Association between the serotonin 2A receptor gene and tardive dyskinesia in chronic schizophrenia

Tardive dyskinesia (TD) is a long-term adverse effect of antipsychotic drugs that are dopamine D2 receptor blockers.(1) Serotonin receptor antagonism has been proposed as a common mechanism contributing to the low extrapyramidal effects profile of atypical antipsychotic drugs.(2) We examined the association of three polymorphisms in the 5-HT2A receptor gene (HTR2A) with TD susceptibility--T102C(3) and his452tyr(4) in the coding region and A-1438G(5) in the promoter--in matched schizophrenia patients with (n = 59, SCZ-TD-Y) and without TD (n = 62, SCZ-TD-N) and normal control subjects (n = 96). The T102C and the A-1438G polymorphisms are in complete linkage disequilibrium but not his452tyr. There was a significant excess of 102C and -1438G alleles (62.7%) in the SCZ-TD-Y patients compared to SCZ-TD-N patients (41.1%) and controls (45.9%; chi(2) = 12.8, df = 2, P = 0.002; SCZ-TD-Y vs SCZ-TD-N, chi(2) = 11.4, df = 1, P = 0.0008, OR 2.41, 95% CI 1.43-3.99) and of 102CC and -1438GG genotypes (SCZ-TD-Y 42.4%, SCZ-TD-N, 16.1%, controls 20.8%, chi(2) = 13.3, df = 4, P = 0.01). The 102CC and the -1438GG genotypes were associated with significantly higher AIMS trunk dyskinesia scores (F = 3.9; df = 2, 116; P = 0.02) and more incapacitation (F = 5.0; df = 2, 115; P = 0.006). The his452tyr polymorphism showed no association with TD. These findings suggest that the 5-HT2A receptor gene is significantly associated with susceptibility to TD in patients with chronic schizophrenia. Previously reported association of the T102C and A-1438G polymorphisms with schizophrenia(6) may reflect association of a sub-group of patients with a susceptibility to abnormal involuntary movements related to antipsychotic drug exposure.

Association between the serotonin 2C receptor gene and tardive dyskinesia in chronic schizophrenia: additive contribution of 5-HT2Cser and DRD3gly alleles to susceptibility

RATIONALE

Tardive dyskinesia (TD) is a longterm adverse effect of dopamine receptor blockers. The dopamine D3 receptor gene (DRD3) ser9gly polymorphism has been previously associated with susceptibility to TD. Serotonin receptor antagonism has been proposed as a common mechanism contributing to the low extra-pyramidal effects profile of atypical antipsychotic drugs.

OBJECTIVES

To examine the association of a functional polymorphism in the 5-HT2C receptor gene (HT2CR) with TD and the joint contribution of HT2CR and DRD3 to susceptibility.

METHODS

Case control association analysis of allele and genotype frequencies among schizophrenia patients with (n=55) and without TD (n=60), matched for antipsychotic drug exposure and other relevant variables, and normal control subjects (n=97). Parametric analyses of the contribution of 5-HT2Cser and DRD3gly alleles to dyskinesia scores.

RESULTS

We found a significant excess of 5-HT2Cser alleles in schizophrenia patients with TD (27.2%) compared to patients without TD (14.6%) and normal controls (14.2%; chi2=6.4, df 2, P=0.03) which was due to the female patients (chi2=8.6, df 2, P=0.01). Among the female TD patients there was an excess of cys-ser and ser-ser genotypes (chi2= 11.9, df 4, P=0.02). Analysis of covariance (ANCOVA), controlling for age at first antipsychotic treatment, revealed a significant effect of 5-HT2C genotype on orofacial dyskinesia (OFD) scores (F=3.47, df 2, P=.03). In a stepwise multiple regression analysis, 5-HT2C and DRD3 genotype (5-HT2Cser and DRD3gly allele carriage) respectively contributed 4.2% and 4.7% to the variance in OFD scores.

CONCLUSIONS

These findings support a small but significant contribution of the HT2CR and DRD3 to susceptibility to TD, which is additive in nature.

The prevalence of seborrheic keratoses in people aged 15 to 30 years: is the term senile keratosis redundant?

BACKGROUND

Seborrheic keratoses (SKs) are common skin lesions that have been shown to occur with increasing age, although the age of onset is not well recorded.

OBJECTIVE

To determine the prevalence, nature, and distribution of SKs in young people.

METHODS

One hundred seventy people aged 15 to 30 years were given a total body examination during which the presence, number, site, and size of SKs were recorded. Biopsy specimens were taken from the first 22 people who had lesions clinically diagnosed as SKs. Data on age, skin type, eye color, and hair color were recorded for all respondents.

RESULTS

Forty (23.5%) of 170 respondents had at least one SK, with no significant difference between the sexes. There was an increase in prevalence with age from 15.7% in 15- to 19-year-olds to 32.3% in those aged 25 to 30 years. The size of the SKs also increased with age. A total of 77.5% of SKs were found on the trunk and 22.5% on the limbs, head, and neck. There was no correlation between SKs and any particular hair and eye color or skin type.

CONCLUSIONS

These findings confirm that SKs are common lesions in young Australians, appearing in a substantial proportion of people younger than 30 years. The term senile keratosis is no longer appropriate for these lesions.

Pathology quiz. A pigmented skin lesion

Melanomas can usually be distinguished histologically from benign lesions by the application of accepted criteria of high discriminatory value. Occasionally, the distinction cannot be made with certainty. It is convenient to consider cutaneous melanoma as essentially of one type, with the prognosis being mainly determined by the thickness of the lesion. There is a trend to narrower excision margins with adequacy being judged solely by careful histological assessment. A formula-driven approach should be avoided.

[Alopecia due to Seroxat therapy]

There are 2 stages of alopecia, anagen and telogen effluvium, both of which may be associated with medication-related alopecia. We describe massive hair loss in a 51-year-old woman during treatment with Seroxat (paroxetine), which remitted after it was discontinued. Pathological mechanisms of drug-associated alopecia are complex and have yet to be fully elucidated.

A puzzling rash. Is a skin biopsy a useful diagnostic tool?

The diagnosis of a puzzling skin rash may require the clinician to provide a well taken biopsy specimen with an accompanying detailed description of the rash. The pathologist needs to be cognizant of the clinical manifestation of skin eruptions and to correlate the histopathological findings with the clinical features.

Genotypic association between the dopamine D3 receptor and tardive dyskinesia in chronic schizophrenia

Dopamine receptor antagonism is a common mechanism underlying the therapeutic efficacy of all classical antipsychotic drugs. It is also thought to underlie the propensity of these agents to induce the movement disorder, tardive dyskinesia (TD), in one fifth of chronically exposed schizophrenia patients. We examined the polymorphic serine to glycine substitution in the first exon of the gene encoding the dopamine D3 receptor (DRD3) inn 53 schizophrenia patients with TD, 63 matched patients with similar antipsychotic exposure but no TD and 117 normal controls. There was a difference in allele frequency that was of borderline significance (P = 0.055), due to an excess of the DRD3gly allele (allele 2) in the schizophrenia patients with TD. The difference in genotype distribution among the groups was highly significant (chi2 = 19.1, d.f. 4, P = 0.0008) due to an excess of the DRD3ser-gly genotype in the schizophrenia patients with TD. The difference between the schizophrenia patients with TD and the controls was highly significant (chi2 = 19.0, d.f. 2, P = 0.00007), even after correction for multiple testing, as was the difference between the combined group of schizophrenia patients and the controls (chi2 = 12.2, d.f. 2, P = 0.002). Comparing the schizophrenia patients with and without TD, genotypes containing the gly allele (DRD3ser-gly and DRD3gly-gly genotypes combined) were significantly associated with dyskinesia (OR = 2.62, 95% CI 1.18-5.59, P = 0.02). DRD3 genotype and age at first antipsychotic treatment contributed significantly to total score on the Abnormal Involuntary Movements Scale (AIMS). The contribution of DRD3 to the variance in AIMS total was 5.2% and the total proportion of the variance accounted for by these two variables together was 11.9%. These results support and extend the report by Steen et al (1997) of an association between DRD3 and TD in schizophrenia patients.

Intramuscular flunitrazepam versus intramuscular haloperidol in the emergency treatment of aggressive psychotic behavior

OBJECTIVE

The authors examined the efficacy of intramuscular flunitrazepam compared with intramuscular haloperidol for the immediate control of agitated or aggressive behavior in acutely psychotic patients.

METHOD

Twenty-eight actively psychotic inpatients, aged 20-60 years, who were under treatment with neuroleptic agents were selected for the study. Each was randomly assigned on a double-blind basis to receive either 5 mg i.m. of haloperidol (N=13) or 1 mg i.m. of flunitrazepam (N=15) during an aggressive event. Verbal and physical aggression was measured over time with the Overt Aggression Scale. Patients were also rated with the Brief Psychiatric Rating Scale and the Clinical Global Impression scale.

RESULTS

Both flunitrazepam and haloperidol exhibited acute antiaggressive activity. This beneficial effect, as assessed by the Overt Aggression Scale, was obtained within 30 minutes.

CONCLUSIONS

Intramuscular flunitrazepam may serve as a convenient, rapid, safe, and effective adjunct to neuroleptics in reducing aggressive behavior in emergency psychiatric settings.

Lack of effect of vitamin E on serum creatine phosphokinase in patients with long-term tardive dyskinesia

Changes in serum creatine phosphokinase have been associated with exacerbation of tardive dyskinesia. Vitamin E, a drug suggested to be effective in the treatment of tardive dyskinesia, has been implicated as a possible cause of increased creatine phosphokinase levels. Ten patients with long-term tardive dyskinesia were treated with vitamin E in a double-blind, placebo-controlled crossover study. Vitamin E blood levels and creatine phosphokinase serum levels were monitored at various phases during the study. There were no significant differences between vitamin E and placebo treated patients in their abilities to affect tardive dyskinesia or to influence creatine phosphokinase levels. These data do not support the hypothesis that administration of vitamin E may alter creatine phosphokinase levels in patients with long-term tardive dyskinesia.

[Medication group for noncompliant patients in a psychiatric day unit--experiences during a one year period]

A group of noncompliant psychiatric patients was treated on a weekly basis over a 6-month period; 13 started but 3 dropped out. Results indicated greater feeling of security with medication; increased desire to maintain follow-up treatment in the outpatient clinic; greater likelihood of patients accepting their illness; and strong desire to discuss medication-related topics with staff. Our medication group appears to offer a convenient and organized method for addressing issues of psychiatric medication, especially for chronic patients, which we recommend to clinicians in other medical disciplines.

The impact of clinical pharmacy intervention in a psychiatric hospital

One hundred and nine physician-initiated consultations were directed to a clinical pharmacist over a 1-year period. Two hundred and three (88.2%) recommendations out of 229 were adopted. Major question types included preventive measures, non-response, side-effects and mixed factors. The global effectiveness of pharmacist interventions suggests that 67.9% of patients exhibited a very satisfactory or satisfactory response. While our study suggests that a clinical pharmacist may favourably contribute to the quality of patient care, a control-group study is required to confirm our results.

Antipsychotic drugs and tardive dyskinesia: preliminary results in an adolescent psychiatric ward

The systematic study of antipsychotic-induced movement disorders in young psychiatric patients is very sparse. We assessed the presence of tardive dyskinesia in an adolescent in-patient psychiatric ward. Eighteen per cent (3/17) exhibited either pronounced or subtle signs of tardive dyskinesia. Our study suggests that young psychiatric patients may develop signs of tardive dyskinesia even though they are exposed to relatively short-term neuroleptic treatment and at dosages that are relatively low. We advocate frequent and systematic monitoring of adolescent patients taking antipsychotic drugs in order to minimize the emergence of this long-term, troublesome complication of neuroleptic drugs.

[Lithium-associated psoriasis]

A number of medications including clonidine, digoxin and beta-blockers have been reported to cause psoriasis. Lithium has also been implicated especially among women. We describe a 45-year-old man who developed diffuse psoriatic lesions 1 year after treatment with lithium was started. Various topical dermatological preparations failed to alleviate the lesions. Several weeks after discontinuation of lithium the psoriasis resolved. We discuss the possible mechanisms for lithium-associated psoriasis and alert clinicians to the possibility of this troublesome side-effect in lithium-treated patients, with or without a family history of psoriasis.

[Lithium-associated alopecia]

A 39-year-old woman who developed alopecia shortly after treatment with lithium carbonate was initiated is described. The alopecia resolved 2 months after lithium was discontinued. Though this side-effect is relatively rare, we suggest that patients getting lithium for short or long term treatment be monitored for it.

Fluvoxamine-associated sexual dysfunction

OBJECTIVE

To report two cases of sexual dysfunction induced by fluvoxamine, a selective serotonin reuptake inhibitor (SSRI).

SETTING

University teaching hospital.

PATIENTS

Two depressed patients who developed ejaculation and orgasmic difficulties after initiation of fluvoxamine therapy.

DISCUSSION

The literature concerning sexual dysfunction with serotonergic antidepressants is reviewed, and speculated mechanisms for this untoward effect are discussed.

CONCLUSIONS

Sexual dysfunction associated with antidepressant drugs, including SSRIs, may be underreported. This troublesome adverse effect may significantly affect patient comfort and compliance. Careful evaluation of sexual function is warranted, prior to and during drug treatment, especially as more serotonergic antidepressant agents become available.

Fluvoxamine-associated manic behavior: a case series

OBJECTIVE

To report cases of manic-like behavior induced by fluvoxamine, a selective serotonin-reuptake inhibitor; to review pertinent literature; and to encourage replication of our findings in larger patient samples.

DESIGN

Description of a case series of fluvoxamine-induced, manic-like behavior.

PATIENTS

Eight patients with depression or obsessive features who developed manic-like behavior after initiation of fluvoxamine therapy.

RESULTS

Manic symptomatology resolved in all eight patients following dosage reduction or withdrawal of fluvoxamine. Four patients still are maintained on low-dose fluvoxamine without recurrent manic symptoms.

CONCLUSIONS

Our case series suggests that fluvoxamine may have the ability to induce or unmask manic behavior in depressed patients. Clinicians are alerted to monitor for this "switching" effect, especially in patients previously or currently treated with neuroleptics or lithium, and in those patients exhibiting characteristics of obsessive-compulsive disorder.

Platelet dysfunction associated with clozapine therapy

Clozapine, an atypical antipsychotic agent used in cases of treatment-resistant schizophrenia, is known for its relative absence of extrapyramidal side effects and its potential hazardous effect on white blood cell function. We have described a case of clozapine-associated epistaxis and reduction of the platelet count. Discontinuance of clozapine therapy resulted in cessation of epistaxis followed by normalization of the platelet count. We suggest routine monitoring of platelet count and function in patients treated with clozapine.

Medication maintenance of chronic schizophrenic out-patients by a psychiatric clinical pharmacist: 10-year follow-up study

A psychiatric clinical pharmacist, acting as a primary clinician under the supervision of the attending psychiatrist, monitored the medication for 14 chronic schizophrenic out-patients over a 10-year period. Successful treatment resulted in a decreased rate of rehospitalization, shorter length of hospital stay, a decrease in total neuroleptic dosage, significantly fewer medication-related side-effects, and improved compliance as compared to the 10-year period prior to entry into the study. Our study suggests that with the expansion of community health services, expanded roles and the use of a clinical pharmacist may contribute significantly to the medication management of chronic schizophrenic out-patients. However, a parallel group study is required to confirm our results.

Idiopathic unconjugated hyperbilirubinemia (Gilbert's syndrome) and concurrent psychotropic drug administration

Gilbert's Syndrome is a benign familial condition in which unconjugated hyperbilirubinemia occurs in the absence of structural liver disease or hemolysis. Phenothiazines and tricyclic medications are often withheld in patients with preexisting liver disease. The authors present four patients with Gilbert's Syndrome and concurrent psychiatric illness. Administration of phenothiazine antipsychotics or tricyclic antidepressants proved beneficial and produced no adverse effects on hepatic function. The authors discuss clinical aspects of Gilbert's Syndrome in psychiatric patients and conclude that phenothiazine antipsychotic medication should not necessarily be withheld from these patients.

Vulvitis circumscripta plasmacellularis. A clinicopathologic entity?

Four cases of vulvitis circumscripta plasmacellularis (plasma cell vulvitis) are presented. One case was associated with cutaneous lupus erythematosus and another with a history of desquamative vaginitis. Two patients were postmenopausal, and two were premenopausal. The presenting symptoms were pruritus, tenderness, superficial dyspareunia and vulvar dysuria. The lesions were situated in the introitus in three patients and on the lateral aspect of the labium minus in the fourth and appeared as well-circumscribed, glistening, erythematous patches with a faint orange hue. Histologically, epidermal edema and inflammation, a dense upper dermal band of chronic inflammatory cells, including many plasma cells, dilated capillaries, extravasated red blood cells and hemosiderin deposition, were seen. There was a variable response to local steroid therapy, but one of the postmenopausal patients responded to local estrogen alone. The term vulvitis circumscripta plasmacellularis is useful to describe an idiopathic form of erosive vulvitis with a characteristic clinical and histologic appearance.

Propranolol in the treatment of akathisia caused by antipsychotic drugs

We have reported the case of a patient with neuroleptic-induced akathisia who had rapid amelioration of his symptoms after treatment with the highly lipophilic beta-blocker propranolol. His symptoms had previously failed to respond to traditional pharmacologic treatment. There is clearly a need for more double-blind studies to assess the efficacy of propranolol and other beta-blockers in the treatment of this troublesome side effect of antipsychotic medications.

[Lithium carbonate augmentation in tricyclic antidepressant-resistant depression]

Combinations of lithium carbonate and tricyclic antidepressants are effective in the treatment of resistant unipolar depression. We present a case in which addition of lithium carbonate to a maximal dose of desipramine provided rapid and sustained improvement in a severely depressed 57-year-old woman. She had previously failed to respond to maximum doses of antidepressant drugs of 2 different classes. Although the lithium-tricyclic combination was successful in our case, we caution against its routine use.

"Goodbye Sunshine": effects of a television program about melanoma on beliefs, behavior, and melanoma thickness

Of 333 persons interviewed after a television show about the effects of melanoma, 113 (34%) saw the show and 73% believed that the sun protection/skin examination message applied to them. Fifty-six percent of persons examined their own skin and 36% examined someone else's skin after seeing the program. Fifteen persons (4.5% of the total sample) planned to visit a doctor for an abnormal skin spot as a result of the program, of whom three actually did so within 4 weeks of the show. An increase of 167% was observed in the number of melanomas diagnosed in the 3 months after the show, compared with those diagnosed in the same period the year before. There was a significant shift in the proportion of tumors removed in the thin, easily cured stage. The high rate of diagnosis of new tumors and the high proportion of thin tumors was maintained a year after the program. By extrapolation from these figures, it is estimated that 208,000 Victorians out of a total population of 4.1 million intended to seek a consultation after a single television program. Of these, it is estimated that about 27,000 actually sought attention in the month after the viewing.

Mania associated with clonazepam

Clonazepam is a potent, long-acting benzodiazepine approved for use in myoclonic and petit mal seizures. Initial reports have demonstrated encouraging results with clonazepam in the treatment of acute mania as well as a favorable side-effect profile. A trial of adjunctive clonazepam was initiated in a 41-year-old patient with chronic schizophrenia. Two weeks later, while on an 8-mg dosage, he became manic, developing pressured speech, euphoria, inflated esteem, agitation, and insomnia. Initiation of electroconvulsive therapy with gradual tapering and discontinuation of the clonazepam resulted in amelioration of the manic episode and a return to his previous clinical status. Clinicians should be alerted to the potential of clonazepam to cause manic-like behavior in susceptible patients.

Psychotic exacerbation attributed to low-dose bromocriptine treatment of galactorrhea and hyperprolactinemia

Low-dose bromocriptine administered for antipsychotic drug-induced hyperprolactinemia and galactorrhea precipitated an acute psychotic state in a female patient. Discontinuation of the bromocriptine and increase in antipsychotic dosage resulted in complete remission. We advise caution in the use of bromocriptine especially in patients with a pre-existing psychiatric history and recommend monitoring for changes in mental status when bromocriptine is prescribed.

[Bromocriptine-associated postpartum psychotic exacerbation]

2 cases are presented in which bromocriptine (Parlodel) was administered to suppress physiological lactation; parturition had precipitated deterioration in mental status and psychotic behavior. Discontinuation of bromocriptine and administration of antipsychotic medication resulted in gradual improvement in the psychotic symptoms, without complications of galactorrhea or breast engorgement. We recommend that changes in mental status be looked for when bromocriptine is given.