome in an acute psychiatric inpatient population in four governmental psychiatric hospitals in Sudan.

METHODS

A cross-sectional study was conducted in four psychiatric hospitals in the capital, Khartoum, in Sudan. The data were collected using an interviewer-administered questionnaire tool, which included sociodemographic data (age, sex, educational level, marital status, and residence). Signs and symptoms of catatonic syndrome were assessed using the Bush-Francis Catatonia Rating Scale (BFCRS) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria. χ² tests were used to compare categorized variables. Multivariate analysis was not performed because none of the variables were found to be different between patients with and without catatonic syndrome.

RESULTS

Of the 384 patients, 50.0% and 49.3% were males and females, respectively, and their median age was 30.0 years. One hundred and sixty-three (42.4%) patients had catatonic syndrome according to the BFCRS criteria. Of these patients, 104 fulfilled the DSM-5 criteria, with a 27.1% prevalence of catatonic syndrome. Echopraxia/echolalia (84.5%), mutism (71.2%), posturing/catalepsy (67.3%), and mannerisms (66.3%) were the main manifestations among patients with catatonic syndrome. There was no significant difference in age, sex, marital status, or job between patients with and those without catatonic syndrome. Of the 163 patients with catatonic syndrome, 31.3% had bipolar disorder, 28.2% had schizophrenia, and 19.6% had major depressive disorder.

CONCLUSION

Catatonic syndrome is highly prevalent in an acute psychiatric inpatient population in Sudan regardless of age or sex. Echopraxia/echolalia (84.5%) and mutism were the main manifestations among the patients with catatonic syndrome.

Functional pathology of neuroleptic-induced dystonia based on the striatal striosome-matrix dopamine system in humans

Neuroleptic-induced dystonia is a source of great concern in clinical practice because of its iatrogenic nature which can potentially lead to life-threatening conditions. Since all neuroleptics (antipsychotics) share the ability to block the dopamine D2-type receptors (D2Rs) that are highly enriched in the striatum, this drug-induced dystonia is thought to be caused by decreased striatal D2R activity. However, how associations of striatal D2R inactivation with dystonia are formed remains elusive.A growing body of evidence suggests that imbalanced activities between D1R-expressing medium spiny neurons and D2R-expressing medium spiny neurons (D1-MSNs and D2-MSNs) in the striatal striosome-matrix system underlie the pathophysiology of various basal ganglia disorders including dystonia. Given the specificity of the striatal dopamine D1 system in 'humans', this article highlights the striatal striosome hypothesis in causing 'repetitive' and 'stereotyped' motor symptoms which are key clinical features of dystonia. It is suggested that exposure to neuroleptics may reduce striosomal D1-MSN activity and thereby cause dystonia symptoms. This may occur through an increase in the striatal cholinergic activity and the collateral inhibitory action of D2-MSNs onto neighbouring D1-MSNs within the striosome subfields. The article proposes a functional pathology of the striosome-matrix dopamine system for neuroleptic-induced acute dystonia or neuroleptic-withdrawal dystonia. A rationale for the effectiveness of dopaminergic or cholinergic pharmacotherapy is also provided for treating dystonias. This narrative review covers various aspects of the relevant field and provides a detailed discussion of the mechanisms of neuroleptic-induced dystonia.

Comparative efficacy of akathisia treatments: A network meta-analysis

OBJECTIVE

Akathisia, a common side effect of psychotropic medications, poses a significant challenge in neuropsychiatry, affecting up to 30% of patients on antipsychotics. Despite its prevalence, akathisia remains poorly understood, with difficulties in diagnosis, patient reporting, and treatment efficacy. This research aimed to shed light on effective interventions to improve akathisia management.

METHODS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted, encompassing controlled trials in English and Italian languages. Databases, such asPubMed, Scopus, and EMBASE, were searched until July 9, 2023. Treatment effectiveness was assessed using standardized mean differences (SMDs) in post-treatment akathisia scores.

RESULTS

Thirteen studies involving 446 individuals met the inclusion criteria. Benzodiazepines, beta-blockers, and NaSSA demonstrated significant efficacy as compared with placebo. Anticholinergic, anticonvulsant, triptan, and other treatments did not show significant differences. Benzodiazepines ranked highest in P-scores (0.8186), followed by beta-blockers and NaSSA.

CONCLUSIONS

Effective management of akathisia is crucial, with benzodiazepines, beta-blockers, and NaSSA offering evidence-based options. Treatment rankings provide guidance for clinicians. Future research should prioritize larger, more robust studies to address limitations associated with small sample sizes and publication bias. This research enhances our understanding of interventions for akathisia, offering promising options to improve patient quality of life and prevent complications related to non-adherence and mismanagement.

The Role of Magnesium in Parkinson's Disease: Status Quo and Implications for Future Research

Neurodegenerative diseases represent an increasing economic, social, and, above all, medical burden worldwide. The second most prevalent disease in this category is Parkinson's disease, surpassed only by Alzheimer's. It is a treatable but still incurable systemic disease with a pathogenesis that has not yet been elucidated. Several theories are currently being developed to explain the causes and progression of Parkinson's disease. Magnesium is one of the essential macronutrients and is absolutely necessary for life as we know it. The magnesium cation performs several important functions in the cell in the context of energetic metabolism, substrate metabolism, cell signalling, and the regulation of the homeostasis of other ions. Several of these cellular processes have been simultaneously described as being disrupted in the development and progression of Parkinson's disease. The relationship between magnesium homeostasis and the pathogenesis of Parkinson's disease has received little scientific attention to date. The aim of this review is to summarise and critically evaluate the current state of knowledge on the possible role of magnesium in the pathogenesis of Parkinson's disease and to outline possible future directions for research in this area.

Atypical Presentation of Ziprasidone-Induced Neuroleptic Malignant Syndrome: A Case Report

Neuroleptic malignant syndrome (NMS) is a severe adverse reaction associated with neuroleptic or antipsychotic drugs. This case report discusses a 43-year-old man with a history of bipolar disorder and polysubstance abuse who presented with altered mental status, autonomic dysfunction, and muscular rigidity. The patient had recently started on ziprasidone, a second-generation antipsychotic, leading to an atypical presentation of NMS. Unlike classic findings associated with NMS induced by first-generation antipsychotics, this case lacked high fever, lead pipe rigidity, or elevated creatine kinase levels greater than 1000 on initial presentation. The delay in diagnosis was attributed to the milder symptoms and absence of typical findings, resulting in extensive diagnostic workup and interventions. The patient responded positively to treatment with lorazepam based on the Woodbury severity stage guidelines. This case underscores the complexity of diagnosing NMS induced by second-generation antipsychotics and highlights the need for awareness and tailored treatment approaches for atypical presentations.

Catatonia and ECT across the lifespan

Electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia with high response rates. Although empirical data suggest that tolerability and efficacy are at least as good as in adults, ECT treatment of children, adolescents, and geriatric patients seems to pose a specific challenge for many practitioners. This article intends to explore and discuss reasons hindering the use of ECT in these patient groups, give an overview on the use of ECT to treat catatonia and provide practical advice on ECT in children, adolescents, and geriatric patients for the treatment of catatonia. Classification of catatonia as a subform of schizophrenia and a diagnostic overlap with other common conditions in children, adolescents, and geriatric patients might lead to underdiagnosis of catatonia. Concerns about the mechanism of action and about a lack of controlled studies as well as general concerns about the use of ECT in children and adolescents might lead to underutilization of ECT. However, studies of ECT to treat catatonia in children, adolescents, and geriatric patients consistently show its safety and effectiveness. Administration of ECT needs to consider some specific characteristics of children, adolescents, and geriatric patients. In conclusion, ECT is a safe and highly effective treatment for catatonia across the lifespan. Existing evidence does not warrant restrictions of its use in certain age groups.

Regional Homogeneity in schizophrenia patients with tardive dyskinesia: a resting-state fMRI study

Neuronal degeneration and apoptosis may play an important role in the pathogenesis of tardive dyskinesia (TD). Previous studies suggested brain structural and functional abnormalities in patients with TD. We investigated changes in cerebral regional homogeneity (ReHo) in patients with TD using resting-state functional magnetic resonance imaging (rs-fMRI). Imaging data were collected from schizophrenia patients with TD (TD group, n=58) and without TD (non-TD group, n=66) and healthy controls (HC group, n=67), processed with SPM, and evaluated at a corrected threshold. Psychopathology and severity of TD were assessed with the Positive and Negative Syndrome Scale (PANSS) and Abnormal Involuntary Movement Scale (AIMS), respectively. Results: TD vs. non-TD group showed significantly higher ReHo in the Left Inferior Semilunar Lobule and Right Fusiform Gyrus and lower ReHo in Left Supramarginal Gyrus, Right Inferior Tempotal Gyrus, and Left Medial Frontal Gyrus. The ReHo value in the Left Inferior Semilunar Lobule was negatively correlated with AIMS upper limbs scores. Conclusions: The findings suggest altered regional neural connectivities in association with TD and may inform research of the etiology and monitor the course of TD in patients with schizophrenia and potentially other psychotic disorders.

The Outcome of Antipsychotics-induced Tardive Syndromes: A Ten-year Follow-up Study

Objective

Tardive syndrome (TS) is an umbrella term used to describe a group of abnormal movement disorders caused by chronic exposure to dopamine receptor blocking agents. Few follow-up studies have been performed on the outcome of TS in patients using antipsychotics. The purpose of our study was to investigate the prevalence, incidence, remission rate, and factors associated with remission in patients using antipsychotics.

Methods

This retrospective cohort study consisted of 123 patients who received continuous treatment of antipsychotics in a medical center in Taiwan, from April 1, 2011 to May 31, 2021. We assessed the demographic and clinical characteristics, prevalence, incidence, remission rate, and factors associated with remission in patients using antipsychotics. TS remission was defined as a Visual Analogue Scale score ≤ 3.

Results

Of the 92 patients who completed the 10-year follow-up, 39 (42.4%) were found to have at least one episode of TS, with tardive dyskinesia (TD) being the most prevalent subtype (51.3%). With regard to concurrent physical illness, a history of extrapyramidal symptoms were significant risk factors for TS. During the 10-year follow-up period, the remission rate of TS was 74.3%. The use of antioxidants including vitamin B6 and piracetam was related to the remission of TS. Patients with tardive dystonia had a higher remission rate (87.5%) compared to TD (70%).

Conclusion

Our study suggests that TS may be a treatable condition, and the key to a better outcome is early detection and prompt intervention, including closely monitoring antipsychotics-related TS symptoms and using antioxidants.

Rebound Catatonia Associated With Injectable Paliperidone

Paliperidone is an atypical antipsychotic medication commonly used to treat schizophrenia, schizoaffective disorder, and bipolar disorder. It is a metabolite of risperidone and has a similar mechanism of action, primarily blocking dopamine 2 receptors (D2 receptors) in the brain. Paliperidone has various adverse effects, including extrapyramidal symptoms, weight gain, and metabolic disturbances. Catatonia is rare but severe side effects can occur in the context of an underlying psychiatric, neurologic, or general medical condition. Paradoxically, antipsychotics for treating schizophrenia or bipolar spectrum disorders can precipitate or worsen catatonic symptoms. The report suggests that 17-19% of all cases diagnosed as catatonia due to other medical conditions are medication-induced. Catatonia is a neuropsychiatric syndrome that presents as a cluster of psychomotor signs and symptoms resulting in movement and behavior aberrations. Various symptoms, including mutism, stupor, rigidity, and abnormal movements, characterize catatonia. Catatonia is a potentially life-threatening condition requiring prompt recognition and management. Here, we present a case of a patient with catatonia associated with long-acting injectable paliperidone intramuscular therapy in a patient with schizophrenia.

Morbidity Due to Disparity in Pediatric Electroconvulsive Therapy

Dr. Miller and colleagues recently submitted a Letter to the Editor discussing current state laws that result in disparity of electroconvulsive therapy (ECT) availability.¹ In this current letter, we present a case of treatment-resistant childhood-onset schizophrenia (COS), with morbidity due to limited access to ECT. The patient and his family presented from Kentucky to Tennessee, despite less legislative regulation in the former. The patient's family provided informed consent for this report to be published.

[Acute catatonia]

BACKGROUND

Catatonia is an underdiagnosed psychomotor syndrome that can occur in the context of various mental and somatic diseases. Malignant catatonia is particularly relevant in the context of intensive medical care. Clear recommendations in guidelines are missing.

OBJECTIVE

To present the current state of the diagnosis and treatment of catatonia, especially malignant catatonia.

MATERIAL AND METHODS

The literature was evaluated with respect to acute catatonic conditions, with a special focus on the differential diagnosis, relevance to intensive medical care and treatment of catatonia.

RESULTS

In psychiatric inpatients, catatonic syndromes are relatively frequent with a prevalence between 9% and 17%, and in neurological patients somewhat less frequent with a prevalence of 3.3%. There is a clear recommendation for pharmacological treatment with lorazepam. Additional electroconvulsive therapy (ECT) should be considered as early as possible, especially in cases not responding to benzodiazepines. Response rates to ECT have been shown to be 80-100%. In malignant catatonia, ECT should be performed immediately as an emergency indication.

CONCLUSION

Several factors lead to the underdiagnosis of catatonia. It is problematic that even life-threatening malignant catatonia is often not recognized as such, although there is a mortality of about 50% if untreated. The best treatment outcome is achieved with a combination of benzodiazepines and ECT. The treatment of severe malignant catatonia represents an emergency indication for ECT.

Molecular and cellular mechanisms leading to catatonia: an integrative approach from clinical and preclinical evidence

This review aims to describe the clinical spectrum of catatonia, in order to carefully assess the involvement of astrocytes, neurons, oligodendrocytes, and microglia, and articulate the available preclinical and clinical evidence to achieve a translational understanding of the cellular and molecular mechanisms behind this disorder. Catatonia is highly common in psychiatric and acutely ill patients, with prevalence ranging from 7.6% to 38%. It is usually present in different psychiatric conditions such as mood and psychotic disorders; it is also a consequence of folate deficiency, autoimmunity, paraneoplastic disorders, and even autistic spectrum disorders. Few therapeutic options are available due to its complexity and poorly understood physiopathology. We briefly revisit the traditional treatments used in catatonia, such as antipsychotics, electroconvulsive therapy, and benzodiazepines, before assessing novel therapeutics which aim to modulate molecular pathways through different mechanisms, including NMDA antagonism and its allosteric modulation, and anti-inflammatory drugs to modulate microglia reaction and mitigate oxidative stress, such as lithium, vitamin B12, and NMDAr positive allosteric modulators.

Therapy of Catatonia in Schizophrenia and Schizophrenia Spectrum Disorders

Background: the study of catatonia’s treatment methods is one of the most important researchers’ tasks, nevertheless the common therapeutic strategies of cupping the catatonic phenomena haven’t been created yet. The aim: review to therapeutic interventions for catatonic disorders in schizophrenia.Materials and methods: according to the keywords “catatonia treatment”, “catatonia therapy”, publications found in the Scopus, PubMed, Cochrane Library, eLibrary databases were selected and analyzed.Results: historical background, illustrating the development of catatonia treatment methods, is given; the results of the last decades scientific studies of catatonia’s treatment and preliminary results of own study, devoted to the effectiveness of diazepam and cariprazine in relieving catatonia manifestations are presented. Based on the studies’ results, presented in the review, it can be concluded that the most common modern method of treating catatonic disorders is the use of benzodiazepines, however, in some cases, the use of antipsychotics is also advisable. Electroconvulsive therapy (ECT) remains an important treatment for catatonic phenomena. There are also isolated clinical cases of successful testing of both: other pharmacological groups (antidepressants, dopaminergic and anticholinergic drugs, normothymic drugs, etc.) and non-drug interventions (transcranial magnetic stimulation — TMS) presented in modern research data.Conclusion: the effectiveness of benzodiazepines in catatonia, associated with schizophrenia and schizophrenia spectrum disorders (SSD), remains controversial according to modern authors’ opinion. In turn, among antipsychotics, antipsychotics of the second and third generation seem to be safe for the treatment of psychomotor symptoms. In accordance with the results of our own study, catatonia in the structure of schizophrenia and SSD is heterogeneous and, depending on the psychopathological structure of catatonic disorders, a different reaction of psychomotor symptoms to therapeutic intervention was observed.

Genes of the Glutamatergic System and Tardive Dyskinesia in Patients with Schizophrenia

Background: Tardive dyskinesia (TD) is an extrapyramidal side effect of the long-term use of antipsychotics. In the present study, the role of glutamatergic system genes in the pathogenesis of total TD, as well as two phenotypic forms, orofacial TD and limb-truncal TD, was studied. Methods: A set of 46 SNPs of the glutamatergic system genes (GRIN2A, GRIN2B, GRIK4, GRM3, GRM7, GRM8, SLC1A2, SLC1A3, SLC17A7) was studied in a population of 704 Caucasian patients with schizophrenia. Genotyping was performed using the MassARRAY Analyzer 4 (Agena Bioscience™). Logistic regression analysis was performed to test for the association of TD with the SNPs while adjusting for confounders. Results: No statistically significant associations between the SNPs and TD were found after adjusting for multiple testing. Since three SNPs of the SLC1A2 gene demonstrated nominally significant associations, we carried out a haplotype analysis for these SNPs. This analysis identified a risk haplotype for TD comprising CAT alleles of the SLC1A2 gene SNPs rs1042113, rs10768121, and rs12361171. Nominally significant associations were identified for SLC1A3 rs2229894 and orofacial TD, as well as for GRIN2A rs7192557 and limb-truncal TD. Conclusions: Genes encoding for mGlu3, EAAT2, and EAAT1 may be involved in the development of TD in schizophrenia patients.

Catatonia: Back to the future of the neuropsychiatric syndrome

Catatonia is an undertreated and underdiagnosed neuropsychiatric syndrome whose prognosis is benign if treated early, thus avoiding possible complications and compromising the health of patients. The latest epidemiological studies indicate a prevalence of catatonia of 9.2%, being frequent in medical pathologies (especially neurological ones), as well as in psychiatric pathologies. The use of validated scales is recommended for its diagnosis, to be able to measure the severity and response to treatment. Once catatonia has been identified, it is necessary to perform a protocolized diagnostic study of the underlying aetiology («Catatonia Workup»). Treatment of choice is benzodiazepines and electroconvulsive therapy. In recent years, new therapeutic alternatives such as non-invasive transcranial magnetic stimulation have emerged. In this review we propose several initiatives to promote the dissemination and knowledge of catatonia in the clinical setting.

Catatonia in autism spectrum disorders: A systematic review and meta-analysis

BACKGROUND

Catatonic features can appear in autism spectrum disorders (ASDs). There can be overlap in symptoms across catatonia and ASD. The overall aim of this review is to provide evidence for the presence of catatonic features in subjects with ASD.

METHODS

A systematic literature search using the Web of Science database from inception to July 10, 2021 was conducted following PRISMA, MOOSE guidelines and the PROSPERO protocol. (CRD42021248615). Twelve studies with information about catatonia and ASD were reviewed. Data from a subset was used to conduct meta-analyses of the presence of catatonia in ASD.

RESULTS

The systematic review included 12 studies, seven of which were used for the meta-analysis, comprising 969 individuals. The mean age was 21.25 (7.5) years. Two studies (16.6%) included only children and adolescents. A total of 70-100% were males. Our meta-analysis showed that 10.4% (5.8-18.0 95%CI) of individuals with ASD have catatonia. Motor disturbances were common in ASD subjects with catatonia. No differences were found in comorbidity. Several treatments have been used in ASD with catatonic features, including benzodiazepines, antipsychotics, and electroconvulsive therapy (ECT). The findings of the systematic review showed that ECT might help manage catatonic symptoms.

CONCLUSIONS

Different features of catatonia can exist in individuals with ASD and core symptoms of catatonia are reported in ASD. Longitudinal and longer-term studies are required to understand the relationship between catatonia and ASD, and the response of catatonic symptoms to treatment.