Adverse effects of anticholinergic antiparkinsonian drugs in tardive dyskinesia. An investigation of mechanism

[Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 3 : Tardive dyskinesia]

The treatment of schizophrenic psychoses with antipsychotic drugs (AP) is often associated with an increased risk of delayed occurrence of antipsychotic-associated movement disorders. Persistence and chronicity of such symptoms are very frequent. The risk of developing tardive dyskinesia (TD) is associated with the pharmacological effect profile of a particular AP, with treatment duration and age. This systematic review article summarizes the current study situation on prevalence, risk factors, prevention and treatment options and instruments for early prediction of TD in schizophrenic psychoses. The current data situation on treatment strategies for TD is very heterogeneous. For the treatment of TD there is preliminary evidence for reduction or discontinuation of the AP, switching to clozapine, administration of benzodiazepines (clonazepam) and treatment with vesicular monoamine transporter (VMAT2) inhibitors, ginkgo biloba, amantadine or vitamin E. Although TD can be precisely diagnosed it cannot always be effectively treated. Early detection and early treatment of TD can have a favorable influence on the prognosis and the clinical outcome.

Striatal cholinergic interneurons and D2 receptor-expressing GABAergic medium spiny neurons regulate tardive dyskinesia

Tardive dyskinesia (TD) is a drug-induced movement disorder that arises with antipsychotics. These drugs are the mainstay of treatment for schizophrenia and bipolar disorder, and are also prescribed for major depression, autism, attention deficit hyperactivity, obsessive compulsive and post-traumatic stress disorder. There is thus a need for therapies to reduce TD. The present studies and our previous work show that nicotine administration decreases haloperidol-induced vacuous chewing movements (VCMs) in rodent TD models, suggesting a role for the nicotinic cholinergic system. Extensive studies also show that D2 dopamine receptors are critical to TD. However, the precise involvement of striatal cholinergic interneurons and D2 medium spiny neurons (MSNs) in TD is uncertain. To elucidate their role, we used optogenetics with a focus on the striatum because of its close links to TD. Optical stimulation of striatal cholinergic interneurons using cholineacetyltransferase (ChAT)-Cre mice expressing channelrhodopsin2-eYFP decreased haloperidol-induced VCMs (~50%), with no effect in control-eYFP mice. Activation of striatal D2 MSNs using Adora2a-Cre mice expressing channelrhodopsin2-eYFP also diminished antipsychotic-induced VCMs, with no change in control-eYFP mice. In both ChAT-Cre and Adora2a-Cre mice, stimulation or mecamylamine alone similarly decreased VCMs with no further decline with combined treatment, suggesting nAChRs are involved. Striatal D2 MSN activation in haloperidol-treated Adora2a-Cre mice increased c-Fos⁺ D2 MSNs and decreased c-Fos⁺ non-D2 MSNs, suggesting a role for c-Fos. These studies provide the first evidence that optogenetic stimulation of striatal cholinergic interneurons and GABAergic MSNs modulates VCMs, and thus possibly TD. Moreover, they suggest nicotinic receptor drugs may reduce antipsychotic-induced TD.

Anticholinergics in the era of atypical antipsychotics: short-term or long-term treatment?

Anticholinergic agents are usually prescribed to prevent or treat antipsychotic-induced extrapyramidal symptoms. Their long-term benefits are questionable and they carry diverse adverse effects, including cognitive impairment and worsening of tardive dyskinesia. This literature review explores the impact of anticholinergic medication discontinuation on movement disorders, cognition and psychopathology in patients receiving antipsychotics. Medline, Embase and PsycInfo were searched from 1950 to July 2011 using "cessation /withdrawal /discontinuation /stopping" with "anticholinergic*" or "antiparkinson*" and "neuroleptic*" or "antipsychotic*". Additional articles were obtained by searching the bibliographies of relevant references. Earlier studies of anticholinergic agent discontinuation in patients receiving first-generation antipsychotics reported relapse rates of extrapyramidal symptoms between 4% and 80%, reflecting the heterogeneity of the studies. Two recent studies of patients prescribed second-generation antipsychotics obtained relapse rates of 4% and 33%. Some studies suggest improvement in tardive dyskinesia with cessation of anticholinergics. Four studies examined the effects of anticholinergic agent discontinuation on cognition and all observed an improvement post-discontinuation. Changes in symptoms of schizophrenia with anticholinergic discontinuation are conflicting, with more recent studies suggesting an improvement. Given their questionable benefit with continued use, clinicians should consider a gradual withdrawal of anticholinergic agents in stable patients receiving antipsychotics.

Pharmacological and physiological characterization of the tremulous jaw movement model of parkinsonian tremor: potential insights into the pathophysiology of tremor

Tremor is a cardinal symptom of parkinsonism, occurring early on in the disease course and affecting more than 70% of patients. Parkinsonian resting tremor occurs in a frequency range of 3-7 Hz and can be resistant to available pharmacotherapy. Despite its prevalence, and the significant decrease in quality of life associated with it, the pathophysiology of parkinsonian tremor is poorly understood. The tremulous jaw movement (TJM) model is an extensively validated rodent model of tremor. TJMs are induced by conditions that also lead to parkinsonism in humans (i.e., striatal DA depletion, DA antagonism, and cholinomimetic activity) and reversed by several antiparkinsonian drugs (i.e., DA precursors, DA agonists, anticholinergics, and adenosine A(2A) antagonists). TJMs occur in the same 3-7 Hz frequency range seen in parkinsonian resting tremor, a range distinct from that of dyskinesia (1-2 Hz), and postural tremor (8-14 Hz). Overall, these drug-induced TJMs share many characteristics with human parkinsonian tremor, but do not closely resemble tardive dyskinesia. The current review discusses recent advances in the validation of the TJM model, and illustrates how this model is being used to develop novel therapeutic strategies, both surgical and pharmacological, for the treatment of parkinsonian resting tremor.

Role of calcium-independent phospholipase A2 in cortex striatum thalamus cortex circuitry-enzyme inhibition causes vacuous chewing movements in rats

RATIONALE

High levels of calcium independent phospholipase A2 (iPLA2) are present in certain regions of the brain, including the cerebral cortex, striatum, and cerebellum (Ong et al. 2005).

OBJECTIVES

The present study was carried out to elucidate a possible role of the enzyme in the motor system.

METHODS

The selective iPLA2 inhibitor bromoenol lactone (BEL), the nonselective PLA2 inhibitor methyl arachidonyl fluorophosphonate (MAFP), and an antisense oligonucleotide were used to interfere with iPLA2 activity in various components of the motor system. Control animals received injections of carrier (phosphate buffered saline, PBS) at the same locations. The number of vacuous chewing movements (VCM) was counted from 1 to 14 days after injection.

RESULTS

Rats that received BEL and high-dose MAFP injections in the striatum, thalamus, and motor cortex, but not the cerebellum, showed significant increase in VCM, compared to those injected with PBS at these locations. BEL-induced VCM were blocked by intramuscular injections of the anticholinergic drug, benztropine. Increased VCM was also observed after intrastriatal injection of antisense oligonucleotide to iPLA2. The latter caused a decrease in striatal iPLA2 levels, confirming a role of decreased enzyme activity in the appearance of VCM.

CONCLUSIONS

These results suggest an important role for iPLA2 in the cortex-striatum-thalamus-cortex circuitry. It is postulated that VCM induced by iPLA2 inhibition may be a model of human parkinsonian tremor.

Methods for Assessing Drug-Related Anticholinergic Activity

The geriatric population is a large consumer of both prescription and over-the-counter drugs. Positive outcomes from drugs depend on the delicate interplay between therapeutic and adverse effects. This relationship becomes tortuous with simultaneous administration of several drugs. Numerous concomitant drug therapies may be essential for providing quality patient care but may also increase the possibility of an adverse drug event. Increasing sensitivity to drug effects in the geriatric population also creates concern over adverse effects. Drugs that possess anticholinergic properties are especially worrisome, as these properties may manifest as hazardous physiologic and psychological adverse drug events. Consequently, clinicians strive to minimize total drug exposure to agents possessing anticholinergic properties in elderly patients. A review of the literature revealed four methods that might help clinicians systematically reduce or eliminate potentially offending anticholinergic drugs. Each of the four has merits and limitations, with no ideal evidence-based approach used. Three of the four methods described have research utility; however, only one of the methods is clinically useful.

Validation of the tremulous jaw movement model for assessment of the motor effects of typical and atypical antipychotics: effects of pimozide (Orap) in rats

Drug-induced tremulous jaw movements (TJMs) in rats have been used as a model of parkinsonian tremor. Previous studies demonstrated that the typical antipsychotic haloperidol induced TJMs after acute or subchronic administration, while atypical antipsychotics did not. Moreover, it has been suggested that the relative potency for suppression of tacrine-induced TJMs relative to the suppression of lever pressing can be used to discriminate between typical and atypical antipsychotics. In order to validate this model with additional drugs, the present studies assessed the effects of the typical antipsychotic pimozide. In the first series of experiments, the effects of acute pimozide on tacrine-induced TJMs and lever pressing were examined. As with haloperidol, pimozide failed to suppress tacrine-induced TJMs, even at doses considerably higher than those that suppressed lever pressing. In the second group of experiments, rats were given single daily injections of pimozide (0.125-1.0 mg/kg) or tartaric acid vehicle for 13 days, and were observed for TJMs on days 1, 7, and 13. Pimozide induced TJMs in a dose-related manner on all days. The jaw movements occurred largely in the 3-7 Hz frequency range characteristic of parkinsonian tremor. These data support the hypothesis that typical antipsychotics can induce TJMs in rats, and demonstrate that chronic administration of typical antipsychotics is not necessary for induction of TJMs. TJMs induced by acute or subchronic pimozide may be related to early-onset motor syndromes such as drug-induced parkinsonism.

Tardive dyskinesia in Chinese inpatients with chronic schizophrenia

The objective of the study was to determine the point prevalence of tardive dyskinesia (TD) in Chinese inpatients with chronic schizophrenia and its association with sociodemographic, clinical and treatment variables and other movement disorders. A cross-sectional assessment of a randomly selected cohort of inpatients (n=225; mean age=42+/-7 years) with DSM-IV schizophrenia was employed using standard rating instruments for TD and other drug-induced movement disorders, in addition to catatonia, and psychotic, negative, depressive and obsessive-compulsive symptoms. Using Schooler and Kane's criteria, 15 subjects (6.7%) had TD. Patients with TD were significantly older and significantly fewer of them were taking antiparkinsonian medication than subjects without TD. There was no significant difference between the TD and non-TD groups with respect to other demographic, clinical and treatment variables including sex, age of onset, length of contact with psychiatric services, current antipsychotic dosage, negative symptoms, catatonia and parkinsonism. The results confirmed the low prevalence of TD in patients with chronic schizophrenia compared to those found in Caucasian patients. The study has also replicated the association of TD in Chinese schizophrenia patients with older age but failed to demonstrate any association between TD and other demographic or clinical characteristics including catatonia.

Treatment predictors of extrapyramidal side effects in patients with tardive dyskinesia: results from Veterans Affairs Cooperative Study 394

Predictors for the development of tardive dyskinesia (TD) have been studied extensively over the years, yet there are few studies of predictors of the course of TD after it has developed. Moreover, few studies have examined predictors of the course of other extrapyramidal side effects (EPS) in patients maintained on neuroleptics. The purpose of this study was to determine which modifiable variables are important in the prediction of EPS in patients with persistent TD over a period of as long as 2 years. One hundred fifty-eight patients enrolled in the Veterans Affairs Cooperative Study 394 were included in this study. A linear mixed-effects (LME) analysis to estimate the Abnormal Involuntary Movement Scale score (for TD severity), Simpson-Angus Scale (for parkinsonism severity), and Barnes Akathisia Scale at any given time after intake assessment was performed. The severity of each of the TD and EPS outcomes at any given visit was predicted by their respective baseline severity scores. Additional predictors of a favorable course of TD included lower doses of antipsychotic medications and use of anticholinergic medications. Other predictors of a favorable course of EPS included younger age and the use of atypical antipsychotic medication (for rigidity) and the use of anticholinergic medication (for tremor). These findings indicate that clinician-modifiable factors related to medication usage can influence the outcome of TD and EPS in patients with persistent TD.

Tardive dyskinesia model in the common marmoset

Thirteen adult common marmosets (Callithrix jacchus) were given once-monthly injections of haloperidol decanoate (5-15 mg/kg i.m.) for one year. Thereafter, drug-free and treatment periods alternated at 3-month intervals. After 2.5 to 14 months, 12 monkeys showed symptoms of tardive dyskinesia (TD), such as periocular and perioral twitchings, tongue protrusions, masticatory movements, and choreic movements in arms and legs. When TD symptoms were evident, the periodic treatment was interrupted and symptoms persisted for at least 5 months after the last haloperidol dose, worsened by injection of the anticholinergic drug biperiden. An injection of nondepot haloperidol (0.12 or 0.25 mg/kg) produced a reduction of TD symptoms. At the end of the study, nondepot haloperidol was injected once a week at two doses (0.12 and 0.25 mg/kg i.m.). A syndrome of excitation with peculiar behavior, interpreted as acute dystonia, was precipitated in all animals. The animals showed sustained retrocollis, climbing upside down, biting the perch, repetitive turnings, and frequent backward movements. The dystonic movements lasted approximately 6 hours and were reduced but not completely extinguished by biperiden (0.1 mg/kg). The TD syndrome registered in marmosets may provide a useful model for screening new antipsychotics for their propensity to induce TD.

Tremulous jaw movements in rats: a model of parkinsonian tremor

Several pharmacological and neurochemical conditions in rats induce 'vacuous' or 'tremulous' jaw movements. Although the clinical significance of these movements has been a subject of some debate, considerable evidence indicates that the non-directed, chewing-like movements induced by cholinomimetics, dopamine antagonists and dopamine depletions have many of the characteristics of parkinsonian tremor. These movements occur within the 3-7 Hz peak frequency range that is characteristic of parkinsonian tremor. Tremulous jaw movements are induced by many of the conditions that are associated with parkinsonism, and suppressed by several different antiparkinsonian drugs, including scopolamine, benztropine, L-DOPA, apomorphine, bromocriptine, amantadine and clozapine. Striatal cholinergic and dopaminergic mechanisms are involved in the generation of tremulous jaw movements, and substantia nigra pars reticulata appears to be a major basal ganglia output region through which the jaw movements are regulated. Future research on the neurochemical and anatomical characteristics of tremulous jaw movements could yield important insights into the brain mechanisms that generate tremulous movements.

Study on the suitability of a rat model for tardive dyskinesia and the preventive effects of various drugs

1. Male Sprague-Dawley rats (weighing 260-300 g) were administered 1.5 mg/kg of haloperidol (HPD) intraperitoneally once daily for 28 days to produce an animal model for tardive dyskinesia (TD). The daily administration of HPD significantly increased the frequency of involuntary orofacial movements (chewing movements, tongue protrusions and buccal tremors). 2. Its suitability as a model for TD was assessed in terms of the therapeutic effects of 6 drugs [trihexyphenodyl hydrochloride(THP), clonazepam(CZP), sodium valproate(VPA), alpha-tocopherol(Vit E), ritanserin(RS) and propranolol hydrochloride(PPL)]. These drugs were also used concomitantly with HPD to study their preventive effect. 3. As for the therapeutic effects of the drugs, both the single and the 14-day daily administrations of CZP as well as of VPA significantly suppressed the chewing movements. The results were mostly consistent with the effect of each drug on human TD, indicating this would be an excellent model for TD in terms of the drug responsiveness. 4. The concomitant administration of RS from the start of HPD administration significantly suppressed the appearance of chewing movements. The concomitant administration of Vit E for 42 days also suppressed chewing movements and buccal tremors. On the other hand, the concomitant administration of THP tended to aggravate these involuntary movements. 5. The fact that the therapeutic and preventive effects of the drugs on this model differed suggested that the development and recovery of the movements might also differ, at least in part.

Involvement of pallidal and nigral GABA mechanisms in the generation of tremulous jaw movements in rats

Four experiments were conducted to investigate the role of pallidal and nigral GABA in the generation of tremulous jaw movements in rats. In these experiments, tremulous jaw movements were induced by i.p. injections of the anticholinesterase tacrine (5.0 mg/kg). Previous work has shown that the tremulous jaw movements induced by cholinomimetics and dopamine depletion are dependent upon striatal mechanisms. Thus, the present study investigated potential striatal output pathways that could be involved in the generation of these movements. Because there are GABAergic projections from neostriatum to entopeduncular nucleus (medial globus pallidus) and substantia nigra pars reticulata, the GABA agonist muscimol was injected directly into these structures to study the effects of GABA stimulation on tacrine-induced jaw movements. Injections of muscimol into the entopeduncular nucleus (25-100 ng) failed to have any significant effects on tacrine-induced vacuous jaw movements. However, injections of muscimol (12.5-50 ng) into the substantia nigra pars reticulata blocked the jaw movements induced by tacrine. In the third experiment, it was again demonstrated that 25.0 ng of muscimol injected directly into the substantia nigra pars reticulata blocked the jaw movements induced by tacrine; in addition, it was shown that injections of this dose 2.0 mm dorsal to the substantia nigra pars reticulata failed to affect tacrine-induced tremulous jaw movements. It was shown in the fourth experiment that injections of muscimol into a more medial portion of the substantia nigra pars reticulata also reduced tacrine-induced tremulous jaw movements. These results indicate that stimulation of GABA(A) receptors in substantia nigra pars reticulata can block tacrine-induced tremulous jaw movements. This finding is consistent with the notion that striatonigral GABA projections are involved in the generation of tremulous jaw movements. It is also possible that striatonigral GABA mechanisms are involved in human clinical phenomena such as parkinsonian tremor.

The effects of raclopride on vacuous jaw movements in rats following acute administration

Classic neuroleptics produce a syndrome of vacuous jaw movements in rats, whereas atypical neuroleptics like clozapine do not. The present study compared the effects of repeated administration of raclopride, clozapine, haloperidol, or vehicle on vacuous jaw movements in rats over a 4-week period. Rats received an IP injection of drug once a day. On days 1, 8, 15, and 29 the rats were observed for a 5-min period by two trained observers who recorded their vacuous jaw movements. The dose-response curves at which each drug produced vacuous jaw movements are presented and discussed in terms of their predictive capabilities of early onset extrapyramidal side effects.

Repeated scopolamine injections sensitize rats to pilocarpine-induced vacuous jaw movements and enhance striatal muscarinic receptor binding

This experiment was conducted to determine if repeated administration of the muscarinic antagonist scopolamine could increase pilocarpine-induced vacuous jaw movements and also enhance muscarinic receptor binding. Rats received daily injections of either scopolamine (0.5 mg/kg IP) or saline for 14 days. On day 15 rats received no injections of scopolamine, but did receive injections of pilocarpine (1.0, 2.0 or 4.0 mg/kg IP) or saline. After administration of pilocarpine or saline, all rats were observed for vacuous jaw movements and rearing behavior. The day after pilocarpine injections, rats were sacrificed and samples of tissue from the lateral neostriatum were removed to assess muscarinic receptor binding using 3H-QNB as the ligand. Analyses of the vacuous jaw movement data indicated that there was a significant dose-related increase in vacuous jaw movements induced by pilocarpine, and also that there was a significant enhancement of pilocarpine-induced vacuous jaw movements in rats pretreated with repeated scopolamine injections. There was not a significant scopolamine x pilocarpine interaction, suggesting that pretreatment with scopolamine produced an apparent parallel shift in the pilocarpine dose-response curve. Pilocarpine significantly suppressed rearing behavior, and scopolamine pretreatment significantly enhanced the suppression of rearing produced by pilocarpine. Analysis of the receptor binding data indicated that there was a significant increase in the number of muscarinic receptor sites (Bmax) in rats that received repeated scopolamine injections as compared to saline-treated rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Antiparkinsonian drugs in the treatment of neuroleptic-induced extrapyramidal symptoms

Most patients on neuroleptic therapy experience extrapyramidal symptoms in one form or another during treatment. While the risk of extrapyramidal symptoms appears diminished with the newer and "atypical" neuroleptics (for example, risperidone, remoxipride, clozapine), it is not eliminated. It is essential that the treating clinician monitor for such side effects since if they are left untreated they can be an ongoing source of discomfort to the patient and may affect compliance with therapy. Antiparkinsonian medication represents the mainstay of treatment for neuroleptic-induced extrapyramidal symptoms. Their clinical use is reviewed here with reference to mode of action, indications, choice, side-effects and precautions.

Persistent tardive dyskinesia: demographic and pharmacological risk factors

The demographic, clinical and pharmacological risk factors for persistent tardive dyskinesia (TD) were investigated in a sample of 1745 patients. When simultaneously adjusting for the effects of demographic and pharmacological factors using multivariate logistic regression, female sex and advanced age were positively and significantly associated with increased risk of TD. Interaction between these two variables, investigated by cross-stratification, was significant. Furthermore, high neuroleptic dose and concomitant use of neuroleptic and antiparkinsonian drugs were both significantly associated with increased risk of TD. The results support the view that both vulnerability factors and high neuroleptic doses contribute to the occurrence of TD and further stress the relevance of a conservative use of antipsychotic medication, particularly in older women.

Vacuous jaw movements induced by sub-chronic administration of haloperidol: interactions with scopolamine

The present series of experiments was conducted to investigate the vacuous jaw movements induced by sub-chronic administration of haloperidol (HP). In the first experiment, daily injection of 0.4 mg/kg HP for 10 days increased vacuous jaw movements and decreased rearing behavior. The second and third experiments investigated the interaction between the effects of HP and the anticholinergic drug scopolamine. Co-administration of 0.5 mg/kg scopolamine with 0.4 mg/kg HP for 9 days reduced vacuous jaw movements and increased rearing responses relative to rats that received HP alone. Co-administration of HP with 0.25 mg/kg scopolamine for 9 days increased rearing relative to rats that received HP alone, but there was no effect of the lower dose of scopolamine on vacuous jaw movements. Administration of 0.5 mg/kg scopolamine plus 0.4 mg/kg HP on days 11-14 to rats that had received HP alone for 10 days reversed the effect of HP on rearing, but not on vacuous jaw movements. Rats that had received HP plus scopolamine for 10 days showed dramatic increases in vacuous jaw movements when scopolamine was withdrawn. Because vacuous jaw movements are produced within the first few days of administration, reduced by administration of scopolamine, and exacerbated by withdrawal of scopolamine, the pharmacological characteristics of these movements do not appear to bear a close relation to those of tardive dyskinesia in humans. The present results are consistent with the hypothesis that vacuous jaw movements in rats share some characteristics with Parkinsonian symptoms.

Tardive dyskinesia in schizophrenics under 60 years of age

Ninety-one schizophrenics (mean age 34 years) were examined for tardive dyskinesia (TD) during chronic neuroleptic treatment. Dyskinesia was found in 23 (25.3%). The only variable that showed an association with TD was the current doses of neuroleptics: in none of the TD patients did the dose of fluphenazine decanoate (or equivalent) exceed 45 mg/week, whereas it was higher in 23 of the 68 without TD (p less than 0.01). When these 23 "high-dose" patients were disregarded, the TD group differed significantly from the 45 dose-matched non-TD subjects in that it had more common anticholinergic drugs, more common parkinsonian symptoms, and less instances of good remission (p less than 0.05 in each case). There was no association between TD and other considered variables (drug history, age, sex, clinical characteristics, size of the lateral brain ventricles, neurological "soft" signs, cognitive impairment). The results illustrate a relationship between TD prevalence and current doses of neuroleptics and indicate that differences in doses between the groups with and without TD may obscure associations between dyskinesia and other factors.

Natural history and treatment of tardive dystonia

We retrospectively reviewed the clinical course and response to treatment of 67 patients with tardive dystonia. The age at onset ranged from 13 to 72 years without predilection to any particular age group or sex. Patients developed tardive dystonia even after relatively short duration of exposure to dopamine antagonists (21% within one year). Five of 42 patients withdrawn from these drugs remitted. Overall clinical improvement occurred in 52% of patients. Tetrabenazine and reserpine were most effective (greater than 50% response rate) in controlling dystonia. Anticholinergic drugs diminished dystonia in 46% of patients.

Effect of anticholinergics on tardive dyskinesia. A controlled discontinuation study

In a double-blind, placebo-controlled study, ten chronic schizophrenic patients with pronounced symptoms of tardive dyskinesia (TD) were withdrawn from anticholinergic medication. All patients had previously been under long-term treatment with neuroleptics and anticholinergics for at least two years. The rating-scales used were the AIMS, our own TD Scale, and the Simpson-Angus scale for extra-pyramidal side-effects. The severity of TD decreased significantly in nine patients with in two weeks; this improvement, most pronounced in the oral region (P less than .001), persisted during a six-week placebo period. There was a slight increase in parkinsonian symptoms (P less than .05), which was not a prerequisite for improvement in TD. Hence, discontinuation of anticholinergic medication is a possible therapeutic approach in patients with TD.

A theory of the functional organization of the neostriatum and the neostriatal control of voluntary movement

A theory of the intrinsic, functional organization of the neostriatum and the neostriatal control of voluntary movement is presented. The cell types of neostriatum are described in accordance with the classification scheme of Pasik, Pasik and DiFiglia (ref. 204) and their suspected neurotransmitters are identified. The functional relations between the afferent projections to neostriatum and the intrinsic elements of neostriatum are described. A division of the neostriatal efferents into two functional cell systems is conceived, in which one efferent system, the Spiny I cell matrix, is thought to be represented by a lateral inhibitory network comprised of the common Spiny I neurons which inhibit their targets, while another is termed the Spiny II cell cluster and consists of the far less numerous excitatory efferents of neostriatum (the Spiny II cells) and is represented by clusters of neurons, the members of each cluster consisting of one excitatory efferent neuron and three interneurons. The implications of this view for neostriatal input--output relations are discussed, and the theory is developed by reference to a variety of converging lines of empirical evidence, and is used to interpret the effects of various pharmacologic strategies which have been employed to achieve symptom management in disorders of voluntary movement. In the course of this review, there emerges an integrative theory of the principles governing the neostriatal control of voluntary movement.

Pimozide in the treatment of newly admitted schizophrenic patients

Pimozide, a specific dopamine blocking agent, was compared with chlorpromazine in a 4-week double-blind study of the treatment of 40 schizophrenic patients newly admitted to hospital through the emergency room. Dosage was adjusted according to therapeutic effect and during the final week ranged from 10--70 mg/day (median 30 mg/day) for pimozide and 600--1,500 mg/day (median 900 mg/day) for chlorpromazine. Pimozide was found to exert somewhat less of an overall therapeutic effect than chlorpromazine, particularly in highly agitated patients. Women responded better to either treatment than men. A weighted mean of the doses given to male and female patients during the final week suggests that in the treatment of acutely ill patients the mg dose equivalency of pimozide in terms of chlorpromazine is approximately 1:25, considerably lower than estimates from maintenance studies. Pimozide induced significantly more parkinsonian symptoms but less autonomic side effects than chlorpromazine. It is suggested that the weaker presynaptic dopamine blocking effect of pimozide might be responsible for its reduced potency in the treatment of acute schizophrenic symptoms.